Updating a Rural Clinic in Tiburón, Haiti

Abstract

Background

Tiburón is a small fishing village in Haiti with a clinic overseen by the Oblate missionaries and the Ministry of Public Health and Population (MSPP). This village was hugely impacted by Hurricane Matthew in 2016, leading to increased health care demands. The clinic was inaccessible from the furthest parts of the village and lacked basic medication supplies and adequate manpower. We aimed to reinforce the infrastructure and update the clinic using a multifaceted approach.

Methods

We developed a quality improvement project to strengthen the clinic’s infrastructure and modernize its facilities with a comprehensive approach focused on enhancing health care for the people of Tiburón. We analyzed the data collected by MSPP statisticians, encompassing records of over 2000 patients visiting the clinic between 2017 and 2019. This analysis included all patients aged 1 to 80 years, with no exclusion criteria. We examined both pre- (before 2018) and post- (after 2018) intervention variables, including the number of patients, their gender, various visit types, and trends in encountered pathologies. In 2018, we implemented several interventions in collaboration with the MSPP, such as increasing staffing, expanding health care outreach efforts, providing financial support for medications, adopting a targeted approach to prevent common pathologies, educating and raising awareness about communicable and vaccine-preventable diseases, and placing greater emphasis on maternal health.

Results

We assessed the effects of our interventions by comparing data from previous years using the quality metrics established by the MSPP. Significant changes were observed pre- and post-intervention, including an increase in the number of patients, a rise in all visit types, expanded health care outreach, a reduction in communicable and vaccine-preventable diseases, and improved maternal health.

Conclusion

This was a promising quality improvement project, highlighting the improvement of studied variables after adding sustainable and efficient interventions. With our continued effort, we aim to facilitate future interventions based on the success of the current study to further update the clinic and to cater to the increasing health care needs of the population of Tiburón and other such underserved communities.

Introduction

Tiburón is a small coastal fishing village situated in the arrondissement of Chardonnières in southwestern Haiti, with a population of 23 680 residents. The Tiburón clinic represents a collaborative effort between the Oblate missionaries and the Ministry of Public Health and Population in Haiti (MSPP) (Figure 1). The Oblate missionaries have been serving the rural communities for over a century, contributing to the clinic’s physical infrastructure, while the government supplies the clinic with its medical staff. This clinic serves as the primary health care provider for the entire village. Tiburón experienced significant challenges following the impact of Hurricane Matthew in 2016, resulting in a heightened demand for health care services. A post-Hurricane Matthew report revealed that 43% of surveyed individuals expressed a need for improved health care, while 35% sought increased access to medications.¹

Figure 1.

The Tiburón Health Clinic located in “Centerville,” Haiti.

The Tiburón Health Clinic located in “Centerville” (a local name for the center of the village) faced several challenges. Its geographical location made it inaccessible to some of the village’s remote areas, forcing residents to rely on horses or donkeys for transportation. Due to low socioeconomic status, most people did not have a car, and few motorcycles in the village were used as taxis. There was no public transportation, and only 1 ambulance was available to carry referred patients to a higher center in Port-à-Piment, Les Cayes, for difficult labor and unresolved medical cases. The Oblates purchased medications for the clinic based on the needs of the clientele. The clinic also grappled with inadequate medication supplies due to a low patient influx. Staffing for the clinic consisted of 1 nurse, 2 nurse aides, and a laboratory technician. Furthermore, concerns arose regarding unexpected clinic closures, unawareness about common communicable and vaccine-preventable diseases in the area, and unsafe home deliveries of newborns.

We reviewed the literature for studies performed in resource-deficient or disaster-affected areas of the world, which gave us some insights on the challenges faced by these regions, regarding geography, the inability to reach health care facilities, and the most common primary care issues encountered in such areas, as well as avenues to tackle health care challenges that include recurring natural calamities and efficient ways to improve maternal health in low socioeconomic regions.^2–5 By reviewing these studies, we formulated a multifaceted quality improvement project specifically targeting the population in Tiburón. Our objective was to increase clinic utilization to address the health care needs of the people of Tiburón following Hurricane Matthew in 2016. A needs assessment was initiated in 2017, and interventions to fortify the clinic’s infrastructure and modernize its facilities through a comprehensive approach were developed and implemented at the beginning of 2018. We aspire to implement further improvements based on the positive outcomes obtained in our initial study. We have highlighted that quality improvement studies within resource-scarce regions can significantly contribute to enhancing the quality of life and health care status of the population residing in such areas. These studies prove especially beneficial in locations repeatedly affected by natural calamities, such as Tiburón.

