Front Cover
 Logic and principal messages of...
 Executive summary
 Table of Contents
 Definition of Haiti's food security...
 Potential magnitude and nature...
 Constraints to food security
 Proposed food security strateg...
 Appendix: Functions of cities

Title: USAID strategy to improve food security in Haiti
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00080849/00001
 Material Information
Title: USAID strategy to improve food security in Haiti
Physical Description: Book
Language: English
Creator: Riordan, James T.
van Haeften, Roberta
Locher, Uli
Augustin, Antoine
Blemur, Marguerite
Guengant, Jean-Pierre
Publisher: Agriculture and Rural Develoment Technical Services Project
Publication Date: 1997
 Record Information
Bibliographic ID: UF00080849
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 183209967

Table of Contents
    Front Cover
        Page 1
    Logic and principal messages of proposed food security strategy
        Page 2
    Executive summary
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
    Table of Contents
        Page 13
        Page 14
        Page I-1
        Page I-2
        Page I-3
        Page I-4
    Definition of Haiti's food security problems
        Page II-1
        Page II-2
        Page II-3
        Page II-4
        Page II-5
        Page II-6
        Page II-7
        Page II-8
        Page II-9
        Page II-10
        Page II-11
        Page II-12
        Page II-13
        Page II-14
        Page II-15
        Page II-16
        Page II-17
        Page II-18
        Page II-19
        Page II-20
        Page II-21
        Page II-22
        Page II-23
        Page II-24
        Page II-25
        Page II-26
        Page II-27
        Page II-28
        Page II-29
        Page II-30
    Potential magnitude and nature of food insecurity in the future
        Page III-1
        Page III-2
        Page III-3
        Page III-4
        Page III-5
        Page III-6
    Constraints to food security
        Page IV-1
        Page IV-2
        Page IV-3
        Page IV-4
        Page IV-5
        Page IV-6
        Page IV-7
        Page IV-8
        Page IV-9
        Page IV-10
        Page IV-11
        Page IV-12
        Page IV-13
        Page IV-14
        Page IV-15
        Page IV-16
        Page IV-17
        Page IV-18
        Page IV-19
        Page IV-20
        Page IV-21
        Page IV-22
        Page IV-23
        Page IV-24
        Page IV-25
        Page IV-26
    Proposed food security strategy
        Page V-1
        Page V-2
        Page V-3
        Page V-4
        Page V-5
        Page V-6
        Page V-7
        Page V-8
        Page V-9
        Page V-10
        Page V-11
        Page V-12
        Page V-13
        Page V-14
        Page V-15
        Page V-16
        Page V-17
        Page V-18
        Page V-19
        Page V-20
        Page V-21
        Page V-22
        Page V-23
        Page V-24
        Page V-25
        Page V-26
        Page V-27
        Page V-28
        Page V-29
        Page V-30
        Page V-31
        Page V-32
    Appendix: Functions of cities
        Page App-1
        Page App-2
        Page App-3
        Page App-4
        Page App-5
        Page App-6
Full Text


1:~~ v: ~ FINWL. 1)RArT

~ ~ s m. USAiDsurATE GY


A Proposal

A:srhot's: J James T. Riordan

Robe'rta van Iiaeften

Uli Lochei

Anitoine Augustin
li" ng eit Beiu

Jean-Pierre Guengant

* 'K:. .Prpe-ared for USA1D/Hafti
LC- TiCH 1IDeliyery Order No. 6
cCiw No. IsG-0807-Q-06-3036-00
Cheionles IInternational JIac.

p. February 1997


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Haiti's food insecurity has its roots in poverty

Reducing poverty permanently requires adoption of developmental pernpcctive


Malnutrition calls Haiti cannot grow
less for reactive its way out of
treatment and more poverty fast enough
for active to make everybody
prevention food secure

Preventing Family planning is
malnutrition essential
requires integration
with health services

Minimum health
package includes:
* Immunizations
* Child feeding
4 Treatment of
sick children
4 Health education
* Family planning
* Prenatal &
maternal care

Targeting of food to
mothers & children
less than two at
nutritional risk can

development of
UCS system

Give high priority
to potable water &
sanitation, including
through cash and
food for work

Permanent solution to poverty) requires sustained high rates of
economic growth

To expand economic activity inclusive of poor ..

Raise productivity Promote investment Attack fundamental
of labor, especially by macroeconomic
through basic constraint of low
education effective demand by

Focus on 1. Inculcating Broadening access
improvement of favorable to markets, both
educational quality investment climate externally &

2. Rehabilitating
and maintaining

Main constraint to
expanding market
access is lack of
physical access

3. Expanding access Give high priority
to market to roads, including
information, through cash and
technology, & food for work
financing, e.g.,
through business
promotion centers

Rural treas are Exodus from rural Proportionally, Many public investment Social service budgets are
overpopulated areas is underway. Port-au-Prince is decisions have geographic stretched. It is impossible to
economically. Haiti is urbanizing most dominant dimension. service everybody everywhere.
rapidly. capital city in Choices must be made.

The logical place to shift the current bias away from Port-au-Prince, to accommodate the exodus of population from rural areas, to focus
limited social services, and to support emerging economic activity both agricultural and non-agricultural is Haiti's secondary cities.


The food security strategy presented in-this document defines the nature and scope of food
Insecurity in Haiti, identifies major constraints to improving food security, and suggests policy
and program responses. The proposed responses are recommendations primarily for
USAID/Haiti. In the final analysis, though, enhancing food security in Haiti is Haiti's job, not
USAID's. As a resulted proposepnonties also ave implications ideally, at least -- first,
for the Government of Haiti and, second, for other donors and non-governmental organizations.

iFood security is defined as "access by all people at all times to enough food for an active and
health life." Food security encompasses three major dimensions: availability, access and
utilization The three dimensions are used to assess Haiti's food security problem.

Of the three dimensions of food security, lack of access is the root cause of food insecuritjin
Haiti. In other words, Haiti'sfood insecurity is more than anything else ajuestioen ojpovery.
If poverty can be reduced, lack of availability and oor utilization can be -datessed as well.
S accordingly, the strategy attaches highest priority to bringing a out sustainable increases in the
income of Haiti's poor.

Poverty reduction is a medium- to long-run proposition. kin the short to medium run, large
numbers of Haitians will continue to be malnourished or at nutritional risk. In particular,
substantial numbers of young children will continue to be vulnerable to irreversible physiological
damage unless measures are taken to enable them to benefit from whatever food to which the
incomes of their households give them access. As a consequence, the proposed strategy's
primary focus on income generation for the poor is complemented by a focus on utilization,
especially on Haiti's most nutritionally vulnerable population, children less than two years of age
currently malnourished or at high nutritional risk.

State food availability is an important,butsecondary cone If Haiti's poor were not
poor, that is, if they could transateteir nutritional needs into eective demand for food, food
availability would increase markedly, either through increases in national production or through
increases in commercial imports. Producing food often is a cost-effective way for poor
Households to increase their access to food. But increasing food production is only one -- and
S not always the most cost-effective -- way to bring about that result. Furthermore, it is not an
Send in itself.

) The root cause of poverty in Haiti is low labor productivity, which, in turn, reflects inadequate
I investment in human and physical capital and poorly developed public policies and institutions.
From a food security perspective, policies and program actions that raise the productivity of
currently poor people call for the highest of attention. Two sets of policy and program actions
are key: first, those that attract investment and generate 'obs aend, second, measures to
improve the quality of education, especially primary education.

To attract investment and generate jobs, three conditions are essential:

* First and foremost, the inculcation of a favorable investment climate, which goes beyond
tax incentives to include, even more fundamentally, guarantees of basic security and
property and contract protection;

Second, the presence of reliable public goods infrastructure -- especially roads,
electricity, and telecommunications -- that lowers the currently exorbitant costs of doing
business; and.

Third,. the availability at reasonable cost of know-how to identify investment
opportunities and address obstacles to bringing them to fruition. In this last connection,
private business promotion centers can play a pivotal role.

Realistically, Haiti cannot grow its way out of its food security problem fast enough to address
the problem in its entirety.- Population programs therefore will continue to be essential for the
foreseeable future.

In general, the proposed strategy recommends a conscious shift from a "welfare" to a
developmental perspective. Specifically, it argues for a change in policy.and program priorities
to nudge Haiti, over time, to growth rates high enough to lift substantial numbers of food
insecure people out of poverty. As part of that shift, it argues that the time has come to view
malnutrition as a problem calling less for reactive treatment and more for active prevention.
It also argues for a focus on secondary cities- and their surrounding countryside. \

Ur ization is on the march in Haiti, and shows no signs of waning. As urbanization
coiues, the percentage ofHaitians with limited access to social services can be expected o t
decline. Depending on the pace of economic growth, the_ number of poor people in rural areas
will decline as well. In urban areas, the number of poor people is likely to increase for the
foreseeable future. For Haiti's next generation, poverty will become increasingly an urban
phenomenon. Problems of urban growth and poverty will not be confined to Port-au-Prince, but
will extend to Haiti's secondary cities too.

'Strictly speaking, the proposed focus on secondary cities is not a necessary condition for growth.
In principle, Haiti's future growth could take place without it. Nevertheless, the current pattern
of growth, in which the Gulliver of Port-au-Prince lords it over the Lilliputians of the rest of
the country, is neither sustainable economically nor desirable socially: Some will argue that
development resources are simply too scarce at this time to "divert" them away from pressing
needs in Port-au-Prince. Migration to secondary cities is not a fad, however. It has been going
on for some tine, and, if anything, it will accelerate. The public policy question, therefore' is
whether it makes sense to go with the flow, so to speak, and accommodate what, by all
accounts, is a socially desirable evolution of demographic trends. The proposed strategy argues
that the time has come not only to accommodate it, but to encourage it.

Empirically, when the strategy talks about "secondary cities,"' it is referring to four
"intermediate cities" and five "market and district towns." The four intermediate cities are Cap

1Jen- Goinaives. Saint Marc, and Les Cayes. The five market and district towns are VWrettes,
J6r6mie, Port-de-Paix, Limb6, and Jacmel.

'The strategy's overall policy and program priorities are summarized in Tables A and B. Table
A presents recommended policy measures, while Table B presents recommended program
actions. In each case, a phasing of the implementation of the recommendations is suggested over
two periods, from 1996 to 2000 and from 2001 to 2010. As one might expect, the
recommendations for the latter period are more generic than those for the former.

Priorities specifically for USAID are a natural outgrowth of the overall priorities outlined in
Tables A and B. In addition to promoting the policy reforms outlined in Table A, the strategy
recommends that the Mission finance program actions consonant both with the priorities
indicated in Tables A and B and with its own comparative advantages. Table C summarizes
the kinds of program actions to which the strategy recommends the Mission give priority.

In overview, the strategy recommends two initiatives that will call for budgetary allocations
significantly higher than what they command at the present time. Otherwise, the strategy sees
implementation of the strategy entailing sharpening and refocusing of activities currently
underway and planned for the future.

The two initiatives that will demand significantly more resources are:

* Policy analysis, dialogue, and reform. Putting the proposed strategy in action will
*require the collaboration and contributions of other parties, especially the Government
of Haiti and other donors. As a result, the Mission will need to dedicate considerable
personnel time and at least a modicum of technical assistance resources to convince
counterparts of the merits of the actions proposed, to formulate options for
implementation, and to assist the government in translating them into action.

Support for private business promotion centers in secondary cities. As indicated above,
the strategy sees the creation of business promotion centers as the critical third leg of the
productive investment expansion triangle.The centers would service not only secondary
cities, \ut their surrounding countrysides\ Under the assumption that four offices are
phased in over the next five years andmat each office will require financial support in
the neighborhood of $750,000 a year, the five-year price tag of this initiative would come
to approximately $12 million.

To a very large extent, the activities currently conducted under the Mission's economic growth
strategic objective also contribute in a significant way to the improvement of food security in
Haiti. Nevertheless, the strategy suggests a number of shifts in emphasis to enhance their impact
both on food security and on growth per se:

* First; the balance in the attention given to policy measures and program actions needs
to shift more toward the former.


Second, at the moment much of the Mission's day-to-day management attention is given
to agricultural concerns. Obviously, agricultural development is essential to Haiti's
Future growth, but. by itself, it will not be sufficient to generate the increases in incomes
Sand jobs needed to make a major dent in Haiti's food security problem. The Mission's
sphere of action must be broadened consciously to include non-agricultural income- and
job-generation possibilities -- for example, light manufacturing and service industries.
Especially in secondary cities.

Third, the Mission's concern for microenterprises -- be they urban microbusinesses or
small farms -- must not blur the necessity of thinking bigger. As laudable as the focus
on microenterprises may be in many ways, realistically it will go only so far irr
generating jobs for the numbers of poor Haitians who need them. To create substantial
numbers of jobs, Haiti needs to promote business activity across the board.

The strategy recommends that the Mission use food for work under PL 480, Title II, and cash
for work under PL 480, Title III, to construct and rehabilitate productive infrastructure,
especially rural access roads. By choosing to concentrate Title II and Title III resources on
roads that tie into selected secondary cities, the PL 480 program not only would provide jobs
for those who need them; it also would contribute directly to broader strategic goals. The same
goes for the use of food and cash for work in the construction and .rehabilitation of social
infrastructure, especially potable water and sanitation facilities -- again, in secondary cities.

In addition to adding to Haiti's food supply and generating local currency revenues for use in
development activities, Title III typically includes policy conditionalities. The strategy
recommends that Title I contribute directly to the policy dialogue and reform process stressed
above. Table D suggests objectives and gives examples of conditionalities the strategy considers
particularly germane.

To achieve its public health, food security, and education strategic objective, the Mission has
sing out three areas for priority attention: first, r auction in malnutrition, largely through
the delivery of integrated packages of health services; second, increase in access to reproductive
health services; and, third, improvement in the quality and efficiency of primary education. The
strategy has no quibble with these priorities. It does, however, highlight key priorities.

Improvements in health are essential to improve the biological utilization of food, to reduce
malnutrition, and to increase labor productivity -- all components of improved food security.
These considerations argue for continued commitment by USAID to improve the quality and
availability .of primary health care in Haiti.

The strategy endorses the UCS model for the delivery of a minimum package of health services.
Components of the minimum package especially important from a food security/nutrition
perspective include: immunizations and vitamin A supplements; health and nutrition education,
including growth monitoring and education in appropriate breast feeding and weaning practices;
treatment of sick children (including treatment of diarrhea, respiratory infections, tuberculosis,
and parasites); family planning; and prenatal and maternal care.

The strategy endorses Mission plans to increase the use of Title II food resources to support the
primary health care program. Food cannot be expected to have much of an impact on child
nutrition on its own. The strategy therefore recommends that Title II food be integrated as much
as possible with other Mission-supported primary health care activities and only used in
situations where the other components of the minimum package are available.

It is recommended that Title II resources be targeted to that portion of the population most
vulnerable to the effects of malnutrition. This population includes pregnant and lactating
women and children under two who are malnourished or at risk of malnutrition. Encouraging
pregnant and lactating women to avail themselves of better prenatal and maternal care and
broadening eligibility to include children at risk will help change the focus of the program
from nutritional rehabilitation to malnutrition prevention.

The strategy also recommends that priority attention be given to:

* Increasing immunization rates in the short run

* Improving child feeding practices

* Development of weaning foods

* Implementation of a vigorous family planning program as part of the minimum package
of services

Improving basic education in Haiti is key to improving food security, although it naturally takes
time to see its effects. The strategy believes it is important for USAID to continue its support
to the education sector at least until planned World Bank and IDB programs come on board.
The Mission's support is especially important because of its focus on the private sector, which
currently accounts for 66 percent of enrollment in primary schools, 86 percent of the schools
themselves, and 70 percent of teachers.

The strategy endorses the Mission's plans to phase down the use of Title II food in school
feeding programs. As the Mission does so, the strategy suggests that improvement of the quality
'of education become the primary concern. Program options include: (1) changing the way
schools are selected to participate in the program -- one possibility might be to require schools
to compete for inclusion in the program, making eligibility for food a function not only of need
but also of demonstrable evidence that schools are taking steps to improve the quality of the
education they offer; (2) changing the criteria for expelling schools from the program -- giving
higher priority to factors such as the absence of teachers and books than to small discrepancies
in food stocks; and (3) changing the time that feeding takes place -- providing food to children
early in the school day so that it can have an impact on improving attention in class and,
thereby, improve learning.

On targeting, food insecurity can be found virtually anywhere in Haiti. For that reason, the
strategy does not look to geography, per se, as a guide to program targeting. There are,
however, other ways to target. The principal criteria proposed in the strategy are:

S Nutritional vulnerability children less than two years of age and pregnant and lactating

S Relationship to priority secondary cities

S Self-targeting nature of interventions -- food for work, for example

S Seasonality focusing on lean periods

1996-2000 2001-2010
Rationalize and make investment incentives Refine and maintain investment incentives
'Institutionalize procedures for resolution of Refine and maintain procedures
business disputes
Reduce tax exemptions and improve Expand tax base and improve enforcement
Privatize electricity, telecommunications,
and ports
Implement current tariff policy Adopt uniform tariff policy
Make support to agriculture evenhanded Continue evenhanded and transparent
and transparent policy
Make family planning a clear national Continue to make family planning a clear
priority national priority
Government assumption of responsibility Continuation of government responsibility
for orphanages, old-age homes, etc. for orphanages, old-age homes, etc.;
funding of greater portion of FAES and
minimum package of health services
Explore options for regularizing property Regularize and refine property rights,
rights, water, and finance policies water, and finance policies
Institutionalize joint government-donor Continue joint programming of local
programming of all local currency currency generations; as the economy
.generated under food aid programs improves, gradually phase out food aid

1996-2000 2001-2010

Rehabilitate and maintain major trunk roads Complete rehabilitation of trunk roads;
rehabilitate major access roads; maintain
all roads rehabilitated

Develop private business promotion centers Expand private business promotion centers
in four major secondary cities to additional secondary cities; gradually
phase out external support
Increase focus of social sector activities in Continue to focus social sector activities in
secondary cities secondary cities
Expand current focus on microenterprises Maintain expanded focus
to promote business activity across the
Improve quality of primary education Raise primary school efficiency; improve
quality of secondary and technical
Increase UCS coverage to 60% Gradually increase UCS coverage to 95%
Target PLUS-like interventions in strategic Continue to target PLUS-like interventions
watersheds; expand commercial orientation in strategic watersheds; continue
of program commercial orientation of program

Productive Sector Social Sector
Program Actions Program Actions

Support of business promotion centers in Support for development of UCS system
-secondary cities
Support for other programs that make Complementary support for immunization
investment attractive and lower costs of campaigns
doing business
Support of income-generating activities, Complementary support fcr education in
including micro- and other enterprises child feeding practices
Cash and food for work in rehabilitation Development of weaning foods specifically
and maintenance of productive for Haiti
infrastructure, especially roads
Support of PLUS-like interventions in Promotion of family planning
strategic watersheds
Support for formalization of property rights Support for improvement of primary
and business activity in secondary cities education, including through school feeding
Cash and food for work in social
infrastructure, especially potable water and

Cap Haitien


Saint M




Executive Summary


1. Introduction

1.1. Objectives of the Food Security Strategy
1.2. Definition of Food Security

2. Definition of Haiti's Food Security Problems

2.1. Food Availability
2.2. Food Access at the Household Level
2.3. Food Utilization

3. Potential Magnitude and Nature of Food Insecurity in the Future

3.1. Overall Demographic Trends
3.2. Geographic Dimensions
-3.3. Implications of Growing Urbanization for Poverty
3.4. Emigration: A Mixed Blessing

4. Constraints to Food Security

4.1. Economic Policies
4.2. Social, Political, and Institutional Factors
4.3. Productive Sector Constraints
4.4." Social Sector Constraints

*5. Proposed Food Security Strategy

5.1. Central Foci
5.2. Vision of Haiti in 2010
5.3. Principles for Setting Food Security Priorities
5.4. Major Development Choices
5.5. Future Policy and Program Priorities for Food Security in Haiti
5.6. Future Policy and Program Priorities for USAID

Appendix Functions of Cities



The strategy presented in this document is the outgrowth of an exercise conducted part time
over four months by personnel from USAID/Washington's LAC TECH Project and three
other organizations, the Centre d'Analyse des Politiques de Sante, the Futures Group, and the
South-East Consortium for International Development. The strategy is first and foremost a
strategy for USAID. Nevertheless, its policy and program Tecommendations are not actions
that USAID can adopt in isolation. Ultimately, the success of the strategy will hinge heavily
on the degree to which the Government of Haiti, other donors, non-governmental
organizations, and other interested parties -- all of whom the team consulted during the
preparation of the strategy -- agree with its recommendations and endorse them. To put it
succinctly, therefore, the proof of the strategy's pudding will be in its eating.

