Haitian community-based organizations at the forefront of sexual and reproductive health services delivery are struggling to address new challenges posed by changing demographics and unfavorable socio-economic conditions.
Urbanization, a breakdown of traditional family structures and poverty are among factors that have given rise to harmful sexual practices among the country’s youth leading to increased exposure to sexually transmitted diseases, unsafe abortions and gender-based violence, according to public health experts.
Statistics from EMMUS 5, a demographic survey produced by Haiti’s Ministry of Public Health and Population, show contraceptive prevalence among adolescent girls (aged 15 to 19) stands at 9 percent only, compared to 24 percent for all age groups, and a majority of youth report being unable to procure contraception methods.
“It’s a catastrophe,” said Dr. Fritz Moïse, executive director of FOSREF, an organization delivering sexual and reproductive health services in close partnership with the Ministry of Public Health and Population.
Early sexual activity and risky behavior are on the rise among adolescents and young adults. Substance use has increased among boys, while sexual abuse, forced sex and transactional sex in urban centers — when sexual favors are exchanged for money or gifts — have become more prevalent among girls. Adolescents are also failing to accurately perceive their risk of exposure to HIV and other sexually transmitted diseases.
In some instances, the link between family planning, poverty and risky sexual behavior is all too obvious. Complications from abortions, which are illegal in Haiti under all circumstances, including rape, are a leading cause of high maternal mortality rates. Unwanted pregnancies, poverty, or both play a role in many a woman’s decision to engage into sex work. According to Moïse, 80 percent of female sex workers have turned to prostitution as a solution of last resort in order to provide for their child, having been unable to secure other forms of employment.
Haiti’s population continues getting younger, in large part because of unmet needs for family planning. While the Haitian government has designated adolescents and young adults as at risk and in need of sexual and reproductive health services, there has been limited action.
“Except for programs that are being run around HIV/AIDS, there are no programs for health and contraception for the youth,” said Olga Benoit, president of SOFA, a leading nonprofit working in the area of women’s health and rights.
Community-based organizations like SOFA and FOSREF usually receive no funding from the Ministry of Public Health and Population, and have had an increasingly hard time securing financing from foreign sources. Funding for social programs is dwindling especially fast. Benoit told Devex that SOFA, which has been active for almost 30 years, recently had to scale down its activities and fire staff after being unable to obtain grants from foreign donors. The organization narrowly averted closure of its flagship women’s health clinic this year thanks to a last-minute funding opportunity. FOSREF also recently shut down a popular program to help female sex workers quit prostitution.
The decrease in funding can be partly explained by the fact that some of these CSOs were running on foreign money earmarked for post-earthquake reconstruction. SOFA, for instance, saw its partnership with UNICEF end recently because the agency couldn’t maintain the programs it had created with local CSOs in the aftermath of the quake.
“These funds are now exhausted, and the financial support which UNICEF Haiti is able to mobilized in the past couple of years has significantly reduced,” according to a UNICEF representative in an email to Devex.
But Benoit said recent donor program design and bidding systems seem to prefer larger projects, making it hard for small and local organizations like hers to compete against large INGOs. SOFA is mostly left to operate as a subcontractor or implementing partner with limited funding for core activities. Benoit also claims her organization has lost funding from agencies such as UNICEF after being told foreign aid was now being directed to the Haitian government.
“I’m all for supporting the state, but certain organizations are doing work that complements what the state is doing,” she told Devex, adding that SOFA has been recognized as a public benefit organization.
According to Moïse, sexual and reproductive health services have lost financing to the fight against HIV/AIDS. “Family planning has suffered a lot from HIV,” he explained. “There used to be many sexual education programs, but all of this is going down. Funding for communication and education is decreasing, and it’s threatening the programs.”
Foreign funding in support of Haiti’s National Strategic Plan to Fight AIDS, or PNLS is provided mostly by the U.S. President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria. It has helped bring the rate of HIV among the population aged 15 to 49 from a high of 6.2 percent in 1993 to 2.2 percent in 2012. But spending on the PNLS prevention activities, which revolve around communication and outreach, have been continuously decreasing since 2009 in favor of antiretroviral treatment.
A 2014 revision document for the National Strategic Plan indicates youth programming has suffered the largest cuts. “HIV prevention programs for youth are absolutely underfunded,” the document says.
According to the same report, prevention activities under the PNLS are generally not showing results, in part because many programs do not follow evidence-based strategic guidelines.
USAID’s Prevention of Sexual Transmission of HIV/AIDS, with the goal of “increased adoption of safer sexual behavior by Haitian youth and adults,” is one of the programs that have been called into question for its lack of effectiveness. A 2013 internal audit from the U.S. agency revealed the program had achieved limited results, notably because World Vision, a major implementing partner, failed to meet expectations and saw its funding revoked, causing major delays in the program. Another partner, Population Services International, had made limited progress in its program for most-at-risk populations by the time the audit was concluded, but results of the PSI portion of the program will not be known until 2017, two years after the program’s end.
SéroVIE, a local organization that received the Red Ribbon Award from UNAIDS in 2012 for its work against HIV/AIDS, is feeling the funding crunch. This NGO runs an emergency shelter for LGBT youth who are victims of violence, as well as a clinic providing treatment for HIV and psychological support. It also used to run a cybercafé that was considered a haven for youth looking for resources or just a safe space to relax, but funding ran out and the café closed when SéroVIE no longer had money to fix broken computers.
“The way healthcare is conceived at the global level puts the emphasis on treatment. It’s a real danger. The psychosocial aspect is not taken into consideration,” said SéroVIE Executive Director Réginald Dupont.
It is difficult to accurately assess the status of international funding for prevention activities. A new agreement signed between the Haitian government and the Global Fund for 2016-2017 has streamlined part of the funding previously dedicated to prevention and applied it to treatment activities in an effort to limit the duplication of programs and reduce administrative costs. About 75 percent of the $45 million grant now fall under the treatment stream.
“Under the new agreement, the budget allocated to traditional subrecipients working on prevention in Haiti seems to have decreased due to the fact that sub-recipients working on treatment will also carry out prevention activities,” wrote a representative from the U.N. Development Program, the principal recipient of the current Global Fund grant.
“Traditional subrecipients working on prevention continue to demand an increase in their budgets,” the representative added.
Local organizations don’t necessarily expect the aid system to cover the costs of social programs, especially when the treatment side of the fight against HIV/AIDS is working well. But Haiti somehow has to face the fact that hundreds of thousands of youths are entering adolescence each year and exposing themselves to a wide range of risks. “Donors who finance 100 percent of antiretroviral drugs cannot finance the social determinants of HIV/AIDS in the same time,” Moïse explained. “The state must do its share.”