Methods

We formulated a quality improvement project by analyzing the data collected by the MSPP statisticians in Haiti. The dataset consisted of records of over 2000 patients visiting the clinic between 2017 and 2019. These included all men, women, and children from ages 1-80 years with no exclusion criteria. Pre- and post-intervention variables were the numbers of men, women, and children among the clinic patients, visit types, including general consultation visits, pre- and postnatal visits, family planning visits, vaccination visits for infants and children, number of births in the dispensary versus home, labor and delivery visits, and urgent care visits. The most frequently encountered diagnoses included those listed in Figure 2, such as malaria, tuberculosis, typhoid, and parasitic infections.

Figure 2.

The most common diseases seen in the target population with trends after the introduction of interventions at the beginning of 2018.

Until 2017, the clinic was running without a schedule and had frequent, unexplained, and unnotified closures. The midwife running the clinic was unaware of her responsibilities and her significant role in the community, while also lacking adequate certification for the job. There was no qualified physician employed at the clinic. In addition to the lack of stable staffing, there was also a lack of an adequate number of staff, gaps in personnel qualifications, and knowledge barriers in the community. There were also barriers to the transportation of patients to and from the clinic. In 2018, multiple interventions were implemented in collaboration with the MSPP, including the scheduled operation of the clinic from 9:00 AM to 3:00 PM, the addition of a local physician, and an additional midwife, with a subsidy for their living arrangements, the replacement of the original midwife by another more experienced midwife, monetary support to replete the medication inventory by the MSPP, enhanced ambulance service to facilitate the transfer of patients to the clinic and referrals to distant centers as needed, and obtaining medications at low cost from Direct Relief and other non-government organizations. Other interventions comprised the administration of regular vaccinations per schedule to children and adults, the addition of 45 matrons (female assistants to the midwives), education on the prevention of common communicable and vaccine-preventable diseases by midwives and matrons, free medications for pregnant women, including prenatal vitamins and injectables for delivery from recurrent donations by the MSPP as well as one-time voluntary donations from multiple non-government organizations, monthly meetings conducted by the midwives and matrons to spread awareness on safe delivery of newborns, and distribution of clean birth kits donated by the Gainesville Chapter of the Links.

Results

The MSPP-established quality metrics guided our assessment of outcomes. We compared data from 2017, when the performance was subpar, to 2019, following the implementation of interventions at the beginning of 2018. Notably, substantial improvements were observed after the addition of interventions, as depicted in Figures 2 to 4. These improvements included an upswing in clinic visits by patients of all ages and genders after the introduction of interventions in early 2018. As seen in Figure 3, there was a surge in female attendance at the clinic, driven by heightened awareness regarding the importance of adhering to scheduled prenatal and postnatal appointments as well as education supporting family planning visits. Similarly, male visits to the clinic significantly increased initially in 2018 compared to 2017 due to improved accessibility. However, the numbers came back to baseline in 2019 given decreased encounters with acute complaints and more emphasis on chronic issues with appropriate follow-up. Furthermore, the pediatric patient population experienced a marked increase in visit numbers, attributed to heightened awareness of vaccinations for preventable and communicable diseases among children.

Figure 3.

There was a general increase in the number of patients visiting the clinic after interventions were introduced at the beginning of 2018, irrespective of gender.

Figure 4.

There was a significant increase in all visit types from 2017 to 2019.

As previously described, Figure 4 illustrates an across-the-board increase in all types of clinic visits following the introduction of these interventions. Notably, there was an increase in prenatal and postnatal visits, with a decrease in home births and a corresponding rise in successful live births at the clinic, attributed to enhanced health care outreach to remote areas of the village and increased education and awareness regarding maternal health and safe delivery practices. However, insufficient data are available to show that these changes were not associated with a general rise in the birth rate in the community.