The scope of work established for the team- was daunting. In brief, the team was charged
with examining the status of food security in Haiti, with identifying the major obstacles to
improving food security, and with defining appropriate policy and programmatic responses.
As discussed in the text, food security was defined in sweeping terms, encompassing the three
rubrics of availability, access, and utilization. As a practical matter, therefore, the team's
tasks ranged from an assessment of macroeconomic policies, to an examination of the
workings of productive and social sectors, to attempts to understand the dynamics of intra-
household behavior.

The conceptual and programmatic sweep of the strategy has made the past four months very
exciting. At the same time, the experience has been very humbling. In the final analysis, the
development of a strategy comes down to making choices, to sticking one's neck out and
saying that some policy and program actions are more important than others. The strategy
team has tried very consciously not to shy away from that task. Given the brevity of time at
the team's disposal, the authors are painfully aware of how lightly. they have touched on a
number of important topics, of the fragility of the empirical foundation for some of the
strategy's conclusions, and, in general, of how much they still do not know. On the other
hand, the team is encouraged by the consistency of the strategic directions that have emerged,
and it believes that they constitute a compelling policy and programmatic package for the

The authors are indebted to a broad range of institutions and individuals, both in and outside
Haiti, for their openness, collaboration, and guidance during the preparation of the strategy.
Although it is impossible to name them here, the team owes them all a profound intellectual
debt and wants them to know how much their contributions are appreciated. The team is
particularly indebted to USAID. It is rare that a team receives such strong urging to "break
out of the box," that is, to reexamine common assumptions about development and, if it
reaches conclusions that depart from conventional wisdom, to say so. For better or for
worse, this document does just that.



The food security strategy presented in this document has three objectives:

* To define the nature and scope of food insecurity in Haiti;

* To identify the major constraints to improving food security; and

* To assist USAID/Haiti in defining appropriate responses to Haiti's food insecurity.


The definition of food security used in this strategy is:

Food security is access by all people at all times
to enough food for an active and healthy life

This is the definition of food security popularized by the World Bank. It also is the definition
used in the Food, Agriculture, Conservation, and Trade Act of 1990, which made important
changes in the U.S. international food assistanceprogram. USAID's 1992 Policy Determination
Number 19 defines food-security as "when all people at all times have both physical and
economic access to sufficient food to meet their dietary needs for a productive and healthy life."
Both definitions emphasize the accessibility of food or effective demand. This contrasts with
earlier definitions that focused more narrowly on food availability or supply.


Current definitions of food security encompass three basic elements: availability, access, and
utilization. The three elements are recognized widely within the international community as
capturing the major dimensions of food security, and, therefore, will be used to assess the food
security problem in Haiti.

* Food Availability

Food availability can be a problem at the national, household, or individual level. A
country cannot achieve food security unless available food supplies are sufficient to
supply every person in the country with an adequate diet. The food supplies necessary
can be produced domestically; they can be imported commercially or through


concessional aid programs; and, in the short-run, they can be drawn from stocks. Food
availability also can be a problem at the household or individual level. If food supplies
are inadequate at the national level, there is not going to be enough food available to feed
all households and all individuals, even if distributed equally among them.

In a world increasingly integrated through trade and political-economic ties, global
availability of food is of increasing importance to household food security. Availability

also requires relatively smooth market operations, functioning infrastructure, and a free
flow of information.

Food Access

Achieving food security in a country also requires that households have the ability -- that
is, the purchasing power -- to acquire sufficient food. Some households will be able to
produce sufficient food to feed themselves. Others will have to rely on earnings from
farm and non-farm activities or on income transfers, food subsidies, etc., to be able to
purchase a nutritionally adequate diet. Food, in other words, is a commodity, access to
which is governed by the same factors that govern access to any other commodity. That
is why poverty and food insecurity are so closely linked. Access also is a concept that
has relevance at the national level: if countries earn sufficient foreign exchange from
\ exports of goods and services, it doeno matter if they produce enough food to feed
S their populations adequately. They can buy it on the international market.

Food Utilization

People also can be said to experience food insecurity when they fail to consume proper
diets, even when food is available. Similarly, food insecurity can occur when people
consume proper diets, but poor health stands in the way of their bodies absorbing
sufficient nutrients. Given food accessibility, improper food utilization is the result of
personal tastes, culture, peer pressures, lack of knowledge, inadequate household
processing and storage, inadequate food labeling, misleading advertising, and lack of
access to or utilization of health, water,and sanitation services.


In theory, two types of food insecurity -- chronic and transitory -- can be distinguished, but,* in
reality, they are closely intertwined. Chronic food insecurity is consistently inadequate diet
caused by inability to acquire food. It affects countries and households that persistently lack the
ability to acquire food, whether by producing it themselves or by buying it, bartering it,
borrowing it, sharing it, etc. Chronic food insecurity is rooted in poverty. Transitory food

insecurity, on the other hand, is a temporary decline in a country's or in a household's access
to food. At the country level, it results from instability in food production or in export earnings.
At the household level, it results from instability in production, household incomes, employment,
or food prices. In its worst form, transitory food insecurity can result in famine. Typically it
is the chronically food insecure who are hit hardest by transitory food insecurity problems.


Food security differs from:

* Food Self-Sufficiency

Food security does not mean food self-sufficiency. Since most foods can be traded
internationally, national self-sufficiency only makes sense when a country has a
comparative advantage in producing them. In addition, food security is achieved only
when all households have the ability to(bu food. Thus, there is no necessary link
'between food self-sufficiency and food security. In fact, empirical studies tend to
confirm that food self-sufficiency has no intrinsic value in eliminating chronic food
insecurity. In some countries, excessive concern with food self-sufficiency has led to
costly and uneconomic investments. The investments have tended to undermine, not only
per capital income growth, but also food self-sufficiency itself, by diverting resources
from otherwise productive uses.

Agricultural Development

Food security focuses on who the food insecure are and how to promote their access to
food. In many cases, one of the better ways to promote access of the food insecure to
food is to stimulate agricultural productivity and growth. Additionally, since demand for
rural non-farm goods and services often stems from the agricultural sector, food security
may depend in part on increased agricultural growth. Even in rural areas, however, the
S needto find ways to assist households at risk to generate additional income quickly
moves the scope of analysis and action beyond the agricultural sector into more
generalized rural growth.

Broadly Based Economic Growth and Poverty Alleviation

Combatting food insecurity requires more than a commitment to broadly based economic
growth and poverty alleviation, although the three are closely related. A strategy
directed to the achievement of broadly based, economic growth differs from a food
security strategy in its geographic scope and in its time frame. In the first case, the
scope is countrywide and the time frame is.long-term; in the second case, the strategy

is more location-specific and medium-term. A strategy directed toward poverty ,
alleviation, like a food security strategy, also will be targeted to the poorest geographical '
regions, occupations, ethnic groups, etc., but, like a strategy to achieve broadly based
economic growth, will be oriented toward the longer term.

Feeding Programs

Feeding programs do not food security make. Rather, they are one particular response
to a food security problem. Their geographic focus is location-specific and their time
frame is immediate.


Food insecurity is not a new problem for-Haiti. Inadequate food availability, lack of food
access, and improper food utilization all are chronic problems.



Total food supplies at the
national level have been
inadequate for many 2400 clones er ersonperDay
years. According to recent
FAO data, per capital 2300 1 11 1 11
calorie supplies fluctuated 2200
between 1,900 and 2,100 2100
calories per person per day 200o
during a 25-year period -
1961 to 1986. This stands 19oo
in sharp contrast to the 1too
2,270 calories per person 1700
per day, which is the level
recommended given the 1061 1966 1971 1976 1981 1986 1991 1996
"age and sex composition of
the Haitian population.
Figure 1: Trends in Calorie Supplies
Recent trends in food
supplies also have been negative. Per capital calorie availabilities began to decline dramatically
in 1987 and stabilized at a new low of around 1,700 calories per person per day between 1991
and 1994. Protein supplies, which had been available in adequate amounts at the national level,
also began to decline in 1987, according to FAO food balance sheet estimates. One recent
estimate, which places per capital calorie availability at 2,108 calories in 1995, suggests that the
food supply situation may be recovering to earlier levels. But this is only one estimate, the
methodology used to construct it is not totally compatible with the FAO estimates, and it still
is too early to determine whether recent improvement represents a trend.

Low levels of per capital food availability are the first indication that a country is having
serious food security problems. When per capital food availability is low, the total amount of
food available in the country is not sufficient to provide everyone with enough food for a healthy

life even in the unlikely event that the food were to be divided equally among all members of /
the population.

The amount of food available in a country is not, strictly speaking, the same thing as supply.
In fact, it represents the intersection between supply and demand for food. Explanations for
Haiti's poor performance with respect to calorie availabilities, therefore, include factors on the
supply side, including low and declining levels of agricultural productivity. Factors on the
demand side also are extremely important, however, particularly the chronic poverty of Haiti's
people, which translates into low levels of effective demand for food by the poor. Political and
economic turmoil exacerbates poverty as well as the low levels of productivity in the country..


The quality of the Haitian
diet has deteriorated. car ni
Haitians continue to get the 40.7'
largest percentage of their
calories from basic grains
(see Figure 2). Still, the
absolute number of
calories coming from 14.3%
grains. has declined Mise
substantially from an
average of 900 calories per
person per day in the early MRots.Ma
1960s to an average of 700 ".5% oa
calories per person per day F. nsi~V Pui.,s 6.3%
during the period 1992- 8.4% 7.2%
1994. The low was
reached during 1987-1992, Figure 2: Composition of the Haitian Diet
when grains supplied an
average of 650 calories. Rice now is the most important grain, accounting for 40 percent of
total calories coming from grains, followed by wheat (32 percent) and corn (20 percent). On
the other hand, the percentage of calories derived from sugar, which is the second most
important product in the Haitian diet, has increased. So too have the absolute numbers of
calories from sugar, from an average of 235 calories per person per day in the early 1960s to
an average of 250 calories per person per day in 1993/1994. The absolute number of calories
coming from meat, milk, and eggs also has decreased, from a high of 110 calories per person
per day in 1987 to around 80 calories per person per day in 1994. Another indication that the
quality of the Haitian diet has decreased is the fact that the percentage of the protein derived
from animal sources has declined from a high of 20 percent in 1987 to 16 percent in 1994.


The diversity of the diet also has deteriorated. At the national level, Haiti now gets its calories /
from a smaller number of commodity groupings than in the past. Information from the recent
baseline surveys conducted by CARE in the Northwest and CRS in the South provides evidence,
at the more micro level, of the reduction in the diversity of diets in rural areas. The reduction
in diversity occurred both on individual farm plots and in the availability of wild plants that rural
households also rely on to a greater or. lesser degree for part of their everyday subsistence needs.
Having to rely on a more limited number of commodities to make up the major sources of
nutrients is not desirable from a nutritional point of view and makes the country as well as poor
households more vulnerable to food insecurity.


Total and per capital food
production have decreased
in recent years (see Figure Index (1961=100)
3). Total food production 18o
increased fairly steadily at 6o Total Production
an average annual rate of
1.9 percent between 1961 140
and 1986. Since the 1
population was growing at 120
approximately 1.7 percent 0, +
per year during that Per Capita Production
period, however, per 80
capital food production
stagnated, growing at only 6o I : I
0.2 percent per year. In 1961 1966 1971 1976 1981 1986 1991 1996
0.2 percent per year. In
1987, a year after the
government initiated some Figure 3: Trends in Total and Per Capita Food Production
far reaching economic
reforms, total food production began to decline, and continued to decline at approximately two
.percent per year until 1995. Since the population also was growing at a rate: of over two percent
per year during that period, per capital production declined at an even faster rate -- four percent
per year.


The rate of population growth has accelerated from 1.7 percent in the 1960s and 1970s to over
two percent peryear in the 1990s. In absolute terms, population is increasing by about 150,000
people each year. This trend will continue over the next 15 years as a consequence of the
present youthfulness of the Haitian population, persistent high fertility, and declining mortality
rates. In fact, even if a strong reproductive health and family planning program were

implemented quickly and emigration continued at approximately 20,000 people per year, Haiti's /
population would increase by nearly two million people by the year 2010, from an estimated 6.8
million people in 1996 to 8.6 million fourteen years later.

Population growth has outstripped growth in the economy as a whole as well as in the
agricultural sector. It also has made it harder to finance social services. Population density has
increased significantly in many areas, which has had an adverse effect on the environment.
Large increases in urban population in Port-au-Prince, in particular has put tremendous
pressure on limited infrastructure and services. At the household level, food security also is
affected by household size, and close birth spacing is highly associated with increased risks of.
malnutrition and death".


Cassava and yams and
bananas and plantains are
the most important food 1000 LOOMetric Tons
crops from the perspective
of volumes of production 8 Cassava and Yams
(see Figure 4). Production '
of these crops increased 6
fairly steadily until the
beginning of the 1980s, but
has stagnated since then.
Total production of 0 Bananas and Plantains Grains
grains, on the other hand, Beans
has declined, as has per __"""'" "
capital production. Total 96I 1966 197 1976 1981 1986 1991 1996
grain production declined
from a high of over
560,000 metric tons in Figure 4: Trends in the Production of Selected Food Crops
.1972 to around 370,000
metric tons in 1993-1995. In per capital terms, domestic production supplied over 120 kilograms
of grain per person per year in the early 1960s. By the early 1990s, the figure had declined to
50 kilograms. In percentage terms, total production declined by one third between 1972 and
1993-1995, and per capital production declined by almost 60 percent.

The relative importance of different grains also changed over time (see Figure 5). Domestic
rice production has increased in importance, supplying over 20 percent of domestic grain
production in the 1990s, compared to around 12 percent in the early 1960s. Sorghum
production, on the other hand, has decreased in importance, supplying only 20 percent of grain
supply in the 1990s, compared to almost 40 percent in the early 1960s. Production of corn,


* The second season,
which runs from
September through

* The third season
(dry season), which
runs from January
through May

The second season is the
most productive in
quantities of food
produced. The third
season the dry season --
is the least productive.


First S

,000 Me


*tric Tons

Second Season

Third Season

Figure 6: "Normal" Food Production By Season


One result of the declining"
production trends has
been an increased reliance
by the country on imports
to meet domestic food
needs. The cost of
imported food averaged
$200 million a year at the
beginning of the 1990s,
double the average cost of
the food import bill at the
beginning of the 1980s and
twenty times the value of
the food import bill at the
beginning of the 1970s.

1~LA-C -jil~r

Grain imports, in Figure 7: Trends in Grain Production and Imports
particular, increased
substantially, from approximately ten percent of the total grain supply in the early 1960s to
almost 50 percent in the 1990s (see Figure 7). Until the end of the 1980s, wheat accounted for
the major share of grain imports -- almost 100 percent between 1961 and 1974 and between 80
and 90 percent between 1975 and 1989. Rice imports, however, more than quadrupled in
volume terms between 1989 and 1990, and by 1994 had surpassed wheat imports in value ($46.5
million versus $36 million), though not in volume (140,000 metric tons versus 167,000 metric



which was declining in the
1970s, began to increase
again in 1990-1991 during 1.000MetricTons
the period of the embargo.
250 --
Total grain production Corn
declined as a result of 200
declines in both yields and Sorghum
area planted. Rice
production, on the other oo.
hand, continued increasing ,,Rice
until 1991. The area so-
planted to rice increased
fairly steadily until the 1961 1966 1971 176 1981 1986 1991 1996
beginning of the 1990s.
Yields of rice, which uses
more modern technology Figure 5: Trends in Grain Production
on irrigated land, are
approximately double the yields of corn and sorghum. At their high, in the mid-1980s, average
rice yields reached 2.4 metric tons per hectare. After the 1986 policy changes that reduced
protection for basic grains, however, rice yields also began to decline. By 1995 they had fallen
to an average of 1.6 metric tons per hectare.

Grain production is much lower in the arid regions of the country -- the departments of the
Northwest, the Northeast, and the Southeast. Differences in productivity also exist within
regions, often as a result of irrigation. For example, the irrigated Artibonite Valley is much
more productive than the dry area of Savane Desol6e. In the Northwest, the dry Plaine de
l'Arbre is much less productive than the irrigated banana producing area of Jean Rabel.

Since most agriculture in Haiti is rainfed, food production also varies by season, according to
the different rainfall patterns in different parts of the country. In the South, there are two rainy
seasons April through June and August through October -- separated by a short dry season in
July and a long, cool dry season from November through April. In the North, there is a long,
cool rainy season from September through June. In the Center (Artibonite and Central Plateau),
there is a four- to six-month rainy season from April through September and a long dry season
from October through March.

These differences translate into three production seasons for the country as a whole (see Figure

* The first season, which runs from June through August


tons of wheat and wheat flour). For years, most wheat was imported in grain form and milled
locally. When the government-owned flour mill closed down in 1993, however, imports of
wheat flour replaced wheat.

The corollary of these trends on the consumption side has been an increase in the number of
calories per person derived from wheat, which is imported, and a decrease in the number of
calories derived from corn and sorghum, which is grown domestically. In the national diet,
the number of calories from imported wheat tripled over the last 30 years, while the number of
calories from corn declined to only a third of what it was 30 years earlier.


The fact that Haiti has
increased its dependence
on food imports would not 50 ,00 Metric Tons
have been a problem if the
country had been able to 400
afford to import those
supplies commercially. 30o
Nevertheless, poor Total Volume oGrainImported
economic performance, 200
coupled with the additional
food needs created by .
periodic natural disasters,
has resulted in Haiti ohnme of Grain Donat
becoming more reliant on 1972 1977 1982 1987 1992 1997
donated food to meet its
food import needs.
Figure 8: Trends in the Volumes of Grain Imported
Since the early 1980s, Commercially and Donated
Haiti has received on
average of 100,000 metric tons of food aid a year. The main food aid products have been
wheat/wheat flour, bulgur, pulses, corn, and rice. In most years, these products accounted for
over 90 percent of all food aid provided to Haiti. About two thirds of food aid has been
distributed directly to beneficiaries rather than through market sales.

The United States, which has provided donated food to Haiti since the initiation of the PL 480
program in 1954, has been the mqjor supplier offood assistance to Haiti in most years. The
value of food resources provided to Haiti was fairly small until 1977 when the addition of a $10
million Title I program brought the total resources provided to the country to approximately $20
million. In 1991, a $20 million Title III program increased the value of food resources made
available to Haiti to almost $30 million. In 1993 and 1994, during the height of the embargo,
the total value of food resources made available to the country through the Title II and III


programs exceeded $40 million. At the height of the emergency program, one estimate was that /
U.S. food assistance was helping feed over a million Haitians a day.


Haiti does not have to
produce all its own food in
order to insure food Million U.S. Dollars
security for its population. 2
Food self-sufficiency, in 200
other words, is not
other words, is not 2Agricultural Imports
necessary to the 1
achievement of food
security. Nor is it a
reasonable objective for
the country to aspire to.
Agricultural self-
sufficiency also is not AgriculturalExports
necessary for food 1961 1966 1971 1976 1981 1986 1991
security. There is no
reason that Haiti has to pay
for the food imports it Figure 9: Trends in Agricultural Trade
needs with the foreign
exchange earned from agricultural exports.

In fact, Haiti has not
earned enough from its
agricultural exports to pay
for its agricultural imports Million U.S. Dollars
since the mid-1970s. The
cost of the country's 0 AgrIcultural-Trade
agricultural imports (most -o0
of which are food imports) .100
has significantly
outweighed the value of -0so Total Trade
the country's imports since .200
1979 (see Figure 9), and .250
its overall trade balance .300
has been negative since
1967 (see Figure 10). 1961 1966 1971 1976 1981 1986 1991 1996

On the other hand, self-
reliance is a reasonable Figure 10: Changes in Haiti's Trade Balances Over Time


* ,

objective for Haiti to aspire to. There is no reason Haiti should not be able to pay for the food /
imports that it will need, particularly grain imports, if the government provides the kind of
stable and supportive economic and political framework needed for broad-based economic
growth. The important question concerning food aid is not when food donations can begin to
be replaced with domestic production, but when the economy will develop sufficiently so that
concessional imports can be replaced with commercial imports paid for by foreign exchange
earned by exports of both agricultural and non-agricultural products.


The mqiority of the
Haitian population does
not have access to
sufficient food for a
healthy and productive cALOR.s
ife. Household access,
not national average is
the real test of food
security in a country. The
clearest evidence of this PROTmN
dimension of the food
security problem in Haiti \
comes from the data from O. 2%. 40. 6. sw,. o0%.
the 1987 Household PTrcC To
L..es T T 5b 4 0350 To 75MY 75 To < 100, A Least 100W/
Expenditure and
Consumption Survey
(HECS). According to Figure 11: Distribution of Per Capita Calories and Protein as
these data, in 1987 a Percent of Recommended Levels
approximately 70 percent
of Haitians did not have access to sufficient calories (defined as 100 percent of recommended
leves), and approximately 50 percent did not have access to sufficient protein. Even worse,
-nearly 50 percent of Haiti's household members had access to less than 75 percent of the
recommended levels for calories and 36 percent had access to less than 75 percent of the
recommended levels for protein (see Figure 11).


The most significant factor limiting access to food in Haiti is the very low purchasing power -
or lack of economic access of the Haitian population. According to the 1987 household
survey data, over 85 percent of households with total annual expenditures of less than 2,000
Gourdes (about U.S $320 in 1987 dollars) consumed less than 75 percent 6f the recommended
daily allowance of calories. For households with total expenditures between 2,001 and 4,000


Gourdes, the figure was 68
percent, and for
households with total
expenditures between
4,001 and 6,000 Gourdes,
58 percent. Only at
expenditure levels of
12,000 Gourdes or more
did a majority of
households consume at
least 100 percent of the
RDA (see Figure 12).
Although the survey has
not been repeated in recent
years, it is doubtful that
economic access has
become any easier for
most households, given the
declines that have taken
place in per capital incomes
and food availability.

0% 20% 40% 60% 80% 100%
iLess Th 50%S00 To 75y/675 To < 100At Lewt 100%

Figure 12: Ability of Households at Different Income Levels to
Access 100 Percent (or Less) of the Recommended Daily
Allowance of Calories


Poverty and food insecurity in Haiti are inextricably linked, definitionally as well as functionally.
Households that do not have sufficient income to access a nutritionally adequate diet are, by
definition, extremely poor. Poverty contributes to food insecurity in Haiti by restricting
people's access to the amount and quality of food they need to live healthy and productive
lives. Poverty also constrains households' access to services such as health, water and
sanitation, and education. By increasing people's productivity, these services contribute to food
security in Haiti in the short, medium and long term.

Poverty and lack of purchasing power in Haiti also are the ultimate cause of low levels offood
availability in Haiti. If Haiti's poor households had enough purchasing power to translate their
nutritional needs into effective demand for food, domestic food production would increase and/or
foreign exchange would be used to pay for the food imports needed to make up any gap between
domestic production and total food needs.

As elsewhere, the root cause of poverty in Haiti is low productivity. Low productivity, in turn,
reflects inadequate investment in human and material capital and poorly developed, and even
abusive, public policies and institutions. Poverty, combined with increased population pressure
on land, also has contributed to further deterioration in the environment, especially soil erosion,
which has lowered agricultural productivity even more.



# 1 0-

In other words, chronic food insecurity is a major problem in Haiti, and chronic poverty is the
root cause of that problem. Both manmaae an natural causes alsnake Haiti vulnerabeto
transitory food insecurity. Haiti's food security situation worsened in the early 1990s as a result
of political instability and subsequent deterioration in the economy. The economic decline,
coupled with natural disasters such as the drought in the Northwest and a tropical storm in the
South, has led many to focus on the emergency -- or transitory -- aspects of Haiti's food security
problems rather than on their underlying causes. In reality, however, the households hardest
hit by transitory food insecurity problems are and will continue to be the households that are
chronically poor and food insecure.


If poverty is viewed primarily in terms of lack of income, then broadly based, employment-
intensive growth is the best way to reduce poverty and hunger. But poverty also can be looked
at in terms of lack of access to social services. When looked at in that light, the alleviation of
poverty necessarily involves well planned and sustained social sector spending.

Lack of access to social services, in fact, is both a consequence of poverty and a contributor to
poverty and food insecurity. Therefore, it is not surprising that in Haiti, most people who are
poor in economic terms also lack access to important social services such as health, water and
sanitation, and education. Only about 60 percent of the Haitian population has access to
primary health services, compared with an average of 74 percent for Latin America as a whole.
Only 15 percent of households have access to water in their own homes, either through a
municipal water system or from a household well. Thirty one percent have access to a public
fountain or well. Only four percent of households have access to a public sewerage system. The
rest either use latrines (53 percent) or lack facilities entirely. School enrollment is only about
48 percent. Literacy rates are low, 48 percent for men and 42 percent for women, the lowest
rates in the Western Hemisphere.

Poverty still is primarily a rural phenomenon (see discussion in Chapter 3), and access to
social services also is most limited in rural areas. For example, an estimated 45 percent of
'rural households are at least 15 kilometers from the nearest hospital, and 26 percent are at least
15 kilometers from the nearest health center. Some 71 percent of rural households report that
it takes them more than one hour to travel to the nearest health center. In rural areas, over 60
percent of households have to rely on streams or rivers for water, and only 40 percent of the
population has access to latrines. The rest lack sanitation facilities entirely. School enrollment
rates drop to 22 percent in rural areas.


Although the data base is weak, poverty in Haiti does not appear to be concentrated in easy-to-
identify geographical areas. Instead, what appears to be typical of Haiti is the great variation


in poverty levels both economic poverty and lack of access to social services within
departments, communes, towns, and even neighborhoods. The o in averages among
regions and departments is insignificant when compared to variations internally within much
smaller geographic units. Aid interventions aimed at some regions to the exclusion of others,
therefore, are bound to miss a portion of their targets.

Haitianfamilies have done an excellent job in adapting to economic difficulties by diversifying
their human and economic resources. As a result, it is difficult to find strong link between
poverty and specific geographical areas of the country or between poverty and the socio-
economic characteristics of households. One of the most important steps that most Haitian
households have taken to reduce risk and to increase their incomes is to iversifuytheir income
sources. Most households earn their incomes from a variety of sources. Even in rural areas, .
where most households derive some income from agricultural production, other sources of
income are likely to be very important. For example, agricultural production accounts for only
48 percent the largest share -- of all household income i the southern part of the country
(CRS baseline survey), and less than a quarter of all household income in the Northwest (CARE
baseline survey). Commerce also is an important source of income in rural areas. In the
Northwest, petty commerce, which traditionally is carried out by women, is the most important
source of income (28 percent), and over two thirds of the households surveyed engage in it. In
the South, commerce is the second most important source of income (32 percent), followed by
ariculural wage labor (23 percent) and migration (16 percent). Households in the Northwest
also receive a significant share of household income from sales of livestock (13 percent),
followed by wages from agricultural labor (nine percent) and migration (eight percent).

Classical economic theory sees migration as a mechanism that balances labor demand, incomes,
and the resource endowments of different areas. This theory is difficult to accept in Haiti.
Outmigration from rural areas and provincial towns does not make labor demand and incomes
rise there, and the fact that Port-au-Prince needs produce from rural areas does not necessarily
lead to prosperity in the hinterland. Migration simply is an expression, and a cause as well, of
the increasing concentration of resources in the capital city. Attempts to slow or redirect
migration always have failed; rural development leads to more, not less, migration. tu v-.

Selective migration between rural and urban areas, Port-au-Prince, and abroad has
reconstituted family networks in such a way that they now span different lliigl,
and economicpheres. ThisTar-flung risk aversion and income diversification strategy has three
important consequences: first, it reduces rural population pressure in relative terms; second, it
slows the fragmentation of landholdings; and, third, it reduces dependence on agricultural
production for survival, even for rural people. The coping strategies of the rural poor
themselves are nt necessarily, and certainly not exclusively, targeted at agricultural production
on eroded hillsides.

Haiti does not have a subsistence peasantry in the sense of a rural population that lives off the
land in relative self-sufficiency and independence. All Haitian farmers are linked to and
producefor and buyfrom the market. Eighty percent of farmers have some non-agricultural


income. The vast majority also are net food buyers. For example, according to the 1987 /
household survey data, only 12 percent of all food consumed by households in Haiti was by the
households who produced it. The poorest households were more dependent on what they were
able to produce for themselves than higher income households. Food produced and consumed
within households accounted for over 40 percent of the total food budget of Haiti's poorest
households, for example, while it accounted for only five percent of the total food budget of its
highest income households. On the other hand, even the country's poorest households, including
many in rural areas, depended on markets for almost 60 percent of their basic food staples..

This dependence on markets has two consequences. On the one hand, Haitian farmers are
subject to fluctuations in price and demand. Given poor storage technology, these fluctuations
tfreuently put farmers at a disadvantage. On the other hand, peasants profit from the rapid flow
of information and products in the internal market system. Whoever has buying power can be
food secure, wherever he or she may be living. This latter point may appear trivial, but it is
far from that. Within the confines of risk aversion, Haitian farmers strive for higher incomes,
not necessarily higher production, as a subsistence economy would require.


As indicated in Chapter 1, food insecurity can exist even when people have access to adequate
quantities of food. That can happen when poor health prevents people's bodies from absorbing
sufficient nutrients. This is the utilization dimension of food insecurity.

Nutritional status provides the most direct measure of food utilization (see the Note at the end
of the chapter for a description of alternative methods for measuring nutritional status). Low
nutritional status is an indicator of whether people are consuming appropriate quantities and
qualities of food. It also is an indicator of whether people's bodies are able, biologically, to
absorb the nutrients available. Changes in the nutritional status of pre-school children -- in their
height and weight -- are a particularly sensitive indicator of food insecurity. This is because
young children, particularly those less than 36 months of age, usually are the first in a household
to be affected by changes in food availability as well as in availability of time, sanitation, and
.health services.


In 1994, almost a third of children under five in Haiti were chronically malnourished,
according to data from the USAID-sponsored Demographic and Health Survey (EMMUS II).
That is, their height for age was less than minus two standard deviations from the median of a
health reference population (see Figure 13). This proportion falls considerably above the levels
of chronic malnutrition found in other countries in the Caribbean. In the Dominican Republic,
for example, only 19 percent of children under five are stunted. In Jamaica and Trinidad and
Tobago, the rate drops to five percent. In fact, only three countries in the Americas have


significantly higher levels
of chronic malnutrition
than Haiti, namely, Peru
and Honduras with 39 Ntonal
percent, and Guatemala
with 58 percent. PPort-1.Pince

Height for age is the bestther U
indicator of whether th bm
malnutrition is a chronic
problem. That is because u
it reflects the past as well o 10 20 30 40
as the current nutritional percent
status of a child. When mChronic (H/A Acute (W/H)
children do not get
adequate amounts of
nutrition during their first Figure 13: Incidence of Chronic and Acute Malnutrition
few years of life Among Children under Five in 1994
(regardless of whether the
cause is a lack of food in the household, poor child feeding practices, or poor biological
utilization due to illness), their growth is retarded and they appear too short for their age. These
nutritional insults are particularly important in young children, because they never are able to
recuperate fully the growth lost during those years. Moreover, even moderate nutritional insults,
when they occur frequently enough, can show up as serious growth retardation.

In 1994, eight percent of the children surveyed also suffered from acute malnutrition. That
is, their weight for height was less than minus two standard deviations from the median of a
health reference population. Acute malnutrition is a very serious problem since children with
it have a high risk of dying from it. Acute malnutrition is a more serious problem in Haiti than
in other countries in the Western Hemisphere, where even countries with high rates of
chronically malnourished children tend to have much lower (one to two) percentages of children
with low weight for age. Worldwide, Haiti's rate is lower than those found in a number of
South Asian and African countries such as Bangladesh (17 percent), Niger, Mauritius,
Mauritania, and Sri Lanka (16 percent), and Nepal and Sudan (14 percent).


Progress was made in reducing the prevalence of child malnutrition during the 1980s. Almost
40 percent of children under five were malnourished when the 1978 nationwide nutrition survey
was conducted. This rate dropped to 34 percent. in 1991. The percentage of acutely
malnourished children also had been declining; it was almost nine percent in 1978, but dropped
to 4.7 percent in 1990.


Malnutrition trends during
the 1990s are less clear.
By the end of 1994,
chronic malnutrition rates
had dropped another two
percent to 32 percent.
Acute malnutrition, which
is a measure of current
malnutrition, however,
increased to almost nine
percent at the end of 1994.
The open question is
whether the situation has
improved since the time of
the 1994 stress (actually,
the survey was conducted
at the end of 1994 and the
beginning of 1995), which
undoubtedly was a difficult

Figure 14: Changes Over Time in the Prevalence o
Malnutrition in Children Under Five

time for Haitian families. Preliminary analysis of data from a UNICEF-sponsored, nationwide
nutrition survey conducted in 1995 suggests that rates of acute malnutrition have declined -- to
6.3 percent while the rate of chronic malnutrition has increased -- to 36.3 percent -- no doubt
as a consequence of the higher rates of acute malnutrition the year earlier.

Another source of more
recent information on the
nutritional status of Haiti's
children comes from the
monthly reports that
USAID has prepared on
the state of the Haitian
economy. Information
from these reports
indicates that the
percentage of children
underfive with weightfor
age below standards
peaked in the latter half of
1994 (about the time of
the 1994 nationwide
survey), and has been
decreasing since then (see
Figure 15). Weight for
age is a composite indicator

Figure 15: Monthly Changes in the Prevalence of Malnutrition
Among Children Under Five

that picks up the impacts of both chronic and acute malnutrition,


4 .



-/A M 1978 1990 1994

Jan Jn Jan Jan Jan
1991 1992 I 1993 I 1994 I 1995 1196


although it is less sensitive to the effects of deprivation of small amounts of food over longer /
periods of time, which is the hallmark of chronic malnutrition. Health posts scattered around
the country report these numbers monthly. Changes in them could represent an improvement
in coverage rather than an actual increase or decrease in the numbers of malnourished children.


The greatest nutritional
threat to children takes
place between the ages of
six months and two years.
That is when the biggest
increase in the percentage
of stunted and acutely
malnourished children
takes place (see Figure

Two adverse events occur o0-6 6-11 12-23 24-35 "36-47 48.59
around the age of six Age in Months
months. The first is that IH/A +W/H -W/A
breastmilk ceases to be
sufficient to meet the needs
of the growing child. The Figure 16: Prevalence of Malnutrition by Age of Child
second is that the child,
who now is able to crawl, begins to explore ith environment and to put things into its mouth -
which leads to infections and diarrhea. The first two years of a child's life also are
characterized by a rapid rate of brain and physical growth that tapers off thereafter.
Consequently, children who are malnourished during those years never recover fully from the
effects of malnutrition. They do not recover the growth lost. Nor do they recover motor and
cognitive skills.


The monthly data on children's weight for age from USAID's monitoring system also indicate
that there is a significant relationship between the nutritional status of children and the season
of the year. The percentage of malnourished children increases most rapidly during the months
of June through October, and is highest in the months of August through December. These
seasonal changes in the prevalence of malnutrition only account for three percent of children
with low weight for age, however. Looked at the other way, at least 17 percent of children
under five are malnourished throughout the year.



DEFICIENCIES 20 Percent Chfldret Under Five With Low Weght-for-Age
20 /a
Serious micronutrient /1.
deficiencies also exist in 194
Haiti, including iodine 19.2
and Vitamin A deficiencies /
and iron deficiency ,.6 /
anemia. Iodine deficiency 18.4
appears to be more of a "1 /
localized problem (the 17.1
highest prevalence is found 17.6
in the West Department), 17AN MAR AP MAY JUN JUL AUG SEP OT NOV DE
whereas Vitamin A
deficiency and iron
deficiency anemia are Figure 17: Seasonal Changes in Malnutrition
more generalized
throughout the country. Anemia is a particular problem. In 1978, it affected over 40 percent
of children between 24 and 59 months of age, 36 percent of non-pregnant women, 35 percent
of lactating women, and 39 percent of pregnant women. Vitamin A deficiency, which is
associated with increases in the duration and severity of childhood illnesses, blindness, and
mortality, also is a serious problem.


Malnutrition is not a disease, and food is not its cure. Lack of access to food may not be the
only reason that people are malnourished. Improper and inadequate food utilization also may
be a problem. For example, pre-school children may not be eating adequately, not because food
is in short supply, but because their mothers do not follow adequate breast-feeding and weaning
practices. For some mothers, this may be due to a lack of knowledge. For others, it may be
a lack of time: they may have economic responsibilities to their families as a whole, for
example, that make it impossible for them to feed their children exclusively from the breast for
the first six months of their lives. Inadequate health and water and sanitation services also mean
that large numbers of people -- adults as well as children -- may not be healthy enough to absorb
all the nutrients available to them.

One model, around which a considerable amount of consensus has developed, posits that
improvements in nutrition are a function of three variables -- health, caring (which is particularly
important in improving the nutrition of small children), and food consumption (see Figure 18).
Improvements in household income also play an important role in the model, because with
higher incomes families are able to access more and better food and health services. Education
of mothers presumably affects the nutrition of the child through all four variables -- food


consumption (particularly
breast-feeding and weaning
behavior), income, health,
and caring. Health status Nutrion
is influenced by infections
(diarrhea, respiratory
infections, and, in the case Caring
of Haiti, measles), which, Fonsumto
in turn, are influenced by
the availability and
utilization of water and
sanitation and health Income Health
services (the availability
and use of vaccinations for
childhood diseases,
Vitamin A supplements,
and oral rehydration salts Figure 18: Improvement in Household Nutrition A Function
(ORT) are important of Food AND Other Variables
indicators for pre-school
children). Three fertility factors are most relevant to the nutritional status of children --
maternal age (under 20 years), parity (multiple births), and birth interval (less than 24 months).
By and large, these factors result in low birth weight (both premature and small-for-date births).
As noted in the Annex to this chapter, low birth weight is a marker of fetal malnutrition, and
low birth weight babies -- 12-18 percent of live births in Haiti, depending on the study -- may
account for as much as 65 percent of malnutrition in infancy and between 50-65 percent of infant
deaths (Boulos, gt aL, 1984). As a point of reference, Office of Technological Assessment data
indicate that the seven percent of low birth weight babies in the United States account for 60

Geographical Location (urban/rural)

Chronic malnutrition is a more serious problem in rural areas. In 1994, over 35
percent of children living in rural areas were chronically malnourished (EMMUS II),
compared to less than 21 percent in Port-au-Prince and 30 percent in all other urban
areas (see Figure 11). In addition, approximately three quarters of chronically
malnourished children live in rural areas. Thus, chronic malnutrition still is primarily
a rural problem. An analysis of the anthropometric data on a sub-sample of children in
the 1987 Expenditure and Consumption survey also found that living in rural areas has
a statistically significant negative effect on children's height and weight.


S Geographical Location (agro-ecological zones)

Knowledge of the relationship between malnutrition and agro-ecological zones is
partial. Initial analysis of the data from the CRS baseline survey in the southern part of
the country in March 1995 found the worst nutritional status in the humid mountain zone.
Initial analysis of the data from the CARE baseline survey in the Northwest in December
1993 January 1994 found the lowest mean height-for-age scores in the plateau dry zone,
and the highest in the interior dry zone. Interestingly, the CRS study notes that the
CARE analysis found no significant differences in nutritional status by agro-ecological
zone. These relationships need further study.

S Health Status

Infectious diseases are a major health problem in Haiti. To begin with, diarrhea -- which
leads to under-nutrition even when the total amount of food available is adequate -- is
very common among young children. According to the EMMUS II survey data, over
27 percent of the children included in the survey had diarrhea in the previous two weeks.
Within the group of children aged six to 23 months, which is the period during which
most chronic and acute malnutrition takes place, almost 45 percent of children suffered
from diarrhea during the two weeks prior to the survey. This is a particularly serious
problem from a food utilization perspective, because diarrhea causes loss of appetite,
physical weakness, loss of nutritional substances, and growth faltering (see discussion in
the Annex to this chapter). Epidemics of measles, meningitis, rabies, and anthrax also
are common, and tuberculosis is endemic. Immunization rates, on the other hand, are
very low. At the time of the EMMUS II survey, for example, over half of children
between the ages of 12 and 59 months had received some protection against tuberculosis,
DPT, and polio -- but only 26 percent had received the full three doses of the DPT and
polio vaccinations, and only 25 percent had been vaccinated against measles. All told,
only 15 percent of children had completed all recommended vaccinations. Less than 40
percent of children had received at least one dose of Vitamin A supplements.

These health factors are important, because children are more likely to be malnourished
if they have had diarrhea or diseases such as measles and upper respiratory infections.
Initial analysis of the CRS.baseline survey data found that children with diarrhea within
the last 12 months were more likely to suffer from all three measures of malnutrition --
stunting (chronic), wasting (acute), and under-nutrition. The CARE survey found that
children who had diarrhea within the last 24 hours were 2.5 times more likely to'be
wasted, and 61 and 73 percent more likely to be stunted and underweight, respectively.
Numerous research studies also demonstrate the relationship between malnutrition and
diseases such as measles and upper respiratory infections (see the discussion in the Annex
to this chapter). Nevertheless, the nature and importance of these relationships need to
be documented with analysis of national data (the EMMUS II data, for example).


Environmental Conditions

An analysis of the anthropometric data collected on a sub-sample of households in the
HECS survey found that households using either bottled water or in-home or in-yard
running water had better nutritional outcomes than households using potentially more
contaminated river water, well water, or public fountains. Additional analysis of the
EMMUS II data is needed to document these relationships further and to explore whether
similar relationships exist between types of sanitary facilities and malnutrition.

S Mothers' Education

Chronic malnutrition and under-nutrition are more prevalent among children whose
mothers have no education (38.6 percent). Among mothers who have primary
education, the percentage of chronically malnourished children drops to 27.7 percent, and
if they have secondary school education,- the rate drops to 17.1 percent (EMMUS II
data). Similarly, the higher the mother's education, the less likely she is to have an
under-nourished (that is, low weight for age) child.

S Child Feeding Practices

Poorfood utilization and malnutrition also is linked to inadequate and inappropriate
child feeding practices. The recommendation that children be breast-fed exclusively for
at least four and ideally six months, when it is followed, reduces the risk of infectious
diseases such as diarrhea. After four to six months, however, breastmilk becomes
insufficient and children have to be given other foods. Families may not understand that
children have unique nutritional needs at this age, including multiple feedings during the
day and a diet that includes food with high caloric density. Breast-feeding, although a
common practice in Haiti, is not always initiated on the day of birth and usually is not
exclusive. Infants often receive some liquid food before they are put on the breast.
Supplemental feeding also starts at a very young age -- one month after birth or earlier.
Again, this practice increases the risk of diarrheal diseases. In addition, the supplemental
foods provided do not always match the nutritional needs of the growing child. Observed
child feeding practices are thought to be influenced by a combination of factors. The
factors in question include the need for women to earn a living, lack of health and
nutrition information, and the fact that mothers do not take their infants to the field or
market. Still, the relative importance of these factors as determinants of child feeding
practices needs to be better understood, as well as how important child feeding practices
are as a determinant of child malnutrition.


* Household Income/Economic Status

Children from higher-income households are less likely to suffer from chronic
malnutrition and under-nutrition. Analysis of the anthropometric data collected in the
HECS survey found that per capital incomes, measured as total expenditures (a good
proxy for total household income in developing countries), had a statistically significant
and positive effect on children's weight and height. Initial analysis of the CRS data also
found that the presence of stunted and under-nourished children decreases significantly
with increases in total household expenditures. The CARE baseline survey analysis also
reports that the prevalence of stunted and under-weight children is related significantly
to the level of per capital income of the household. WHAT IS NOT KNOWN ABOUT THE DETERMINANTS OF

* The Relative Importance of Individual Determinants

As indicated above, it is known that certain health and income variables are associated
with higher rates of child malnutrition. What is not known is whether these variables
still arc important when one holds others constant. For example, the apparently strong
relationship between mothers' education and child malnutrition merely may be picking
up the fact that women from higher income households tend to be better educated and,
thus, it is the higher income, not the higher education, that is the more important

Some of the data needed to sort out the relative importance of different factors are
available from the EMMUS II and the CARE, CRS, and ADRA baseline surveys, but
they have not been analyzed thoroughly. To date, the data have not been subject to
multi-variate analysis.

The results of a multi-variate analysis would have important policy and programmatic
implications. If household incomes are the major determinant of child malnutrition, then
broadly based, employment-intensive growth is the best way to reduce malnutrition over
the medium to long term. In the short run, the most appropriate type of safety-net
program would be one that transfers income, through cash or food for work, for
example, to low-income households. On the other hand, if health factors, such as
illnesses or lack of access to health services are relatively important, then a
corresponding degree of attention would need to be paid to strengthening the health
system and improving the delivery and accessibility of primary health care services. In
that case, it might make sense to subsidize primary health care or to provide food
supplements to encourage households to make fuller use of the health system.


* The Etiology of Urban and Rural Malnutrition

The data indicate that the prevalence of malnutrition is higher in rural than in urban
areas. It is not clear, however, whether the same determinants of malnutrition are as
important in rural areas of the country as they are in urban. For example, is total
household income as important in rural areas, or is source of income more important?
Again, the results of this type of analysis would have important programmatic
implications. If the determinants of malnutrition are different, the responses may have
to be different.

S The Etiology of Chronic and Acute Malnutrition

Further analysis also is needed to determine whether, in combination, the factors that are
responsible for acute malnutrition are the same as those that are responsible for chronic

S Food Availability in the Household and Child Malnutrition

Although food is only one of the determinants, many in Haiti assume that increasing food
available to households is essential to reduce malnutrition among pre-school children.
That may or may not be the case. The answer to the question has important
programmatic implications, especially for the use of Title II food. Throughout
Honduras, the nutrition levels of pre-school children are related strongly and positively
to the incomes earned by their households. The nutrition levels are not related to the
amount of food available in the households, however, except in the western region of the
country. Unfortunately, the data needed to shed light on this issue in Haiti are not



Measures of growth are the most reliable indicators of children's nutritional status and also
furnish an indication of the nutritional status of a country's population as a whole. Protein
calorie malnutrition, which is the most common form of malnutrition among children in
developing countries, generally is measured in three different ways. The easiest way is to
measure children's weight for age, which usually is referred to as global malnutrition or under-
nutrition. This measure is a synthesis of the two other types of malnutrition and, unfortunately,
is not very sensitive to cases in which children are deprived of small amounts of food over long
periods of time, which is a characteristic of chronic malnutrition. A second measure, weight
for height, indicates whether a child is malnourished currently. It is referred to as wasting, or
more technically, as acute malnutrition. The third measure, height for age, reflects past as well
as current nutritional status and is the best indicator whether malnutrition is a chronic problem.
Measuring acute and chronic malnutrition is more difficult than measuring under-nutrition: it
is not easy to measure the height -- length -- of young children who do not stand still -- or stand
at all -- and small differences in measurement can affect results dramatically.




A.1. The Disease Model of Malnutrition

This traditional model posits that malnutrition is a disease and food is its clre. Standard texts
of medicine list at least 20 types of nutritional disorders -- marasmus, kwashiorkor, pellagra,
beriberi, scurvy, rickets, osteomalacia, hypervitaminosis D, xerophthalmia, hypervitaminosis A,
sodium depletion, magnesium depletion, riboflavin deficiency, pantothenic acid deficiency,
vitamin E deficiency, pyridoxine deficiency, biotin deficiency, folic acid deficiency, vitamin K
deficiency, iodine deficiency, not to mention various malabsorption disorders. For each disease,
the cure is calories, protein, or various dietetic supplements. The World Health Organization
recognizes four principal nutritional problems in developing countries: protein-calorie
malnutrition, nutritional anemia, endemic goiter, and xerophthalmia.

A.2. A Revised Conceptual Framework for Malnutrition

In the revised model, malnutrition is a marker for intermediate variables through which two
fundamental factors act: mother's education and household income. The intermediate variables


Contamination of the environment by infectious agents

Access to food by the fetus and child

Individual behavior (feeding practices and locus of illness control)

In this model, malnutrition can occur when people consume proper diets, but poor health stands
in the way of their bodies absorbing sufficient nutrients (Riordan, eta). This section focuses
on the four major dimensions of utilization most relevant in the Haitian setting: fertility factors,
infections, maternal knowledge, and utilization of health services.


Fertility Factors Are Linked to Malnutrition

The three fertility factors most relevant to the nutritional status of children are maternal age
(below 20), parity (multiple births), and birth interval (less than 24 months). By and large,
these factors result in low birth weight, both prematurity and small-for-date births. Low birth
weight is a marker offetal malnutrition, and low birth weight babies -- 12-18 percent of live
births in Haiti depending on the study -- may account for as much as 65 percent of malnutrition
in infancy and between 50-65 percent of infant deaths (Boulos, et al., 1984). As a point of
reference, Office of Technological Assessment data indicate that the seven percent of low birth
weight babies in the United States account for 60 percent of infant deaths.

Data from Jdrdmie presented recently at the Haitian Studies Association clearly show a link
between birth interval and occurrence of childhood malnutrition. As a rule, malnourished
children can be distinguished from well nourished children by a birth interval of about 12
months. A short birth interval displaces the previous child from the mother's breast and
attention at a particularly critical period in his or her development, the weaning phase. In
addition, short interval births increase the number of children under five living under the same
roof. That variable also is associated with an increased risk of malnutrition.

A.2.2. Infection and Malnutrition Act in Synergy

In a paper entitled, "Diarrhea Is a Nutritional Disease," Rohde, et al,, use data from Haiti and
other parts of the world to highlight the importance of diarrhea in relation to malnutrition.
Diarrhea causes loss of appetite, physical weakness, loss of nutritional substances, and growth
faltering (Mata, 1985). Diarrhea also may cause severe malnutrition.

Contamination with infectious agents that may cause diarrhea frequently begins at birth --
through unsanitary delivery conditions, through contact with maternal intestinal pathogens in the
rectum, etc. Breast-feeding protects the child somewhat during the early neonatal period, but
the child is particularly at risk during weaning. In Haiti, introduction of food other than
breastmilk begins very early, which results in relatively high incidence of diarrhea even during
the neonatal period.

Each episode of diarrhea increases the risK that the child, particularly the marginally nourished
child, suffer from acute malnutrition. Repetitive episodes of diarrhea, especially poorly
managed episodes, can result in severe malnutrition and death.

A similar story can be told about measles. By extension, therefore, measles is a nutritional
disease. The 1991-92 measles epidemic in Haiti was associated with an increased prevalence
of malnutrition (Berggren, personal communication). The increase was reported in the
international press but ascribed more generally to the impact of economic sanctions. Data from
Cite Soleil document a strong link between measles and malnutrition. At 42 months, the mean



weight of children whose mothers reported they had measles was a full 1.7 kilograms less than
the weight of children who had not had measles.

In recent years, the value of Vitamin A, a nutritional supplement in the management of measles
cases, has been recognized universally. Administration of 400,000 IU of Vitamin A to children
with measles complications, but with no overt signs of measles deficiency, decreased mortality
by 50 percent and lowered morbidity significantly.

A.2.3. Access to Food By the Fetus and Child

A.2.3.1. Malnutrition Begins During Fetal Life

The birth weight of an infant is the single most important determinant of its chances of survival,
health, growth, and development. In Haiti, the prevalence of low birth weight is between 12
and 18 percent, that is, 12 to 18 percent of newborns have a birth weight equal or inferior to
2500 grams (Augustin, a, 1993). An infant weighing less than 2500 grams may have been
born premature, but frequently is small for its gestational age. In poor communities in
developing countries, about seven percent of infants will be borne premature; the remainder of
the low birth weight -- 5-11 percent in Haiti -- will be attributable to intrauterine growth
retardation. Even in developed countries, it has been difficult to prevent prematurity. In the
United States, the prevalence of low birth weight has been oscillating around seven percent for
the past 20 years at the same time that neonatal mortality has declined. What has changed is
the increased chances of survival of low birth weight infants due to progress in neonatal care.

Low birth weight has a significant impact on infant mortality and on the nutritional status of
infants. Babies weighing more than 2750 grams at birth have an almost 100 percent chance of
surviving their first year if their mothers breast-feed them exclusively during the first six months
of life (Mata, 1985). Conversely, babies with low birth weight may account for as much as 60-
70 percent of neonatal or infant deaths. Low birth weight babies appear much more likely to
die in infancy "for, in many instances, low birth weight culminates in severe malnutrition during
infancy and results in a greater susceptibility to infections, primarily due to low resistance"
(Shah, 1983).

Birth weight and gestational age have independent effects on fetal and neonatal mortality (Koops,
etl., 1982). As noted above, the seven percent of infants with low birth weight in the United
States account for 60 percent of the infant mortality rate (Office of Technological Assessment,
1980). In parts of Central America, low birth weight accounts for 70 percent of infant mortality
independently of the proportion of infants born with low birth weight (Mata, 1985). In Cit6
Soleil, the following factors were related to low birth weight: age of mother, order of
pregnancy, and parity (see Tables A.1, A.2, and A.3).


Table A.1.

Percentage of Children with Low Birth Weight by Age of Mother, Sainte /
Catherine's Hospital, 1984

Table A.2.

Percentage of Children with Low Birth
Sainte Catherine's Hospital, 1984

Weight by Order of Pregnancy,

Table A.3:

Order Of Pregnancy Percent Low Birth Number

1 14.15 106
2-3 4.10 148
4+ 5.80 137

Percentage of Children with Low Birth Weight by Parity, Sainte Catherine's
Hospital, 1984

Parity Percent Low Birth Number
0-1 12.59 168
2-3 4.20 130
4+ 3.80 130

In the same setting, the mean weight for age of children at 12 months was significantly higher
for children with higher birth weight. Children whose birth weight was less than 2900 grams
had a mean weight of 7.1 kilograms; for children with birth weight above 2900 grams, the mean
weight at 12 months was 9.1 kilograms.


Maternal Age Percent Low Birth Number

15-19 13.04 46
20-24 7.29 137
25-29 5.04 119
30-34 3.75 80
34+ 5.80 52

Data from the U.S. Collaborative Perinatal Project indicate that the relationship between weight
gain during pregnancy and perinatal mortality is influenced strongly by maternalpre-pregnancy
nutritional status. Thus, weight gain during pregnancy is more important for women who
were underweight prior to pregnancy. The combination of underweight prior to pregnancy and
low pregnancy weight gain increases the risk of a poor outcome for the fetus. The effect
appears to be mediated via the incidence of low birth weight. If a woman is underweight before
pregnancy, there will be an increased rate of intrauterine growth retardation, which is related
inversely to weight gain during pregnancy. Thus, underweight women appear to derive greater
benefit from a given gestational weight gain than women with adequate or excessive weight.
It also is desirable that they gain more than women with normal weight. Data from the literature
suggest that it is better to gain the weight after week 20 of pregnancy, that is, during the second
and third trimester.

A.2.3.2. A Thin Woman: More Than in the Eye of the Beholder

While the definition of what constitutes a "thin" woman may vary (especially in the eyes of
beholders), the usual scientific standard is a measure of maternal weight for height known as the
body mass index (BMI), which is defined as weight in kilograms divided by height in meters
squared. In the United States, a low BMI would fall below 19.8, a moderate score would lie
between 19.8 and 26.0, and a high BMI would be greater than 26. In the EMMUS II survey,
the cut-off for "normalcy" was a BMI of 18.5. Below that score, a woman was considered
under-nourished. Using the EMMUS definition, "only" 18 percent of Haitian women would be
classified as acutely under-nourished. Using the U.S. definition of "underweight," over 45
percent of Haitian women would qualify.

A.2.3.3. Chronic Malnutrition Begins with Acute Malnutrition

Chronic malnutrition begins with acute malnutrition. The precipitating factor may not
necessarily be an acute shortage of food, but rather the onset of an infectious process in a
marginally nourished child.

Data from Maissade document the impact of the measles epidemic that accounted for 14 percent
of child deaths in 1992, and that occurred because of low measles vaccination coverage. The
children who died of kwashiorkor or severe (third-degree) malnutrition, or of an infection
associated with such malnutrition, accounted for 22 percent (40 of 184) of the deaths.
According to Berggren, a number of the deaths probably were sequelae to measles.

Berggren reports that the shortage of food in 1992 was reflected in the amount of third-degree
malnutrition seen in growth monitoring sessions (see Tables A.4 and A.5).


Table A.4.

Results of Weight/Age Measurements on Under-Fives Weighed during ,
April-June 1992, Using the Gomez Classification

Source: Berggren, 1993

Table A.5.

Results of Weight/Age Measurements on Under-Fives Weighed During July-
September 1992, Using the Gomez Classification

Degree of Malnutrition Age in Months (Children Weighed July-September 1992)
0-11.99 12-23.9 24-60 Total Percent
Total 1,196 647 72201 2,565 100
Normal 1,009 39

M-1 343 353 370 1,066 i 42
M-II 52 140 252 444 17
M-m1 11 10 23 46 2

Source: Berggren, 1993

As Berggren explains, "the above tables might be thought to reveal an important seasonal
variation, or a food shortage period equivalent to a famine, with 12 percent of children either
suffering from kwashiorkor or third degree malnutrition [Table A.4]. In fact, a serious and
unusual food shortage occurred to which the project responded with a special distribution of
corn. At the same time there was a measles epidemic. The "kwashiorkor" season in Haiti,
which usually occurs July through September occurred three months early (April-June 1992).


Degree of Malnutrition Age in Months (Children Weighed April-June 1992)
0-11.99 12-23.9 24-60 Total Percent

Total 2,222 1,413 1,601 5,236 100
Normal 1,436 323 0 1,759 33
M-I 616 754 272 1,642 31
M-II 141 307 773 1,221 23
M-mI 29 29 469 527 10

This different pattern probably reflects 1) an unusual food shortage year and 2) a measles /
epidemic, followed by a rise in cases of kwashiorkor (see Growth Monitoring Table [A.4]). It
is therefore not surprising to see an increase in the death rates in under-fives in 1992 as
compared to 1991 (139 deaths in under-fives in 1991 as compared with 184 in 1992)."

The USAID monitoring reports from 1992 to 1995 allow construction of velocity curves of
changes in nutritional status. The curves suggest a significant worsening of nutritional status
nationwide during the period of July to August, confirming Berggren's observations on the
"kwashiorkor season."

A.2.4. Poor Food Utilization Is Linked to Inadequate Feeding Practices

The evidence is clearest during the first six months of life: by the first month of life, 79 percent
of infants receive food other than breastmilk (porridge, fruit juices etc.). The reason may not
necessarily be lack of knowledge by the mother. Data from the Jdrdmie area document the high
opportunity cost of breast-feeding for rural and urban working women.

Nonetheless, there is evidence that nutrition education can play a role in improving permanently
the nutritional status of at least some children. Maissade is an area in Central Haiti where, for
the past several years, Save the Children has conducted community-based nutrition surveillance.
Children identified as malnourished are enrolled with their mothers in a two-week rehabilitation
cum education program. During the program, mothers learn to purchase appropriate food in the
market and prepare it for their children in a temporary nutrition center se. up in a host village.
An- evaluation of the Foyer de Demonstration program suggests that up to two thirds of the
mothers who attend the two-week "course" in better feeding practices improve the nutritional
status of their children both in the foyer and after they graduate from it. It appears that one
third of the children receive no permanent benefit. The children in question may suffer from
a chronic illness such as tuberculosis or their parents may be too poor to purchase food.

Health interventions, particularly those that minimize the risk of acquiring diseases -- especially
diarrhea and measles -- and that minimize the infection-associated morbidity and severity of the
illnesses in question -- ORT and Vitamin A administration, for example -- can have a positive
impact on the nutritional status of children. Several factors conspire to limit use of health
services. The factors include distance, cost, general availability, and maternal factors such as
education and locus of illness control. Persons who believe that events are the result of their
own actions are said to have an internal locus of control; those who believe they have no control
over events are said to have an external locus of control. Individuals in the latter category
believe that events lie in the hands of fate, chance, or luck.

Family planning services also have the potential of improving the nutritional status of mothers
and infants by increasing birth intervals, reducing the average number of children per mother,
and reducing average family size, a factor linked directly to nutritional status.




The rate of natural increase of Haiti's population is high, well over two percent per year. In
absolute terms, this rate corresponds to an increase in population of about 150,000 people
annually. The impact of emigration upon demographic growth is not negligible. Still, present
levels of emigration, estimated at about 20,000 people per year, have not reduced significantly
the observed rate of population growth, wifch is driven primarily by persistent high fertility and
declining mortality rates.

Haiti's population is very young, a clear consequence of the lack of appropriate policy responses
to population pressure over the past 30 years. As a result, the observed trend in the natural
increase of Haiti's population will continue, as the following scenarios illustrate:

* Even if a strong reproductive health and family planning program were implemented
quickly and emigration continued at 20,000 people per year, Haiti's population would
increase by nearly two million people by the year 2010 -- from an estimated 6.8 million
people in 1996 to 8.6 million people fourteen years later.

In the absence of any decline in fertility but with continued emigration at current levels,
the population of Haiti would increase by 2.5 million people -- reaching 9.2 million
people by 2010.

If there were neither a decline in fertility not any emigration, total population would
increase by nearly three million people to a total of 9.6 million people in 2010.

At first blush, the impact of a strong reproductive health and family planning program on Haiti's
total population 13 years from now might not appear important. In fact, if it were possible to
launch such a program rapidly, it would allow births to stabilize at their present level, that is,
at 220,000 per year. In addition, the number of children less than two years old would stabilize
at about 400,000 in any given year, and the number of children less than five would stabilize
at about one million. On the other hand, if fertility fails to decline, the number of births each
year and the number of children in the other two categories will increase by about 50
percent between 1996 and 2010, adding an unnecessary burden to the country at large..

Implementing a strorig reproductive health and family planning program effectively would be a
major undertaking. In 1994-95, contraceptive use still was very low in Haiti. It is estimated
that only 18 percent of Haitian women in union used any method at all -- 14 percent a modern
method, and four percent a traditional method. Developing countries most successful in
reducing fertility often called "superachievers" -- have been able to increase contraceptive use

among their populations by about two percentage points per year. When 70 to 80 percent of
their women in union use contraceptives, their "fertility transition" is complete. At that point
each woman has an average of about two children. If Haiti were to become a superachieverr,
it would complete its transition in 30 to 40 years.

In Haiti, "superachievement" would mean a-decline in fertility from 4.8 children per woman in
1995 to about three children per woman by the year 2010 assuming that breast feeding
continued to be practiced widely. In absolute numbers, contraceptive users would more than
triple in the next 13 years, passing from less than 200,000 users at present to more than 600,000
users by 2010. Although this objective clearly is ambitious, accomplishment of anything less
implies a continued increase both in births and in numbers of children for the foreseeable future.

Unfortunately, even if Haiti were to implement a strong reproductive health and family
planning program immediately, it would have no impact on the size of the labor force for at
least 15 years. Even if one assumes a continuation of emigration of about 20, 000 Haitians
per year, the number of persons entering the labor jorce annually is going to increase
dramatically. Currently, more than 100,000 youngsters arrive on the labor market each year.
By 2010, that number will be 180,000 -- nearly double the present figure. Although those
youngsters certainly will be better educated and have higher expectations than their parents,
many will have difficulty in finding jobs in the modem sector of the economy.


At-present, about 40 percent of new arrivals on the labor market do so in urban areas -- about
half in the Port-au-Prince metropolitan area and half in the other "towns" of Haiti. By the year
2010, if current urbanization trends continue, more than 100,000 youngsters will enter the labor
market in urban areas each year, and will make up about 60 percent of all new arrivals. Despite
this significant shift of the labor force to urban areas, arrivals in rural areas fifteen years from
now still will be about 50 percent higher than what they are today.

These calculations assume continuation of the.rather slow pace of urbanization estimated by the
United Nations, from 12 percent in 1950, to 33 percent in 1996, to 42 percent in 2010. These
estimates well may prove wrong. The current official estimate of the percentage of the Haitian
population that is urban is based on administrative boundaries of towns villes -- and rural areas
- sections communales that do not take into account the incorporation into towns of adjacent
settlements. A quick look at the detail of available population estimates shows that several areas
now classified as rural clearly are urban, noticeably in the metropolitan area of Port-au-Prince.
Thus, the number of Haitians now living in urban areas well may be around 40 rather than 33
percent. Accordingly, the pace o uranization probably is faster than assumed generally, and
Haiti may be predominantly urban as early as 2005.

In counterbalance to the misclassification of some urban areas as rural, about two thirds of the
133 villes classified as urban are very small. In 1996, about one third of them had an estimated


population of less than 2,000 people. Another third had an estimated population of between
2,000 and 5,000 people. Together, towns of less than 5,000 people account only for about eight
percent of the urban population. At the other extreme, in 1996 the official estimate of the
population of the metropolitan area of Port-au-Prince was 1.5 million people, which represented
61 percent of all urban people. Most likely that is an underestimate.

After the metropolitan area of Port-au-Prince, only two cities have an estimated population of
more than' 50,000 inhabitants: Cap Haiuen, with about 100,000 people; and Gonaives, with
about 60,000 people. Two other cities have an estimated population close to 50,000 people,
Saint Marc and Les Cayes. Four other villes have an estimated population of more than 20,000
and less than )0,000 people: Verrettes in the Artibonite next to Saint Marc, J6r6mie in the
Department of Grande Anse, Port de Paix in the Northwest, and Limb6 in the north close to Cap
Haitien. The total population of these eight "cities" is less than 400,000 people, and represents
15 percent of the urban population.

In short, only nine relatively large human concentrations represent about 7.5 percent of Haiti's
urban population: the metropolitan area of Port-au-Prince; Cap Haitien and Limbd; Gonaives,
Saint Marc, and Verrettes; Les Cayes; Jdrimie; and Port de Paix. Of these, only the first
seven are connected with roads in at all close to good shape.


To date, poverty in Haiti largely has been a rural phenomenon. Ongoing urbanization will
change Haiti into a predominantly urban society before 2010 and will result, in the longer run,
in predominantly urban poverty. Addressing urban poverty will call for approaches different
from those for addressing rural poverty.

At the beginning of the century, poverty probably already was widespread in rural Haiti, when
tens of thousand of Haitians emigrated to Cuba to work in the sugar cane fields. In 1977, it was
estimated that about three of every four Haitians (72 percent) lived in absolute poverty. In rural
areas, extreme poverty affected four of every five Haitians (78 percent). In contrast, only (so
to speak) about one of every two persons (55 percent) found themselves in the same situation
in urban areas.

In theiearly 1990s, poverty in Haiti was estimated at 65 percent (Head Count Index). Given the
rough' nature of all these estimates, one prudently may assume that percentages of Haitians in
poverty have remained high, and probably have not dropped much over the past 20 years.. With
rapid population growth in recent years, however, the total number of poor people undoubtedly
has increased significantly. Using available estimates of population and poverty, the number' of
poor people may have increased from 3.4 to 4.3 million people, that is, by almost a million
people over the past 20 years.


It is unclear whether the breakdown between rural poverty and urban poverty has remained
unchanged. In the absence of recent data, the differential in poverty rates between rural and
urban areas can serve as a proxy to estimate current numbers of rural and urban poor. Under
that assumption, the present number of poor people in rural areas is approximately 3.3 million,
which represents an increase of about half a million people since the late 1970s. Under the same
assumption, the number of urban poor is approximately 1.1 million, which also represents an
increase of about a half a million people, but amounts to a doubling since the late 1970s.

According to these rough calculations, Haiti's urban poor currently make up a quarter of the
total number of poor people. As urbanization progresses, however, the magnitude and
significance of urban poverty will become correspondingly greater.

It is not possible to project an accurate picture of global and urban-rural poverty in Haiti in the
year 2010. With some rough assumptions, however, one can hypothesize about the future.
From an economic perspective, it would be ideal if Haiti could achieve economic growth on the
order of eight to ten percent per year. Since the rate of population growth is not going to
decrease markedly in the next 15 years, that would mean that real Gross Domestic Product
(GDP) per capital would increase by about six to eight percent per year. Such growth would not
occur overnight. Assume for the sake of argument, however, that Haiti grows at such rates
between 1996 and the year 2010. If that were to happen, GDP per capital would increase 2.5
to three times, and GDP per capital could reach a level as high as US$1,000. Under this
optimistic scenario of economic growth, the percentage of Haitians in poverty would drop from
65 percent -- today's estimate -- to 50 percent by the year 2010. Still, with the population
growth projected for the next 15 years, such-a decrease in the percentage of the population in
poverty would compensate only for demographic growth, and the number of poor people would
remain the same: 4.3 million over the period. In other words, even under the most favorable
demographic and economic growth scenarios, Haiti's total number of poor people would
decrease only if the percentage of the population that is poor dropped very rapidly, that is,
below 50 percent between 1995 and 2010.

What does all this mean for urban and rural poverty? Assume that approximately 55 percent of
the population will be urban and 45 percent will be rural by the year 2010. Assume also that
the percentages of people in poverty in rural and urban areas remain at the levels estimated in
the late 1970s -- about 60 percent in rural areas, and 40 percent in urban areas. Under these
assumptions, in the year 2010 the number of poor in rural areas still would be greater than in
urban areas, but the difference would be slight: 2.3 million against two million people.
-9tw n995 and 2010, however, the number of poor in rural areas would decrease by about
one million people: from 3.3 to 2.3 million. In urban areas, however, it would increase
dramatically. In fact, it would double, passing from one million to nearly two million people.

These various speculative results highlight several features, which can be summarized as
follows. Urbanization is on the march, and shows no signs of waning. As urbanization
continues, the percentage of Haitians with limited access to social services can be expected to
decline. Depending on the pace of economic growth, the number of poor people in rural areas


will decline as well. In urban areas, the number of poor people is likely to increase for the
foreseeable future. For Haiti's next generation, poverty will become increasingly an urban
phenomenon. Problems of urban growth and poverty will not be confined to Port-au-Prince,
but will extend to Haiti's secondary cities too.


For political and economic reasons, Haitian emigration has expanded considerably in recent
decades. It is likely to continue at significant levels. Long considered a safety valve for
overpopulation and underdevelopment, emigration also can be looked to for development
leverage. The resources and talents of Haiti's diaspora need not be lost forever, but can be
targeted and tapped both for investment and for reducing poverty.

Conventional wisdom concerning Haitian emigration is that it will not continue, that it cannot
continue. To a large extent, that is a fallacy. During the last 50 years, there have been repeated
attempts to stave off emigration, not just in Haiti, but throughout the Caribbean. None has met
with lasting success.

After the 1936 massacre of thousands of Haitians in the Dominican Republic and the repatriation
of Haitians from Cuban plantations, the prevalent opinion in the 1950s was that Haitian
emigration was over for ever. In the 1950s and 1960s, however, Haitians started to move again,
first in small and then in large numbers, to the Dominican Republic, to the United States, and
to Canada. In the 1970s, the tightening of controls in those countries led to the firm belief that
emigration was over for good. What happened is that Haitians tapped new outlets: the
Bahamas, French Guiana, Guadeloupe, Frnice, etc. At the same time, emigration to the United
States, Canada, and the Dominican Republic continued unabated. In the 1980s, authorities in
all receiving countries made it clear that illegal immigration, particularly from Haiti, would be
tolerated no longer. What happened? The 1980s probably witnessed the highest ever
outmigration from Haiti. The truth is that at both ends -- at the source in Haiti as well as at
receiving destinations -- movements of people cannot be stopped.

At the source, emigration is the result not only of dire poverty. It also is the result of strong
expectations for higher education, economic opportunities, and social advancement for Haiti's
upper and middle as well as lower classes. The duality of the causes of emigration is illustrated
well by the segmentation of Haiti's emigrants: for years the well educated, coming primarily
from Haiti's cities, went to the United States, Canada, and France; on the other hand, poor,
unskilled emigrants, often of rural origin, went to the Dominican Republic, the Bahamas, French
Guiana, and Guadeloupe. Today, this distinction is not as clearcut as it once was. In recent
years many unskilled Haitians have found jobs in the United States and Canada.

At the destination, other factors have contributed to the perpetuation of migration. They include
family re-unification, humanitarian concerns, and manpower needs in certain sectors.


For all these reasons, it would be naive to assert once again that the day of Haitian emigration
is over. It will not end soon. Even if annual numbers of admissions abroad decrease, it still
will continue to be significant.

Developmentwise, emigration is a two-edged sword with both positive and negative impacts.
In addition to furnishing a safety valve, emigration often deprives the country of valuable
talent. When well educated and risk-taking Haitians leave for other shores, they deprive the
country of its more dynamic elements. In many instances, emigrants have the means and may
be willing to contribute to development back home, not just through remittances but also
through investments in their original communities. The recent establishment of a Ministry of
"Emigres" Ministry of the Tenth Department -- is an indication that the Government of Haiti
recognizes the significance of the country's diaspora, and the potential role it can play in Haiti's
development. So far, however, little has been done.



This chapter forms a bridge between the description of Haiti's current and future food security
problems in Chapters 2 and 3 and the presentation of the strategy itself in Chapter 5. The
various constraints discussed here set the context for the recommended policy and programmatic
responses that follow. Although this chapter does not provide an exhaustive list of constraints,
it does point up the enormity of the food security challenge -- that one cannot attack everything
at the same time. The sorting through of possible priorities takes place in the presentation of
the strategy itself.


Following the collapseof the economy during the international embargoes on most trade and
financial transactions, the constitutional government restored to power in October 1994 put an
Emergency Economic Recovery Plan into effect. The plan sought to stabilize the economy,
restore public administration, and attend to immediate infrastructure and social service needs.
The plan was successful on a number of economic counts: modest growth ensued, inflation
slowed, the gourde remained stable, and net international reserves grew.. During 1995, the
government also introduced a number of important structural reforms, among them lifting
remaining restrictions on imports and eliminating all interest rate ceilings.

With the onset of the presidential election in late 1995, economic performance deteriorated: the
public sector deficit swelled and the economic expansion slowed. On assuming office in early
1996, the Preval government took steps to reestablish control over public sector finances.
Specifically, it set up procedures to. limit government expenditure to revenue collected, it
instituted a wages and personnel policy that freezes the government wage bill for three years,
it closed most discretionary ministerial checking accounts, and it introduced better expenditure
control procedures. As expected, the measures succeeded in slashing the budget deficit and in
lowering inflation. Growth, however, remained sluggish.

On balance, two years of economic policymaking after Haiti's return to constitutional
government have had demonstrable success on the economic stabilization front, but have not
been able to ratchet up the pace of economic growth. For that reason, the government has
solicited assistance from the International Monetary Fund and the World Bank to implement a
medium-term economic recovery program. Under the program, which will run until 1999, the
government proposes to raise real growth in Gross Domestic Product (GDP) to 4.5 percent a
year, to reduce inflation to single-digit levels, and to strengthen the country's balance of
payments. More generally, the program's major objective is to promote recovery of economic
activity through the generation of productive job opportunities, especially for the poor. To
support the program, the government proposes fiscal reforms aimed at mobilizing revenues and

improving control and allocation of expenditures, all with a view to directing a significant /
portion of available resources to infrastructure projects that support economic growth.

The cornerstone of the government's recovery program is the Enhanced Structural Adjustment
Facility it has negotiated with the International Monetary Fund. The structural reform agenda
under the Facility will focus on:

Improvement of public finance, including tax reform and budgeting and expenditure
control processes;

Public sector management, including civil service downsizing and reform;

Privatization of state-owned enterprises;

Trade liberalization; and

Financial sector reform.

The first priority in the first year of the program will be to broaden the country's currently
meager tax base, improve tax administration, and strengthen tax enforcement. This focus is well
taken: if ever the government is to lessen its dependence on external aid, it will need to
generate and manage resources efficiently on its own. That will not be an easy job. Not only
did it recently lower tariff rates significantly; the budget now must accommodate new
commitments for security requirements -- the new police force, for example -- as well as the
recurrent expenditure implications of donor-financed infrastructure investment. Realistically,
the government will be able to finance little infrastructure investment on its own. For that, it
will depend heavily on the World Bank and the Inter-American Development Bank, among other

On the soft side of the equation, the government also has a leadership role to play in
establishing a climate propitious to productive investment. Without such a climate, attempts
at economic recovery will be thwarted. Ultimately, Haiti's growth -must come from private
sector dynamism. To unleash that dynamism, the government needs to be more than neutral;
it needs to adopt a consciously encouraging posture. To date, it has vacillated in the image it
has conveyed to potential investors. Key elements in the inculcation of a pro-business climate
in Haiti include: guaranteed physical security, transparent and enforceable mechanisms for
protection of property rights, and sound and enforceable contract legislation governing
transactions and exchanges. At the current time, the status of these elements can be described
as embryonic.



Most Haitians are risk averse. In rural areas, for example, farmers usually work several plots
under various tenure arrangements, simultaneously owning, sharecropping, and renting. The
arrangements in question change according to seasons, life cycle, and many other variables.
Together with highly varied and flexible agronomic patterns, these practices serve both to avoid
risk and to ensure some income throughout most of the year. Without increased protection of
their assets and profits, Haitian peasants will not produce more.

The propensity to risk aversion is observable throughout Haitian society, in urban as well as
rural areas. The capricious behavior of government officials, unpredictable taxation, a sluggish
and inequitable legal system, the uncertain protection of freedom and property, as well as other
aspects of the "soft state" result in high transaction costs for every action taken, and in low rates
of savings and investment. Under conditions of uncertainty, risk avoidance is rational behavior
even if it limits production and incomes. Political uncertainty is a root cause of poverty and,
by extension, of food insecurity.

Scarcity of social capital makes the deficiencies of the governmental apparatus particularly
damaging. To minirrize vulnerability, large numbers of peasant organizations emerged during
the past thirty years and covered virtually every community and every aspect of rural life.
Compared to the strength of established interests, however, these attempts at peasant
organization were transitory, fragmented and weak. A great deal more "institutional
scaffolding" is needed at every level if Haiti is to reach a higher plateau of food security.

Haiti has the highest urban primacy rate in the region, and it has been growing every decade.
Indeed, urban bias is a dominant aspect of Haitian society, as all large employers, banks,
hospitals, institutions of higher education, and modern infrastructure are urban, indeed
metropolitan. Yet high urban primacy may be necessary during early phases of economic
development and some forms of urban bias may be in the national interest. It is quite likely that
investment in secondary cities as service centers would have positive consequences for the non-
urban areas surrounding them and that the urban employment created by urban investment would
accelerate economic and demographic transitions that rural Haiti will undergo at any rate.

Political constraints frequently have been significant in the channelling of food resources --
indeed, in the institutions that handle resources of any kind. The question must be asked
whether the populist politics prevailing at the current time hinder movement toward greater food
security. To wit: can entrepreneurs be assured of the physical and political safety of their
-investments, can managers of production units, transportation firms, and warehouses be
protected from rent seekers and mobs alike, and might the "d6choukages" of the past ten years
erupt again with all their damaging consequences on the business climate? Although nobody can
venture totally reassuring answers to these questions, there has been much progress in the right
direction, to say the least. Public order, justice, provision of governmental services, and the
restoration of public infrastructure are four pillars of a conducive business climate. In each
case, demonstrable progress has been made. But caution is in order for two reasons. First,


public trust, especially trust in governmental institutions, is still shaky. Second, although there
definitely is a window of opportunity at e tme of this wniung, a departure of the United
Nations force, an economic crisis, or a number of other unforeseen events conceivably could
close the window later in 1997.


This section discusses constraints that affect Haiti's productive sectors. Because of the focus on
food security, the lion's share of attention is given to constraints affecting the country's
agricultural sector.


Haiti's industrial sector consists of state-owned enterprises and medium- and small-sized private
enterprises that produce for domestic demand, as well as a small number of large private firms
that process domestic agricultural products and raw materials and assemble imported components
for foreign markets. The industrial sector currently employs less than 10 percent of the labor
force and contributes about 10 percent of GDP, down from almost 20 percent in 1991. Firm
closures due to the embargo resulted in a sharp drop in employment, especially in the assembly
industry, where women represented 70 percent of the workers. In particular, the number of
firms in the assembly industry (mainly textiles and electronics) fell from about 250 to 44 during
the crisis period, while employment fell from 46,000 to about 8,000. By the end of 1994,
assembly operations for exports had virtually ceased. In the rest of the manufacturing sector,
the trade sanctions forced firms to produce only for the domestic market and activity in the
sector declined generally. Since then, investment has been slow to recover and jobs have
increased very slowly.

On the positive side, the Haitian economy is relatively open and there is considerable
entrepreneurial talent available locally. The Haitian workforce is hard-working, reliable, stable,
and trainable. Workers are also available at very competitive wages and historically have a low
level of absenteeism. This in spite of high illiteracy and the lack of access to both technical and
managerial training. Haiti's close geographical proximity to the large market in the United
States is another advantage. The presence in the United States of a one-million-strong diaspora,
which includes many potential investors and a technical and managerial human resource pool for
Haiti, also is a major plus, as is the absence of any foreign exchange controls, which permits
investors to repatriate capital and earnings at any time and without limits. CONSTRAINTS

* State ownership of a broad range of enterprises including telecommunications,
power, ports, financial institutions, manufacturing enterprises, and agribusinesses -


has resulted in mismanagement, corruption, and very poor performance. Services are ,
unreliable and of poor quality and operations are inefficient, with poor financial control
and substantial overstaffing.

S Haiti's infrastructure is in serious disrepair, lacking rehabilitation and maintenance,
and requiring considerable new investment. Even before the crisis, less than 20 percent
of the paved roads and four percent of the remaining road network were maintained
adequately. The main port is heavily congested, and its operations are hampered by
inadequate equipment, excessive labor, and poor management. Telephone services are
dismal: Only eight out of 1,000 inhabitants have a phone line, and most businesses use
radio-based communications. Power supply is concentrated in Port-au-Prince, often
limited to a few hours a day during the dry season, and falls far short of even Haiti's
limited demand. In addition, non-technical losses and theft consume 40 percent of the
electricity supply. Without significant visible progress in each of these areas, it is
unrealistic to expect that many investors, especially off-shore investors, will be attracted
to Haiti. These conditions reduce Haiti's international competitiveness, incur needless
costs, discourage the return of tourism and the recovery of markets lost as a result of the

S The current policy, legal, and regulatory environment is not sufficiently supportive of
private sector expansion. Policies, legal codes, and regulatory mechanisms still are
outmoded, unclear, and designed to limit market access, and their application is neither
open nor transparent. This increases transaction costs for businesses, provides
opportunities for corruption, and encourages commercial banks to remain very risk

S Experienced business people also are reluctant to commit resources to begin or
reestablish businesses, to invest in inventory, or to hire or rehire a workforce because
of the lack of a reliable judicial system, the lack of adequate physical security and
protection of property, and the absence of any confidence in contract enforcement.
A pervasive problem is that there is no concept of civil contempt and consequently no
penalty for non-compliance with judicial rulings. In cases of egregious civil violations,
the perpetrator may be sent to jail, but there is practically never any recovery of damages
by the victim.

S Local entrepreneurs also lack knowledge of business opportunities and new
technologies. Global trading relationships based on international comparative advantage
have become the name of the game in the 1990s. Since Haiti was out of the market for
several years during the beginning of the 1990s, it has fallen behind its international
competitors. In order to regain its old markets and establish new ones, Haiti's
productive and service sector will need up-to-date information on markets and access to
state-of-the-art technology. Information is key. In addition, labor skills will need to be
updated and upgraded at all levels to meet the quality and price requirements of the
international market.


* The informal sector makes up a large, permanent, heterogeneous, energetic, and high-
profile segment of the Haitian economy. It also faces daunting constraints.
Constraints that apply to the vast majority of informal sector operators include: lack of
legal title to property, which makes it useless as collateral; lack of a proper workplace,
with sufficient production and exhibition space; inadequate availability of basic utilities --
electric power and water; lack of working capital for purchase of raw materials; lack of
sales, linked to insufficient demand for their products; and unhealthy working conditions,
stemming from poor sanitation, air pollution,- lack of clean water, and often unsafe work
sites (Delatour and Duggleby, 1993; ILD, 1997).


Agriculture traditionally has been Haiti's principal economic activity. Even in the 1970s,
agriculture still accounted for almost .47 percent of the country's GDP, employed almost 75
percent of the country's labor force, and accounted for almost 60 percent of the value of the
country's exports. Agricultural production fell steadily during the 1980s. By the end of the
decade, agriculture accounted for only 35 percent of GDP and less than ten percent of exports.
The sector also suffered greatly during the recent crisis, although its share of GDP actually
increased in importance during the period. This phenomenon was due more to the deterioration
of the economy as a whole during the embargo period and its slow recovery since then rather
than to any vibrancy within the agricultural sector itself.

The Preval government has decided to make agriculture a major priority in its development
strategy, both toraise living standards and increase the food security of the maionty of the
population who still live in rural areas and to create favorable conditions for the export of value-
added agricultural products. More specifically, the Ministry of Agriculture, Natural Resources,
and Rural Development (MANDR) has established four priorities: (1) the development of
irrigation infrastructure, especially in the plains; (2) improvements in land security and the
development o water users associations; (3) strengthening agricultural markets through
improvements in tension services, the provision of financial services to farmers, support to
ex poMimarkeing, and the development of domestic agro-food industries; and (4) strengthening
agricultural research.

The government expects that the agricultural sector, to which considerable donor assistance has
been committed, will contribute significantly to growth over the coming years. Programs
currently underway include the IDB-financed irrigation construction and' rehabilitation projects
in the Artibonite and Cul de Sac and rural rehabilitation projects financed by the European
Union. The IDB currently is financing technical assistance to the government in the
development of reforms in land and water policy. In 1997-98, it intends to develop a $30
million project to help modernize the agricultural sector. The project will focus on irrigated
agriculture, agrarian reform, and support services, including research, technology transfer, and
rural financial services. The World Bank (IDA) is providing support to the agricultural sector
under the buffer zone development component of a recently approved environment project. It


also is designing a $20 million agricultural support project for !998. USAID, another major
donor in the sector, has focused much of its support on sustainable agriculture, and other
donors, including France and the European Union, support a wide variety of localized
agricultural development projects. CONSTRAINTS

* The physical environment is difficult and fragile. Haiti is a mountainous country. The
mountains make it difficult to construct and maintain the all-weather roads that are
needed to link people to markets. They also create a diversity of ecological conditions
as well as irregular rainfall patterns that lead to periodic droughts that prevent the use
of intensive agricultural methods. Most of the country was once covered with natural
forests. By 1987, however, only 100,000 hectares remained in forests. Approximately
one million of the country's 2.7 million hectares were cultivated, and 0.5 million were
used as pasture. Thirty percent of cultivated lands are in the plains and 70 percent on
the hillsides. Half the hillside lands have slopes of more that 40 percent where annual
food crops cannot be grown without using soil and water conservation techniques.

* Population pressure on the land leads to environmental degradation (erosion, flooding,
silation of downstream infrastructure works, water depletion). Sixty five percent of the
Haitian population lives in the countryside, and 70-90 percent of people in rural areas
work -ariculture. The rapidly increasing population has exerted increasing pressure
on the land, which has generated serious environmental problems. About 30 percent of
the land that is cultivated is in marginal areas. Trees are cut to clear lands for agriculture
and to harvest wood and charcoal for energy and other needs. Approximately one
million hectares of land have been eroded and can no longer support any agricultural use.
Plus, an estimated 36 million metric tons of soil have been lost, equivalent to 12,000
hectares of land...

* The potential for gravity-fed irrigation is limited, and the implementation of public
irrigation schemes has been plagued by financial and institutional constraints. Gravity-
fed irrigation is an alternative for increasing agricultural production and productivity.
Only 150,000-190,000 hectares are estimated to be irrigable, however, and of them, only
70,000-90,000 hectares currently are irrigated. Irrigated land is divided in:o 128
inventoried systems: (1) the Artibonite Valley system with approximately 30,000
hectares, (2) twelve medium-sized systems (from 1,000 to 9,000 hectares each) that total
approximately 35,000 hectares, and (3) 100 small systems with a total irrigated area of
20,000 hectares. Most of these systems are under the administrative control of MANDR.
Because of financial constraints, however, rehabilitation and maintenance operations are
taking place, with donor support, under the auspices of other autonomous agencies.
Most public irrigation systems have deteriorated over time due to poor maintenance. At
the core of the problem is the fact that users' contributions to cover operation and


maintenance costs are minimal. Design deficiencies also include lack of adequate
attention to water availability, including the protection of upstream catchment areas.

S Haitian farms are too small for families to be able to make a living solely from
agriculture, and opportunities to expand area under cultivation are almost non-existent.
Large farms account for less than one percent of the land under cultivation in Haiti.
Seventy percent of farms are smaller than 1.28 hectares. That contrasts with the
estfimatehat a household needs 2.5 to three hectares in order to make a living from
farming. As a result, percent of rural households have to find sources of income
other than agriculture in order to buy food. Farms o less than three hectares have
i inmcreA from 62 percent of cultivated area in 1971 to 95.5 percent in 1987, and farms
Less than one hectare from 21 percent in 1971 to 60 percent in 1987. Most households
cultivate four to five parcels on average under various tenure arrangements,
simultaneously owning and sharecropping in different ecosystems. These arrangements,
which change according to seasons and life cycle patterns, help farmers avoid risk and
insure some income throughout most of the year. But they also complicate management
and render economies of scale almost impossible. The origins of this structure of
ownership can be traced to land distributions that followed the country's independence
and to inheritance customs that allocate land to each of a deceased's children. The
opportunity for further expansion of agricultural land under cultivation is almost non-

S Land titling is difficult and expensive, and lack of liad tenure security contributes to
stagnation in the agricultural sector. Lack of legal titles prevents access to formal
financial markets, hindering investment and technological change. Lack of tenure
security also has a negative impact on the environment, discouraging on-farm investments
such as terracing and tree planting and biasing the substitution of annual crops for
perennial crops. Property rights are limited by the lack of titling services and a reliable
judicial system. The procedures established by law for land affairs are complicated and
expensive, and the amount of land that is titled and that complies with legal requirements
is extremely small. An informal system provides some land tenure security as long as
conflicts can be resolved.through existing -- albeit limited -- legal documentation and
local customs. This tends to restrict land transactions to community and family
members. Joint possession, particularly on hillsides, is widespread. People try to solve
the problem by sharing the informal rights to cultivate, to harvest permanent crops, to
cut trees, to pasture animals, to build residences, and to bury family members. The
situation is fragile, however, and leads to informal land disputes, legal disputes, and even
to death. The state, which controls about ten percent of farmed area, is the largest single
landowner. Except for the Plantation Dauphin in the Northwest, all state lands are
occupied. The status of renters of state lands is not well-defined, however, and the
revenue derived from annual lease fees is very low, accounting for only 0.4 percent of
fiscal revenues during the last years of the 1980s.


+ Agricultural productivity is low, as are levels of technology. The productivity of land
and labor fell during the 1980s. This decline in factor productivity reflects a continuous
deterioration in the quality of the country's capital stock arising from: (1) continuing
land erosion; and (2) very low levels of investment in basic infrastructure, particularly
irrigation systems and roads. With the exception of rice, crop yields are declining,
falling increasingly below those recorded in other countries in the region. Farm
equipment and tools are rudimentary. Most farmers rely on a machete or hoe as the only
tools to farm their lands. Sixty five to seventy percent of farmers do not possess a
machete or hoe, or the tools are too old to be efficient. Only a few farmers (in the Plain
of Les Cayes and the Central Plateau) use animal traction, and even fewer use tractors
to prepare their lands. The use of inputs is limited primarily to irrigated areas such as
the Valley of Artibonite, the Plain of Cul de Sac, and the Plain of Les Cayes, and the
quantity applied is low (15 kg./ha.). Farmers also have problem getting access to good-
quality seed. Storage techniques are rudimentary. Drying areas called glacis are not
widespread. Few farmers have access to silos, even through group or community
ownership. Post-harvest losses are estimated to be as high as 20-30 percent for grains,
and even higher for perishable products such as fruits.

S Farms have been decapitalized, and lack of access to formal credit markets continues
to limit farmers' production activities. Haitian farmers have become decapitalized. The
decapitalization is due to a combination of factors, beginning with the slaughter of pigs
at the time of the African swine fever crisis, followed by the political instability that
developed after the fall of the Duvalier regime, as well as the embargo imposed after the
fall of Aristide. In the past, households were able to rely on incomes earned by seasonal
migrants to help recapitalize their farms. These earning opportunities have shrunk with
the lapse of an official agreement for workers to cut sugar cane in the Dominican
Republic and the reduction in illegal migration to the Bahamas, Florida, and elsewhere
in the Caribbean. With the closing of the Banque de Cr6dit Agricole (BCA), the only
channels of formal credit to farmers are commercial banks, credit unions, cooperatives,
and non-governmental organizations (NGOs). Since most farms are small, commercial
banks have played an extremely-limited role in Haiti's agricultural sector. Worldwide,
commercial banks seldom lend to small farmers because of high transaction costs, the
inability to use untitled land as collateral, and the existence of interest rate caps that
promote credit rationing away from borrowers whom it is costly to service and for whom
risk is high. Cooperatives and credit unions operate primarily in urban areas. Their
expansion to rural areas will depend on changes in existing laws to allow payment of
competitive rates on savings deposits and on development of an adequate legal and
regulatory framework.

S Poor to non-existent roads isolate producers from markets and contribute to higher food
prices. Although Haiti is a relatively small country, the poor condition of existing roads
-- and the utter absence of roads in many rural areas -- makes it difficult and costly to
move products, whether imported or domestically produced, to deficit areas, thereby
increasing prices to consumers and reducing the incomes received by farmers. The


remoteness of so many production units also acts as an obstacle to investments in
activities with backward and forward linkages to the agricultural sector, such as the
production of agricultural inputs and the processing, packaging, and marketing of
agricultural outputs. High transportation costs, not high profits by marketing agents, are
the major reason for the reportedly high food es in Haiti. This conclusion was
confirmed by a recent SECID survey in the Northwest, which found that market margins
are relatively low once one takes transportation costs into account. Retail margins, for
example, varied from 7.9 percent for rice to 30-39 percent for sorghum and corn, which
were just enough to cover transportation and marketing costs.

S Public sector institutions are weak and fail to supply key public goods. The failure of
the state to supply much needed public goods has been a major constraint to the
development and modernization of the agricultural sector in Haiti. One of the most
serious failures of the government has been the lack of enforcement of property rights
as a consequence of inadequate provision of titling services and the absence of a reliable
judicial system. Other serious shortcomings include the absence of public sector
leadership both in technology generation and transfer and in the maintenance of public
roads and irrigation systems, as well as the lack of prudential regulations that could
contribute to the development of rural financial markets. The combined effects of a
decade of political instability and the more recent embargo have weakened an already
weak set of government institutions, including the MANDR. Donor decisions to
withdraw development assistance from the public sector in favor of NGOs have
contributed to and helped perpetuate these weaknesses. The end result is that the current
government has limited financial resources to invest in the agricultural sector. In 1996-
97, for example, only 900 million gourdes -- six percent of the national budget of 13
billion gourdes will be directed to agriculture. Moreover, few human resources exist
to provide even the most essential public goods and services.

S Coordination is lacking within the sector, both by NGOs and by the donor community.
The role of NGOs in the agricultural sector has increased in importance as the capacity
of the public sector has deteriorated. Coordination among the various actors is poor.
Plus, considerable gaps and duplications exist among programs. A number of donors,
including the World Bank, the Inter-American Development Bank, IICA, FAO, and the
European Union are active in the agricultural sector in addition to USAID. These
agencies attempt to maintain informal contact to avoid duplications and contradictions in
their programs. Still, the potential for redundancy is considerable and there is no process
in place for developing a common vision for the sector or for identifying whether there
are key gaps where no donor support currently is available. In addition, MANDR has
not yet been able to take a strong leadership role in coordinating the activities of the
NGOs or the international donors active in the sector.


* Food aid programs may have created disincentive effects to the domestic production and
marketing of ood. There is no hard evidence tat food aid has had a disincentive effect
on local production. Nor would one expect such an effect at the macro level.
Nationally, donated food has helped increase the overall supply of food available, which
has helped moderate price increases. Without food aid, either commercial imports would
have to increase to fill the gap (if the purchasing power of the population were sufficient)
or the food deficit would rise, resulting in higher prices and the exclusion of more low-
income households from the market. The story could be quite different, however, in the
small, price-sensitive regional markets outside of Port-au-Prince, especially right after
harvest. Injecting food into those markets could lower prices temporarily at the very
moment that farmers need to sell their own production, thus reducing their incomes and
their ability to buy food back later. The availability of non-monetized food aid for sale
in local markets in Haiti also is indicative of the potential for market distortions. The
problem is not that the food is marketed, but that it is sold below its real market price,
since its opportunity cost to beneficiaries is low. Price distortions result that could
discourage the production and marketing of agricultural products. The policy of using
food as food (more than 70 percent of the food assistance made available to Haiti has
been provided in non-monetized form), together with its distribution through
bureaucratically administered rather than market channels, also may contribute to market
distortions and inhibit the development of more efficient food markets.


Social sector programs can make important contributions to food security, and there are a
multiplicity of such programs underway in Haiti. Food assistance programs are the most visible,
and their impact on food security is the most direct and immediate. Among traditional social
sector programs, primary health care and basic education are the most important from a food
security perspective. Nutrition programs, implemented separately or as part of the health
system, also play a role in the alleviation of food insecurity in Haiti. Temporary employment
generation programs, created to assist the poor to maintain their access to adequate diets, also
can contribute significantly to food security, as they did during the economic crisis in 1994-



Special attention needs to
be given to food assistance
programs because food 80 Million Dollars
resources have been such
an important part of the f14
U.S. assistance program to 10Total U.S. Assistance
Haiti. The program was 120
fairly small in value terms 1Tol td ooA a
Total U.S. Food Assistan e
in the years between its 80
initiation in 1954 and so
1977, when the addition of Title II Food Assistance
a $10 million Title I 20 ,
program brought the total n0=,5 :
food resources provided to 1961 1966 1971 1976 1981 1986 1991 1996
the country to
approximately $20 million.
In relative terms, food aid Figure 4.1: Trends in U.S. Assistance, including Food
was very important during Assistance
the latter half of the 1970s,
when it accounted for 60 to 70 percent of the Mission's portfolio. The food aid program also
has been significant during the 1990s. The addition of a $20 million Title III program in 1991
to support the new Aristide government increased the value of the total food assistance program
to $30 million. And the big increase in Title II food resources in 1993 in response to the
embargo brought the total value of the program to over $40 million, where it remained for the
next two years. Because of the relatively large amounts of Development Assistance (DA) and
Economic Support Fund (ESF) resources made available to Haiti, especially in 1994 and 1995,
the relative importance of the food program in the 1990s is smaller than in the late 1970s. On
average, the food assistance program has accounted for 40 percent of USAID's portfolio during
the 1990s.


