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Système de santé en Haïti : mettre le patient au premier plan

Maryanne Sharp's picture

Also available in English and Spanish

Un arbre lui procure un peu d’ombre mais ne la protège guère de la chaleur. Chantal vient de faire la lessive familiale à la rivière. Elle est enceinte de quatre mois.

Nous sommes à une soixantaine de kilomètres au nord de la capitale haïtienne, Port-au-Prince. Le hameau où vit Chantal compte à peine vingt maisons, n’est relié que par un seul chemin de terre et ne dispose d’aucune structure médicale.

Le dispensaire le plus proche (où travaille, deux heures par jour, un diplômé de l’enseignement secondaire) est à une heure de marche et le centre de santé le moins éloigné, à deux heures.

À Haïti, seulement un tiers environ des naissances ont lieu dans un établissement de santé. Cette statistique donne la mesure des efforts tout particuliers que les pouvoirs publics et les donateurs doivent déployer pour encourager les femmes à se rendre aux consultations prénatales et à accoucher en milieu médicalisé.

Il y a une vingtaine d’années, la mère de Chantal a donné naissance à cinq enfants, à même le sol insalubre de sa cahute. Elle était seule, son mari attendait dans l’autre pièce. Deux des bébés sont morts à cause de complications durant l’accouchement qui auraient pu être évitées.

Chantal ne voit aucune raison de déroger à une tradition solidement enracinée. Une matrone (une sage-femme, qui conseille aussi le village sur les questions de santé) l’a convaincue d’accepter son aide pour accoucher, moyennant 1 à 2 dollars. En revanche, l’accouchement est gratuit dans les établissements de santé du pays, et une politique nationale incite les Haïtiennes à recourir à ces derniers. Q

uel que soit l’environnement, les systèmes de santé regorgent d’incitations perverses, qui favorisent des comportements inappropriés ou indésirables. Par exemple, les matrones redoutent, à juste titre, de perdre leur (maigre) rémunération si les femmes ne tiennent pas compte de leurs conseils et se rendent aux consultations gratuites offertes par les structures de santé. La tradition, les problèmes de transport et la piètre qualité des soins constituent d’autres obstacles.

Chacun d’eux est déjà important en lui-même mais, cumulés, ces freins posent un grave problème à l’État soucieux de réduire le nombre des décès évitables et d’améliorer la santé de la population.

Taux record pour la mortalité maternelle

Haïti affiche le taux de mortalité maternelle le plus élevé de l’hémisphère occidental. Dans ce pays, une femme a, durant les années où elle est féconde, une probabilité sur 37 de mourir de causes liées à la maternité.

La mortalité des enfants est trois fois supérieure à la moyenne de l’Amérique latine : les moins de cinq ans courent un grand risque de contracter une maladie évitable, telle que la diarrhée ou la pneumonie.

Compte tenu de ces chiffres et des obstacles évoqués précédemment, comment faire en sorte que Chantal, son nourrisson et sa famille utilisent les services de santé maternelle et infantile proposés gratuitement par les établissements ? Il s’agit, d’une part, d’améliorer la qualité des soins et, d’autre part, de changer le comportement des prestataires.

Mais, pour une fois, la solution ne consiste pas forcément à injecter davantage d’argent. Par comparaison avec l’Amérique du Nord, l’Europe ou l’Asie du Sud-Est, le budget du système de santé haïtien est infime. Pour Haïti, le financement disponible est acceptable à l’heure actuelle et à ce niveau d’organisation du système. C’est pourquoi la véritable priorité doit consister à améliorer nettement la gouvernance et la gestion, de façon à mettre en place un dispositif rendant compte de ses résultats.

Il est impératif de partir du patient en pratiquant constamment une gestion axée sur les résultats, c’est-à-dire d’améliorer la situation sanitaire de la population. Il convient d’inciter les patients à recourir aux services de santé, de revaloriser la rémunération du personnel et d’offrir à ce dernier des conditions de travail appropriées, de limiter le plus possible ses tâches autres que les soins et — objectif peut-être le plus important — de rétablir le lien entre la population et le régulateur du système (l’État).

Des problèmes multiples

Le système de santé haïtien pâtit en effet de difficultés multiples et tenaces, dont notamment la rupture du contrat social et les obstacles d’ordre financier ou physique qui entravent l’accès à des soins de qualité.

Les services de santé souffrent également du manque d’efficacité du personnel qui découle de la surcharge de travail, de l’insuffisance des formations et de la faiblesse des rémunérations. Il faut une approche nouvelle pour remédier à tous ces problèmes.

Afin d’améliorer la couverture et la qualité des services maternels et infantiles, on peut commencer par instaurer un financement en fonction des résultats. Cette stratégie devrait encourager l’élargissement de la prestation des services essentiels et l’amélioration de la qualité des soins, avec, à la clé, un changement durable de comportement parmi les prestataires et la restauration de la relation soignant-patient.

Néanmoins, pour y parvenir, tant le gouvernement haïtien que ses partenaires donateurs devront assumer leurs responsabilités respectives, faire preuve d’audace et prendre des risques calculés. L’État doit réformer la fonction publique, exercer pleinement son leadership et lutter contre la corruption.

Les partenaires, eux, doivent adopter une vision à long terme, à savoir mettre à disposition des ressources permettant de renforcer la gouvernance et faire preuve de fermeté face au refus des compromis et aux faux-fuyants. Il est aussi nécessaire d’apporter un financement direct afin que les pouvoirs publics puissent jouer leur rôle de régulateur et de gestionnaire.

À Haïti, le ministère de la Santé envisage d’introduire une nouvelle approche de gestion axée sur les résultats, via la prestation de services de santé et de nutrition reposant sur des données factuelles, à fort impact et d’un bon rapport coût-efficacité. Ces services seront délivrés en partie au niveau des établissements et en partie au sein de la communauté.

À cette fin, les prestataires (publics et privés) opéreront sur la base de contrats et recevront une prime lorsqu’ils auront atteint le nombre visé de patients traités avec un niveau de qualité acceptable. Cette approche bénéficie du soutien à la fois de l’USAID (agence des États-Unis pour le développement international) et de la Banque mondiale.

La réussite de cette approche dépendra toutefois de la gouvernance et de la gestion du système. Avec, in fine, la création d’un système de santé rationnalisé et nettement plus performant.

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Bonjour,
Les services maternels et infantiles doivent au moins être la priorité dans les prises en charge.