As detailed in Figure 2, malaria was the most common pathology encountered in the area. There was a decline in communicable diseases, such as a significant reduction in malaria incidence in 2019, possibly due to targeted education and awareness. Noteworthy reductions were also observed in cases of anemia and genitourinary infections, attributed to a focus on maternal health, including hygiene education and the distribution of prenatal vitamins and supplements. However, we cannot rule out other external factors that could have been attributed to these results as no comparative data is available. It is worth mentioning that some pathologies experienced a paradoxical increase due to the rise in clinic visits, leading to increased reporting, such as hypertension and dermatitis.

Discussion

The primary aim of this study was to underscore the significance of redeveloping the Tiburón clinic using a holistic approach, which included enhancing the clinic’s infrastructure, allocating additional resources, medications, and staff, and assessing the impact of these interventions on the clinic. Our objectives were to investigate the demographic profile of the population served by the clinic, identify the most prevalent diseases affecting this population, and analyze how our interventions influenced the trends in these diseases. We found significant changes pre- to post-intervention, including an increase in the number of patients visiting the clinic, a rise in all visit types, expanded health care outreach, a reduction in communicable and vaccine-preventable diseases, and improved maternal health. These findings are intended to lay the groundwork for future interventions to further modernize the clinic and meet the growing health care needs of the covered population. Additionally, this research seeks to pinpoint ongoing health care challenges in Tiburón and propose solutions to address them.

It is important to acknowledge the limitations of this study, primarily stemming from the incomplete information available in the data obtained from the MSPP. These limitations include the absence of specific patient age data, except a broad range of 1–80 years (children being <18 years of age), the lack of International Classification of Diseases coding for the most frequently diagnosed diseases, and instances of overlapping pathologies listed together, such as urinary tract infection and genitourinary infections, diarrhea and gastroenteritis, and a separate pathology named febrile illnesses. There was also an absence of consideration for patients presenting with multiple comorbidities among the studied diagnoses. Moreover, the numbers mentioned on the graphs depict the number of visits for each section rather than the number of patients, which can get confusing, considering we analyzed records of over 2000 patients. Nonetheless, this is a promising study, as it possesses sufficient data to assess improvements in variables following the implementation of interventions and offers prospects for enhancing the health care situation in Tiburón.

Areas for improvement include expanding the number of mobile clinics to reach more remote areas, thereby, increasing health care accessibility, identifying the most common disease pathologies to create opportunities for new health interventions, such as insecticide-treated nets, vector control, and indoor-residual spraying, and introducing vaccinations for malaria.⁶ We plan on engaging the police and hiring security to make the staff and patients comfortable with the nighttime delivery of newborns in the clinic, along with the addition of HIV testing kits for pregnant women and the general population. We also aim to improve the accuracy of future studies by working on the above limitations and encouraging the collection of data using a systematic approach. Future studies could benefit from more granular data collection, including patient age breakdowns and standardized disease coding, to facilitate deeper insights and comparisons. While reviewing the existing literature, we found only a few studies conducted in resource-constrained regions worldwide; however, none of them comprehensively covered multiple health care aspects like our study.^2–5 We aim to improve the external validity of this study by performing similar studies in the future in more resource-constrained areas of the world to be able to generalize findings and inform broader health care practices.

Conclusion

Through our cost-effective and sustainable interventions, which comprised using available resources efficiently and creating awareness predominantly by educational sessions and increased outreach in the community, in the setting of low financial support, we demonstrated a substantial positive impact on the community’s health for a span of 2 years. Our goal is to transform the clinic into a self-sustaining and thriving institution. With the enhanced availability of existing resources, patients have regained confidence in the community health system and hold a positive outlook toward the clinic. This study represents a promising endeavor, highlighting significant improvement in clinical use after implementing interventions. We are committed to ongoing efforts aimed at using the success of this study as a foundation for future interventions, further advancing the clinic’s capabilities to meet the increasing health care demands of the population in Tiburón. After witnessing marked subjective improvement with our initial study, we have planned to make quantified interventions and pre- and post-intervention results that can be statistically analyzed and objectively replicated by other researchers. This study will serve as an exemplary model, inspiring further quality improvement projects in other resource-constrained regions worldwide, ultimately enhancing human lives.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity.