Report on Findings from an Assessment of the Integration of Nutrition into HIV Programs in Selected Facilities and Communities in Haiti

Haitian woman carrying food
A Haitian woman carries fresh vegetables.

Preventable public health problems in Haiti remain a significant challenge for the country’s development. Haiti has seen limited progress in reducing malnutrition in the past decade. According to the 2005-06 Haitian Demographic and Health Survey (DHS), 29.4% of Haitian children under age five were stunted (a 1.0% increase from 2000), 9.0% were wasted, and 18.1% were underweight (a 5.0% increase from 2000). In Haiti, the HIV and AIDS crisis has generalized. HIV and AIDS affects 1.9% of the adult population ages 15 to 49 (UNAIDS 2009). It is well established that HIV compromises the nutritional status of infected individuals. Integrating nutrition services into the package of services provided to people living with HIV and AIDS (PLWHA) is important.

SPRING conducted this assessment to (a) better understand the national context of and gaps in HIV and nutrition programming at the facility and community levels and (b) determine the availability of elements of nutrition programs that are essential for adults and children (i.e., assessment, counseling, drugs, and food support) at the service delivery levels in Haiti. The study used mixed methods. Quantitative tools were used to assess health facility resources, services, and capacity, as well as health provider knowledge, skills, and practices related to the integration of nutrition interventions within their current portfolio. Semi-structured interviews and open-ended questions were used to learn about the role of community health workers (CHW) and local community-based organizations in promoting nutrition for PLWHA and other vulnerable groups.

The geographic scope of the assessment included the North, West, South, and Artibonite regions of Haiti. Fourteen health facilities were surveyed in total, including six hospitals, seven health centers, and one dispensary. The number of health providers who participated in the survey was 157. Of these health providers, 68 were interviewed in hospitals, and 89 were interviewed at health centers and dispensaries. The findings were commonly disaggregated by type of facility. Note that, because the sample size for dispensaries was low, the categories for health centers and dispensaries have been combined. In addition, key informant interviews were conducted with representatives from 9 non-governmental organizations (NGOs). Semi-structured interviews were conducted with 33 CHWs as well. There were also certain limitations in the research methodology employed. The purposive sampling of health facilities, NGOs and CHWs, makes generalization of the study to other facilities in Haiti a challenge. The report presents a detailed discussion of key findings, including:

  • Health facilities surveyed were high performing. The health facilities that were included in the assessment were mainly hospitals that play a considerable role in the roll out of HIV/AIDS services in Haiti. They were supported by a number of international partners including Centers for Disease Control, Partners in Health, Miami University and Cornell University.
  • Nutrition assessment and counseling services were implemented in most health facilities. The study findings suggested that there was at least one health provider trained in every facility surveyed, and a room that offered privacy for nutrition counseling in 70% of health facilities. However, there were no standardized methods for conducting nutrition assessment. This varied from facility to facility. In addition, nutrition norms and policies were not commonly available in the health facilities surveyed.
  • Additional capacity-building initiatives were needed for scale up. The findings show that over 50% of health providers surveyed had received training in how to conduct nutrition assessment and counseling. Despite the high knowledge of nutrition among health providers, the research team’s observations of health workers interacting with clients showed that the proportion of health providers who performed nutrition assessment and counseling was low. Only one-quarter of health providers weighed clients during the observation period. Observations of key infant and young child feeding (IYCF) counseling topics were similarly low.
  • Quality assurance systems were in place in most health facilities surveyed. The health facilities surveyed all had regular managerial meetings at the health facility level. Supervision checklists were commonly used to provide feedback to staff. Electronic medical records, in addition to paper records, were in place as a means to improve clinical care and program management. However, the current quality assurance systems are geared mostly towards the clinical management of HIV and tuberculosis (TB) services, and not nutrition services.
  • Human resource management was fairly sound in the health facilities surveyed. The frequency of supervision is high. Of all health providers surveyed, 84% reported being supervised at least once during their work at the facility. Among those ever supervised, approximately 80% received feedback on their work performance and over 90% had their work observed. A system to collect client feedback was in place in over 50% of health facilities surveyed. Still, weaknesses in the referral systems existed at the facility level. Community facility linkages were weak, and demand for maternal and pediatric services was low.
  • Community health workers played a large role in supporting people living with HIV and AIDS and other vulnerable populations; however, their role in overall preventive health and nutrition care was limited. Most of the CHWs interviewed had weak links with the national Ministère de la Santé Publique et de la Population (MSPP) program, and were dependent on NGOs and community-based organizations (CBOs) for their salary, training and other support. A comprehensive change in policy and practice is needed at all levels to ensure that all CHWs in Haiti are part of the national system.

The findings from the assessment lead to clear recommendations and next steps for the SPRING program planning and for other nutrition stakeholders in Haiti. Recommendations include to define nutrition assessment, counseling and support services, including validating standard operating procedures for nutrition assessment, counseling, and support (NACS) in Haiti; use innovative approaches such as on-the-job training and clinical simulations, to enhance the capacity of health providers to deliver NACS services; integrate nutrition indicators into the ongoing quality assurance systems in Haiti; strengthen the supervision system; strengthen referral linkages between health facilities and communities; establish a committee to monitor and evaluate NACS activities in Haiti; increase demand for health services at the community level; and conduct a mapping exercise to identify networks and opportunities for PLWHA and other vulnerable populations.