Title II, which provides
food to NGO cooperating
sponsors to use in direct
feeding programs, has been
the dominant program. In SF MCH
52.4% 47.1%
18 out of the last 34 years,
it was the only U.S. food
assistance program in
Haiti. The food has been GR
allocated to four types of _.
programs -- maternal and MCH
child health (MCH), school 1. F 'CK 28.4% 24.5%
feeding (SF), food for 3.1% 27.s%
work (FFW), and general
relief (GR).

The relative importance Figure 4.2: A Comparison of the Distribution of Regular
attached to these programs Program Beneficiaries in FY 1995 and FY 2000
has changed over time.
Food for work was more important during the 1970s, whereas, more recently, more attention
is given to maternal-child health programs. School feeding programs remained popular for many
years despite evidence that they tend not to be well targeted to more food insecure households.
General relief programs increased in importance during the embargo years, when large amounts
of food were made available through hastily established community kitchens or cantines
populaires. This method of distribution turned out to be inappropriate in more rural areas and
was not effective in targeting resources either to the most vulnerable households or to the most
vulnerable members of those households. In FY 1995, school feeding programs accounted for
the majority of the beneficiaries of the non-emergency Title II program, followed by community
kitchens (CK) and the maternal-child health programs. Food for work and general relief to
orphanages and old age homes each. accounted for only 3.1 percent of total beneficiaries.
Current plans are to exit from general relief programs by FY 2000, to scale down the school
feeding program, and to increase..the numbers of participants in the maternal-child health and
food for work programs.

Large quantities of food assistance have been both an advantage and a disadvantage. The food
that has been distributed through the various direct distribution programs, including maternal and
child health and school and community feeding, has had a direct and positive impact on the food
security of large numbers of households and individuals. These programs were particularly
important during the 1991 to 1995 period, when they contributed significantly to reducing the
negative impact of the embargo and the subsequent economic crisis on the well-being of poor
Haitian households. Food made available under the Title III program also has helped increase
the supply of food and moderate increases in food prices. In the most recent agreement, the
policy reform agenda and the uses of the local currencies generated under the program have been
tied more closely to food security objectives.


* The availability of large amounts of food assistance has encouraged a tendency to
equate food security with feeding programs. The drawback to having large amounts of
food assistance available for Haiti is that it probably has encouraged the tendency to
equate food security with feeding programs and may have led to an excessive reliance
on food assistance to resolve Haiti's food security problems.

* Emergency food assistance programs focused USAID's attention on feeding people in
the short run and obscured the role that food aid can play in helping people improve
their food security over the longer term. Emergency food assistance programs have
dominated much of USAID's attention in the 1990s. The economic crises of recent
years, coupled with the drought in the Northwest, demanded that steps be taken to avoid
hunger if not outright starvation. In reacting to these crises, the use of food aid as an
instrument to promote food security in the longer term was relegated to the back burner.

* Food assistance programs also may have_ encouraged the development of dependency
on the part of program beneficiaries as well as program workers. Donated food has
been available to Haiti and to particular programs and communities for a long time. A
relatively large percentage of the population has been able to rely on food rations for a
number of years. This suggests the possibility that dependency and initiative-inhibiting
behavior may have taken root, even among those who have participated in better targeted
programs such as MCH and food for work. The modalities for distributing food have
contributed to the problem. The community kitchen programs were particularly
vulnerable to the charge that they created a climate of dependency and entitlement. The
fact that so many people, foreign aid workers as well as Haitians, depend on these
programs to make their living, raises a different type of dependency question.

* Food assistance programs have not paid sufficient attention to the importance of
complementary health and education inputs. Traditional social services have an
important role to play in the alleviation of food insecurity in Haiti in the short, medium,
and long run. In Haiti, poor dietary and sanitary practices and poor health are major
constraints to proper food utilization. Low levels of education are associated with low
levels of productivity and incomes as well as with poorer health and nutrition status and
larger families. In the design of food assistance programs in Haiti, insufficient attention
has been paid to the importance of complementary inputs. Food alone, in the absence
of complementary health measures such as micronutrient supplementation, growth
monitoring, and the promotion of better health and nutrition practices, including breast
feeding and appropriate weaning practices, is unlikely to have much of an impact on
child malnutrition. Food used to stimulate attendance at schools is not likely to have
much of an effect on what children learn if the quality of the education provided is low
because there are no textbooks available, because teachers are poorly trained and
frequently absent, because classes are overcrowded, etc.


* Food assistance programs have not been well integrated with each other or with other
Mission programs. Although the situation is changing, the Mission has tended to design
and manage food assistance programs independently of other activities. A particular case
in point was the development of the large community kitchen program during the
embargo. The practice also has been true even in cases where one logically might have
expected relationships to exist with other Mission activities -- for example, in health and
education settings. Title II programs also have suffered from the lack of standard
operating procedures. Programs with the same objectives and target groups vary both
in the levels and in the duration of the assistance they provide. Unit costs, measured in
terms of food costs and total cost per beneficiary, have varied substantially. The absence
of standards for monitoring and evaluation also has made it difficult to set priorities
among programs and to improve their management. The Title II and III programs have
not been linked conceptually, although Title III local currencies have helped cover some
of the logistical costs of Title II cooperating sponsors.

4.4.2. HEALTH

Haiti has some of the worst health indicators in the Western Hemisphere, especially for children
and reproductive-age women. Infant mortality approaches 80 per 1,000 live births, the mortality
rate for children under five is 130 per 1,000 live births, and maternal mortality is estimated at
460 per 100,000 live births. Epidemics of communicable childhood diseases are common, as
are outbreaks of environmentally linked diseases. The disease burden on children is enormous.
Over half of Haitian children have episodes of diarrhea every two weeks, and diarrhea accounts
for 48 percent of deaths of children between one and 11 months. Morbidity data confirm the
widespread prevalence of tuberculosis (two to three percent), sexually transmitted diseases (four
percent), and HIV infection, which affects seven percent of sexually active adults in urban slum
areas and 2.5 percent of newborns.

On the positive side, the Ministry recently defined basic principles for health policy for the next
five years. These principles include: (1) decentralization of decisionmaking and execution to
departmental and local levels; (2) restructuring the national health system around local health
systems or community sites called UCSs.(Unit6s Communales de Sant6); and (3) guaranteed
access to a minimum package of basic services. The UCS strategy has many positive attributes
for the development of basic health services for a wide range of under-served populations and
provides an integrating focus for government, NGO, and donor funding for health services at
the community level. The focus is the services to be provided, not the structures through which
they will be delivered. This approach will allow development of many models of services
delivery. This means that a UCS could provide services through government facilities managed
by the Ministry of Health and Population (MSPP), through government facilities managed by
an NGO, through NGO facilities connected with a government hospital, through a private-for-
profit (franchise) health facility, through a for-profit group practice of doctors providing
community health services, through a health facility with effective outreach services, or through
a community-based program with referral services. The flexibility that the UCS concept offers


is a plus in the Haiti context. Still, the development of effective UCSs will not be an easy task,
given the weakness of the current system, particularly at the community level, and the
complexity of coordinating services and different funding sources among different community
service providers.

A number of donors either are active or are planning to become active in the health sector in
Haiti. The World Bank is financing a $28.2 million health and population project that includes
components to establish basic health service models in the country's western and southeastern
health departments, to establish a national tuberculosis program, and to reduce the transmission
of HIV and other STDs nationwide. USAID's Health Systems 2004 Project will provide $50
million over 4.5 years. It includes a policy component to work with MSPP in the development
of national policies, norms, and standards. It also includes support for MSPP, NGOs, and
commercial providers to deliver child survival and primary and reproductive health care in
geographically focused areas throughout Haiti. The project also supports national programs in
immunization, family planning, HIV/AIDS prevention, and nutrition. The IDB is designing a
$35 million project to support the reorganization and rationalization of the health sector. The
IDB also is providing $35 million in assistance to rehabilitate rural water systems, and a project
financed by the World Bank (IDA) and France is expanding coverage in Port-au-Prince. The
government has requested assistance from the IDB to improve sanitation conditions in Port-au-
Prince and is preparing a Port-au-Prince sanitation master plan with World Bank (IDA)
assistance. The IDB and World Bank also have provided $23.7 million (the IDB is scheduling
an additional $30 million) through Haiti's Economic and Social Assistance Fund (FAES) to
finance critical social infrastructure, particularly health and education facilities. CONSTRAINTS

* Publicfinancing of the health sector is low and unsustainable. Public expenditures on
health in Haiti are strikingly low and have been declining. Between 1990-91 and 1994-
95, public spending in the health sector varied between 1.1 and 0.7 percent of GDP, or
between $20.7 and $17.7 million. The contribution from international donors varied
between $23 million in 1990 and $52.9 million in 1995. A significant share of external
funds were directed to NGOs under the category of humanitarian assistance during the
recent political crises. Private spending is estimated to make up more than half of health
sector financing in Haiti. External donors contribute nearly one third of all expenditures,
and public expenditures provide the rest. This pattern of expenditures is largely a
function of the recent crises. As Haiti regains social and political stability, the public
sector must emerge as a stronger actor, especially in setting health policy and service

* Allocation of public sector health resources is inefficient. The distribution of resources
within the public health sector in Haiti suffers from two problems. First, purchases of
complementary inputs are crowded out by spending on personnel costs. It is estimated
that about 90 percent of the government's health budget is allocated to personnel. Little


remains for urgently needed drugs, supplies, and maintenance. Second, scarce public
resources are allocated disproportionately to hospitals and, in particular, to facilities
within Port-au-Prince, at the expense of primary care and health programs in the rest of
the country.

S The provision of health services is uncoordinated. The current configuration of the
Haitian health system reflects political, economic, and social upheaval, rather than any
systematic planning to address the critical health needs of the population. The role of
NGOs and the number of NGO facilities' have increased as the public system has
deteriorated. The NGO sector now is a major actor in the health care system. Of the
573 health facilities in the country, 36 percent are private (primarily NGOs), 26 percent
are mixed public-private, and 38 percent are public, operating under the auspices of
MSPP. NGO facilities, while providing vital services to many of the country's poorest
populations, operate outside a regulatory framework and without government oversight.

S Institutional constraints limit service delivery. Lack of qualified personnel, drug
shortages, and disrepair of facilities limit the availability of services, particularly in areas
outside of Port-au-Prince. Pharmaceuticals and contraceptives are not available
uniformly at service delivery points, and those that are available are too expensive for
most clients. Part of the problem can be traced to the lack of overall accountability in
the system. The system includes: a central procurement agency (PROMESS), managed
by PAHO; peripheral depots, built by the World Bank and separate from PROMESS; and
service delivery points managed either by MSPP or by individual NGOs. NGOs are
expected to pay cash for the drugs they purchase and transport them to the health
facilities. Other systems also need to be put in place if the UCS strategy is to succeed.
Many service delivery points, especially those in rural areas, do not have trained staff.
The staff they do have are not supervised or paid in a timely fashion.. Referral systems
are lacking. And financial systems are inadequate.

S Policies are inconsistent with broad access to health services. Many policies currently
in force do not promote the widest possible access to health services. For example,
many health facilities open only a few hours a day and, thus, limit the ability of mothers
to receive services. Policies that give short shrift to self-treatment and emphasize the
need to visit health facilities often mean that clients receive no treatment at all. And
reliance on doctors, even medical specialists, for routine procedures limits the availability
of some contraceptive methods.

S Coordination also is lacking within the donor community. Although donors to the
health sector, which include WHO/PAHO, the European Union, USAID, the World
Bank, the Inter-American Development Bank, and UNICEF, attempt to maintain informal
contacts, the potential for duplication, overlapping programs, and even conflicting
programs remains considerable. The Ministry has not yet been able to take a leadership
role in coordinating donor participation in the health sector.



The current policy of the Ministry of Health and Population includes a strong focus on
improving child nutrition. More specifically, the current policy is that each child have access
to a package of integrated services, within which nutritional services play an important role.
The model envisioned by MSPP encompasses growth monitoring, nutrition education, and
targeted supplemental food for the malnourished, coupled with other community interventions,
as well as other services such as immunization and deworming. The providers of these services
will be the UCSs. The minimal package is to include: (1) integrated management of the child;
(2) management of pregnancy and delivery; (3) management of medical and surgical
emergencies; (4) communicable disease control; (5) dental care; (6) essential drugs; (7)
sanitation and potable water; and (8) health education. Examples of the types of nutrition and
health activities that can be expected to contribute to food security in Haiti are identified in
Table 4.1. The advantages and disadvantages of selected alternatives are discussed in Table 4.2
at the end of the chapter.


Direct Nutrition Interventions Non-Specific, Health-Oriented

Rehabilitation of the malnourished child: Control of diarrheal diseases through:
at a hospital + health education
at a rehabilitation center oral rehydration therapy (ORT)
+ at home adequate feeding during the episode

Screening and early diagnosis through nutritional Vaccinations
of at risk groups Treatment of respiratory infections (ARIs)
of the community
Malaria prophylaxis
Nutrition education, including:
breast-feeding promotion Health referral systems
weaning foods
Family planning
Supplemental feeding for:
4 children under five Health education
pregnant women
Prenatal care


The program is a long way from implementation, however. The minimum package has not
been defined in full. Although several small area health systems might be considered to exhibit
elements of a UCS, no UCS currently exists. Some elements of the minimum package are likely
to be better implemented than others. For example, service providers pay particular attention
to EPI services, less to family planning. Few organizations have set up integrated management-
of-the-child programs, and many have no program to address chronic diseases such as
tuberculosis and malaria. Even in "better-off" areas, there. is no continuity of care at the
periphery: a sick child currently has nowhere to go for treatment except to a health center,
which may be far away. These problems are amplified in areas where no organized community
health activities exit. Theoretically, the 2.5 million people living in urban areas have access to
health services. Of the remaining five million people, about 2.5 million are reached by
organized community health systems. Thus, 2.5 million people have very poor, or no access
to health services. Finally, the quality of services has not been addressed in a systematic manner
on a nationwide basis, although it has been reviewed in the evaluation of several projects,
particularly family planning projects. CONSTRAINTS

Specific constraints to implementing the nutritional component of the health program include:

* Only two million people, corresponding to roughly 300,000 children under five years of
age, live in areas where growth monitoring is carried out on a community basis. The
existing infrastructure took ten years to put in place, at considerable investment. The
investments needed to extend this approach to the rest of the country are formidable.

Many organizations that implement health programs refuse to distribute food rations,
stating that such rations provide an artificial stimulus for the use of health services.

+ Even in very well run programs, attendance at growth monitoring sessions oscillates
between 50-70 percent of target children.

* There is no documentation in the literature that growth monitoring programs, when
carried out on a large scale, have a positive impact on nutritional status.

Such models treat children when they are already malnourished -- that is, too late --
while having little or no impact on the prevention of malnutrition.

Growth monitoring also has a positive side of the coin. In small area programs, where growth
monitoring takes place on a community basis, it furnishes a ready-made channel to target food
assistance to needy families. Furthermore, individual growth monitoring can furnish a way to
revitalize underutilized, mostly public, health centers and dispensaries, improve their utilization,
and thereby increase coverage for health services in general.


Even if the health system could reach the entire population, there are technological constraints
that limit the impact of health interventions on nutrition.

There is no guaranteed way to prevent low birth weight. Alternatives include providing
supplemental food to pregnant women (see discussion in the Annex to Chapter 2) or mass
treatment of genital infections during pregnancy. This newer approach has been explored
in the past 15 years and still is being investigated.

The anti-measles vaccine is effective as of the age of nine months. By that time; 40
percent of infants already will have sero-converted to measles.

In two important areas, technological constraints do not rear their ugly head:

There are currently no technological constraints to the improvement of contraceptive
prevalence in Haiti.

The 'means to provide potable water to the population exist, and ORT is a well-
recognized intervention for the treatment of diarrhea.


Although the rate of natural increase of the population remains at over two percent, Haiti has
made progress during the past seven years in reducing its fertility rate and increasing use of
contraceptives. The total fertility rate declined from 6.3 children per woman in 1987 to 4.8 in
1994, a drop of 24 percent in less than ten years. Fertility declines have been particularly sharp
in the peak child-bearing years ages 25 to 34. One important factor contributing to the overall
fertility decline has been the increased use of modem family planning. Since 1987, the
percentage of married women using contraception has increased from seven to 18 percent,
including the 14 percent who currently use modem methods. The increase in contraceptive use
has been particularly strong in urban areas, but rural areas have made significant progress as
well. In fact, there is widespread awareness of contraception and heavy demand for family
planning services throughout the country. Nearly 99 percent of married women know about at
-least one modern method of contraception. When asked about their desire to limit or space
child-bearing, almost 50 percent of women interviewed in the EMMUS II survey said that they,
did not want any more children, and an additional 22 percent indicated a desire to delay their
next child at least two years. Desired family size also has decreased significantly from 4.8
children in 1987 to three children today. As a result, 48 percent of currently married women
have an unmet need for family planning services.


* The number of service delivery points is inadequate and the supply of services at these
points is unreliable. The key constraint to a dramatic expansion of the use of
contraception is the lack of a reliable supply of services. According to a recent facilities
mapping study, only 80 percent (460 of 573) of health facilities in Haiti currently provide
family planning services. In 1994-95, an additional 23 percent of facilities had
interruptions in contraceptive services or supplies. The only methods commonly
available at most facilities are oral pills, condoms, and injectables, and many of them are
not available to clients because of provider bias. A major reason for the absence of
services is the lack of trained providers at many service delivery points. Many providers
are unwilling to live in isolated rural areas where basic amenities such as housing, water,
electricity, and telephones are not available. Another reason is the lack of support for
public health providers, many of whom do not receive their salaries for months at a time
and are likely never to see a supervisor or receive communications from headquarters.

* Contraceptives are not readily available. PROMESS, the central procurement agency,
has not given high priority to contraceptives. The pharmaceutical distribution system
included contraceptives as part of its routine formulary just recently, and still seems to
treat contraceptives as an optional item in its essential drugs program.

* The Haitian medical community has overmedicalized family planning. In other
countries, medical personnel other than doctors routinely provide some contraceptive
services. In Haiti, only doctors can provide them. This practice limits the availability
of contraceptive services and increases their costs. Examples include dispensing multiple
cycles of oral contraceptives and the insertion of IUDs and injectables.

* Donors have relied too heavily on the private sector. Since the mid-1980s, donors have
provided support almost exclusively to private family planning activities. Reasons
include the weak performance of the public health sector as well as overall political
instability. Although this support has contributed to the increase in contraceptive use in
the country, it is questionable whether the private sector -- both for-profit and non-profit
-- will be able to provide quality reproductive health and family planning services to the
entire population. Many private, non-profit providers of family planning services have
a narrow base, are unsustainable, and work in isolation from each other.

* The Government of Haiti has not given enough attention to population and family
planning issues. Despite the importance of family planning to the people and the
economy of Haiti, there remains a lack of strong and sustained political support for such
services both within the Ministry of Health and Population and more broadly throughout
the government. The government does not have a national population policy; nor is there
a commitment on the part of MSPP to attach high priority to family planning and
reproductive health services as part of the basic package of health services to be provided
in all health facilities throughout Haiti.



Human capital formation is an essential ingredient of all progress toward sustainable
development, and basic education has the most favorable cost-benefit ratio of all human capital
formation. All countries ranking high on either economic or human development scales have
excellent primary education systems, while all countries with low rankings, such as Haiti, have
deficient systems. Education affects development directly by increasing knowledge, competency,
and flexibility of the labor force, and by improving the discipline and productivity of labor.
Education is also an indirect cause of development through its effects on health, life expectancy,
fertility, personal incomes, and the quality of life.

In Haiti, the demandfor education is high, and Haitians of all classes sacrifice a large part of
their incomes for education. Most parents now try to send all their children to at least primary
school, and, on average, spend an estimated 16-17 percent of their incomes on schooling. Social
returns are low, however, because of the system's inefficiencies and because the economy fails
to transform educational achievement into more than modest productivity gains.

The private sector, which includes a multitude of private voluntary organizations, religious
orders, and private entrepreneurs, is playing an increasingly important role in the educational
sector in Haiti. Thirty five years ago, private schools accounted for only 20 percent of total
enrollment. In primary education today, they account for 66 percent of enrollment, 86 percent
of schools, and 70 percent of teachers. From an organizational perspective, therefore, the
educational sector is highly decentralized. Some may view the limited role of the government
in the provision of educational services as a constraint -- even a failure -- of the public sector.
An alternative view is that its diversity makes the sector more crisis-proof than a centralized
system would be. Even if some parts fail to perform, there will be others in the sector willing
to accept enrollment spillovers and move into market niches.

The government currently is working on a National Education Plan. The plan will give priority
to redefining the role of the Ministry of Education, giving more emphasis to its leadership and
supervision role, and to institutional reform. The Ministry has three objectives: (1) the
establishment of an open and accessible but fee-paying school system; (2) the provision of
quality education; and (3) the creation. of a partnership among the Ministry, parents, and

USAID, through its Incentives to Improve Basic Education project, has provided support to
education in Haiti since 1986. Most of the support has focused on private schools and on
primary education. Other donors have and will continue to focus primarily on public schools.
Both the IDB and the World Bank are designing new projects to support development of basic
education. The IDB's $30 million project is expected to focus on the provision of texts and
materials, revamping the financing of education, and improving teacher training. The European
Union is assisting the Ministry of Education meet its non-wage recurrent expenditures.


* Access to education is limited. Although formal schooling has a long history in Haiti,
educational opportunities for the vast majority of Haitians are limited by spatial and
economic constraints. The dispersed location of much of the rural population imposes
a heavy price in energy on rural children who attend primary school and effectively
excludes them from secondary education. The direct and opportunity costs of education
also impose a heavy burden on the rural and urban poor, and result in strong fluctuations
in school attendance in response to prevailing economic conditions. The upshot is that
Haiti has the highest rate of illiteracy -- over 50 percent -- in the hemisphere.

* Educational efficiency is low. Haitian schools are marked by high attrition rates at
every level. Grade repetition and dropout rates are hard to assess because of frequent
school changes, but their overall effect is well known. It takes 12.5 student years to
produce a single primary school graduate. The school career of most children consists
of several enrollments, withdrawals, and repetitions. Two thirds of all places are filled
by students who are overage by at least three years, most of whom will never graduate.
Crude enrollment rates are deceptively high (close to 80 percent), but graduation rates
and throughput to secondary school are low. Most children drop out after a few attempts
at completing preschool. Some never complete first grade.

* The quality of education is poor. School quality is high in a small number of urban
schools run mostly by religious orders, but on the whole it is very low. In private
schools, which, again, teach two thirds of enrolled children, only 12 percent of teachers
are qualified. In public schools, only half are. Most schools are ill equipped and in
disrepair, and most pupils have no textbooks or materials. Deficiencies in supplies,
overcrowded classrooms, inadequate supervision, and a generally low level of
organization complete the picture. About 14 percent of private schools operate in the
open air, sometimes without benches.



Advantages Disadvantages

Treatment of the malnourished child in a hospital, rehabilitation center, demonstration foyer or at home

* This approach treats those who need help the most and saves on This approach is curative rather than preventive. That is, the
scarce resources. child is treated after it already is malnourished.
Centers known as foyers de demonstration, which provide This approach also requires a nutrition surveillance/growth
intensive education to mothers, may be effective in the short term monitoring infrastructure that needs to be extensive to cover the
(70 percent of children will improve if rehabilitation is carried population at large.
out well). In certain circumstances, a permanent educational Evaluations of Haitian programs have shown them to be costly,
effect also is seen (Augustin, et al., 1994). to need well trained and motivated workers, and to have severe
* Such programs could be developed where there already exists an limitations in coverage (Beaudry-Darism6 and Latham, 1973;
extensive infrastructure for community-based nutrition Augustin, et al. 1994)
surveillance of pre-schoolers and where resources exist to
educate mothers in the appropriate use of locally available (and
bought) food.
Early screening and diagnosis through growth monitoring
* By identifying growth faltering early, mothers can be alerted and 4 The impact of these programs may be limited if they are not
motivated to give more food to the child. coupled with an education component and some specific
* In any "best practices" book, any child who is in contact with the intervention for those found to be malnourished.
health sector has his or her weight taken and plotted on a growth This approach also requires well trained, well motivated, well
chart. This allows both mother and practitioner to determine supervised field personnel and numerous weighing stations close
whether the child is growing normally. Growth monitoring is to the home (rally posts).
part and parcel of the "integrated management of the child" Another problem with these programs is that only 50-70 percent
wherever the health infrastructure exists to carry this out (ideally of the children come regularly to be weighed (Henrys, et al.,
it should be carried at ill health institutions in the entrntry as part 1991; Beggren, personal communication).
of the health package).
* Henrys, et al. (1991), have reported a positive impact of a
community-based growth monitoring program in Thomonde,
which did not use supplemental food distribution.


Growth monitoring, nutrition education, targeted supplemental food (i.e., the standard package), using donated food

* This is known in some circles in Haiti as the "CRS" model that
was initiated in 1990 under the VACS project and that included
three components: 1) MCH activities at both the community and
clinic levels (which include nutrition recuperation and
surveillance for children and a food supplement for mothers); 2)
income-generating activities for community health workers; and
3) small-scale water and sanitation activities in communities
participating in the MCH program. On the basis of a positive
evaluation, CRS is to expand the model to add, ional
communities in the southern peninsula of Haiti.
* This approach identifies and works with high-risk households
who need services the most and does not waste resources on
those who are not in need.

* This approach is curative rather than preventive. That is, the
child is treated after it already is malnourished.
* This approach also requires well trained, well motivated, well
supervised field personnel ani numerous weighing stations close
to the home (rally posts), with an anticipated 3000 health
workers employed for rural areas alone.
* This approach also requires the permanent availability of food

Growth monitoring and use of local food instead of onated food for supplementation

* This is known in Haiti as the Canadian ("CEC ") model. It has
the same advantages and disadvantages as the 2RS model..
* The education component would be more sust. inable if mothers
are taught which local food to buy.



Supplemental food is targeted to selected groups, such as pregnant women and children under two or three

* Limiting food distribution to children already malnourished may
not be cost-effective, because over half the children under two
suffer from some form of malnutrition.
* Recent data suggest that it also is important to correct mild
* A significant number of pregnant women in Haiti are
underweight pre-pregnancy and would benefit from adequate food
intake to guarantee proper weight gain during pregnancy.

A massive distribution of food on a national level would require
an extensive distribution network even if the targeting were made
simpler by focusing on all pregnant women and all children
under two.
. The evidence that supplemental food during pregnancy impacts
on birth weight is ambiguous, although data on food reserves of
pregnant women in developing countries suggest a need for
Making food available to all pregnant women and all children
under two might discourage the behavior of "positive deviants,"
i.e., those who manage to cope despite severe limitations in
There is a danger that this approach would artificially increase
the demand for health services and that this demand would not be
sustainable once the food is gone.
Making food available to all pregnant women with no limitations
on the number of times a woman could participate in the
program might encourage additional pregnancies.

Provide dietary supplements micronutrientss), i.e., iron and folic acid to pregnant women and Vitamin A to children from six months to six

* Ironlfolate supplementation has been found to be the single most A service delivery mechanism must be in place to make
effective intervention in terms of prenatal survival in several micronutrients available to the community.
international studies.
* In Vitamin A deficient populations, similar to Haiti's, distribution
of Vitamin A capsules has led to a 30 percent decline in the
mortality of children of over one year of age.
S Micronutrients are cheap. By providing them to those who make
regular use of existing health services, a significant proportion of
the population could be reached without significant additional



This chapter covers a lot of ground. Not only does it lay out policy and programmatic priorities
to advance food security in Haiti. It also seeks to explain the reasoning that leads to the
priorities selected. Since food security is multidimensional in character, the upshot is that the
chapter has many messages to convey. To ease the burden on the reader, the diagram on the
following page summarizes the chapter's main messages. It also attempts to portray
schematically the logic that leads to the proposed strategy's major policy and programmatic


Of the three rubrics of food security -- availability, access, and utilization -- lack of access is
the root cause of food insecurity in Haiti. In other words, Haiti'sfood insecurity is more than
anything else a question of poverty. If poverty can be reduced, lack of availability and poor
utilization can be addressed as well.

In what follows, a strategy is outlined that attaches highest priority to poverty reduction. As
discussed in Chapter 1, however, poverty reduction is a medium- to long-run proposition. In
the short to medium run, large numbers of Haitians will continue to be malnourished or at
nutritional risk. In particular, substantial numbers of young children will continue to be
vulnerable to irreversible physiological damage unless measures are taken to enable them to
benefit from whatever food to which the incomes of their households give them access. As a
consequence, the proposed strategy's primary focus on income generation for the poor will be
complemented by a focus on utilization, especially on Haiti's most nutritionally vulnerable
population, children less than two years of age either currently malnourished or at high
nutritional risk.

-Strategically, food availability is an important, but secondary concern. If Haiti's poor were not
poor, that is, if they could translate their nutritional needs into effective demand for food, food
availability would increase markedly, either through increases in national production or through
increases in commercial imports. Producing food often is a cost-effective way for poor
households to increase their access to food. But increasing food production is only one.-- and
not always the most cost-effective -- way to bring about that result. Furthermore, it is not an
end in itself.


Haiti's food insecurity has its roots in poverty

Reducing poverty permanently requires adoption of developmental perspective

Malnutrition calls Haiti cannot grow
less for reactive its way out of
treatment and more poverty fast enough
for active to make everybody
prevention food secure

Preventing Family planning is
malnutrition essential
requires integration
with health services

Minimum health
package includes:
4 Immunizations
* Child feeding
* Treatment of
sick children
* Health education
+ Family planning
* Prenatal &
maternal care

Targeting of food to
mothers & children
less than two at
nutritional risk can

development of
UCS system

Give high priority
to potable water &
sanitation, including
through cash and
food for work

1 I

Permanent solution to poverty requires sustained high rates of
economic growth

To expand economic activity inclusive of poor .

Raise productivity Promote investment Attack fundamental
of labor, especially by macroeconomic
through basic constraint of low
education effective demand by

Focus on 1. Inculcating Broadening access
improvement of favorable to markets, both
educational quality investment climate externally &

2. Rehabilitating
and maintaining

Main consraint to
expanding market
access is lack of
physical access

3. Expanding access Give high priority
to market to roads, including
information, through cash and
technology, & food for work
financing, e.g.,
through business
promotion centers

Rural areas are Exodus from rural Proportionally, Many public investment Social service budgets are
overpopulated areas is underway. Port-au-Prince is decisions have geographic stretched. It is impossible to
economically. Haiti is urbanizing most dominant dimension, service everybody everywhere.
rapidly. capital city in Choices must be made.

The logical place to shift the current bias away from Port-au-Prince, to accommodate the exodus of population from rural areas, to focus
limited social services, and to support emerging economic activity both agricultural and non-agricultural is Haiti's secondary cities.


It is one thing to define Haiti's food security problem and to list constraints to solving it; it is
another thing to suggest appropriate solutions. To do that, one must have a clear conception not
only of where one is now, but of where one would like to go. In what follows, the strategy
team presents a vision of Haiti in the year 2010. The vision is not a projection, but a value
judgement tempered by a sense of the possible. By making its desired destination explicit, the
team presumably can make more informed choices among competing policy and program options
on how to get there.

The vision that follows paints a picture of what Haiti ideally will be like in approximately 15
years from now under the assumption that things go reasonably well between now and then. The
characteristics of this "realistically optimistic" vision of Haiti are:

* Economic growth rates will gradually approach eight to ten percent a year, and the
natural population growth rate will decline from 2.1 percent to 1.5 percent. As a result,
a smaller percentage of Haitians will suffer from poverty in 2010 than today.
Nevertheless, a substantial number of Haitians will continue to be poor. If roughly two
of every three Haitians are poor today, roughly one of every two will be poor in 2010.

* Acute malnutrition and micronutrient deficiencies virtually will disappear. Chronic
malnutrition will halve to approximately 15 percent. The principal cause of chronic
malnutrition will be low birth weight.

* Rural population will increase, but the trend toward urbanization will accelerate. By
2010, there will be close to a 50-50 split between Haiti's rural population and its urban
population. Food insecurity will become increasingly an urban problem.

* Population growth rates will be highest in Haiti's secondary cities, especially in the half
dozen secondary cities that have grown by at least a factor of four since 1950 and that
currently contain at least 20,000 inhabitants. Port-au-Prince will grow, but its rate of
growth will slow. In sum, Haiti's population will be more urbanized, but less
concentrated in the capital city.

* Primary agriculture will grow, but less rapidly than other sectors. Backward and
forward linkages with primary agriculture will take on much more significance. Haiti's
principal cities will be the base of expanded and more efficient agricultural input,
processing, and marketing industries. In short, primary agriculture and its ancillary
industries will be more modern and productive.

* Haiti will produce more food, but will meet an even higher proportion of its food needs
with imports. Commercial imports, which it increasingly will be able to afford, will
make up the lion's share of Haiti's food import bill. Food aid will decline both


proportionally and absolutely. Haiti will be far from food self-sufficient, but it will be /
more food secure.

* Proportionally, Haitian agriculture will shift production out of basic grains to high-value
crops, exploiting comparative advantage. The country's most dynamic farmers will
produce for niche markets, both internally and externally. (. ~J-
~ /^aQQLR t^-. cnL4/4 -
S Haiti's strategic watersheds will be stabilized and protected. Outside of strategic
watersheds, environmental degradation will continue.

S Light manufacturing will be the main engine of Haiti's future economic growth. The
bulk of light manufacturing will be for export. Light manufacturing operations will be
spread among Port-au-Prince and the country's principal secondary cities.

S Haiti's road network will improve dramatically. Good trunk roads will connect Port-au-
Prince and the country's principal secondary cities. Access roads will connect strategic
watersheds with major cities. Roads in most of the rest of the country's rural areas will
continue to be poor.

S The private sector will manage essential public utilities, -especially electricity,
telecommunications, and (sea and air) port services. The companies in question will
furnish effective service not only in Port-au-Prince but also in the country's principal
secondary cities.

S As Haiti becomes increasingly urban, more of its people will benefit from social sector
services. An increasing proportion of investments in primary health, population
programs, and basic education will be directed to Haiti's principal secondary cities, but
local governments still will have difficulty meeting the burgeoning demand of urban
dwellers for social sector services. Realistically, budgets will continue to be inadequate
to meet the social sector service needs of most people in rural areas.

S Primary school efficiency will rise from roughly 50 to 75 percent: more students will
complete primary school and, on average, they will complete it in less time. The quality
of primary education also will improve markedly. The number of secondary schools will
increase, as will their quality.

S The growth of Haiti's secondary cities will bring with it a decentralization of economic
power. The power of the purse will shift markedly away from Port-au-Prince. Local
governments will become much more active protagonists of development.

S Emigration from Haiti will continue to be a two-edged sword. On the one hand,
emigration will continue to be an escape valve from poverty. On the other hand, Haiti's
best educated people will find it easiest to migrate.



Every strategy team brings a mindset to its interpretation of the facts. Ultimately the acceptance
or rejection of its strategy will depend on the degree to which readers share that mindset. Prior
to presenting the specifics of the proposed food security strategy, therefore, this section attempts
to make explicit the principles that guide the team's selection of policy and program priorities.

There are so many worthwhile things one can do to improve food security in Haiti that
one can justify practically any intervention he or she can think of. The difficulty is that
the resources available to address food insecurity pale alongside the magnitude of the
problem. As a consequence, opportunity-cost thinking is essential.

When faced with the juxtaposition of a plethora of needs and a modicum of resources, one must
assess carefully how one chooses to allocate development resources. Any time a scarce resource
-- US dollar, Haitian gourde, or food -- is spent on one thing, it means that it is not spent on
something else -- where potentially, at least, it could fetch a higher social return.

Firm, coherent monetary and fiscal policy is essential to put Haiti's economic house
back in order and to restore public confidence in economic policymaking.

The government is to be commended for the discipline it is exercising on the macroeconomic
front. There now must be no turning back. A consistent hand at the macroeconomic policy
rudder is a precondition for sustained, steady growth in the future.

For a country like Haiti to reduce permanently the number of its people in poverty, its
economy must grow for a number of years at a rate of eight to ten percent a year.

Growth in Gross Domestic Product on the order of four to five percent a year obviously is better
than no growth at all, but does not amount to much more than a holding pattern. For sizable
numbers of poor people to cease being poor people, sustained, dynamic growth is essential.
Fortunately, experience in other parts of the world, especially in East Asia and more recently
in other countries in Latin America and the Caribbean, suggests that growth of that magnitude,
though still years away for Haiti, is not a pipedream. For it to occur, however, one must think
big and be ready to depart from business as usual.


The generous response of external parties to Haiti's crises in recent years has
contributed to a climate of dependence, which is antithetical to a long-term poverty
eradication strategy.

International donors and non-governmental organizations are to be commended for the generosity
of their response to the crises of recent years. Their support literally saved lives. The flip side
of the coin, however, is that the very liberality of the response has reinforced a predisposition
to look at poverty in Haiti as a "welfare" rather than an economic growth problem. Now that
the crises ideally have passed, the time has come to reintegrate the poor as active participants
in the market economy. Haiti's development challenge is not to substitute for market forces,
but to make markets work for the poor.

Realistically, Haiti cannot grow its way out of its food security problem fast enough to
address the problem in its entirety. Population programs will continue to be essential
for the foreseeable future.

Below it is argued that light manufacturing, especially for export, probably is the likeliest sector
to look to to restore economic dynamism. The development/redevelopment of that sector will
take tme. As a consequence of the economic embargo of recent years, relationships between
foreign buyers and local manufacturers that had taken years to build disappeared over night.
Those relationships -- and, in fact, the image of Haiti as a country in which it is attractive to
invest -- will take considerable time to rebuild. Thus, no matter how appealing the notion of
light manufacturing may appear, there is no way that sector will be able to create jobs fast
enough to meet the entirety of the labor force's pent-up and rising demand for jobs. In addition
to the health and human rights arguments that can be advanced for population programs,
therefore, the economic case is clear as well.

For Haiti to make a permanent dent in poverty, the productivity of its poor people must
increase. For the productivity of its poor people to increase, they must have more
capital, both physical and human, to work with.

By all accounts, Haitians are hard-working people. Why then is the productivity of Haiti's labor
force so low? In comparison with labor forces in other countries, the Haitian labor force has
relatively little physical capital at its disposal and exhibits relatively low levels of educational
attainment. As a consequence, investment promotion and education call for high priority


Realistically, poor people have limited capacity to expand physical capital on their own.
As a result, one must look to the non-poor, both in and outside Haiti, for the lion's
share of the investment required for future growth in jobs and incomes.

For many purposes, it is desirable and admirable to work directly with the poor in resolving
their problems. Realistically, though, there are limits to how far, by itself, such a strategy can
go. Haiti's needs for employment-generating investment far exceed the capacity of poor people
to do it themselves. As a consequence, the climate for investment in Haiti is a matter of
primordial importance. To generate jobs, Haiti needs to attract risk-taking employers. A logical
first place to look for such investors/employers is the Haitian diaspora.

Both macroeconomically and locally, the major constraint to development in Haiti is
lack of effective demand. As a result, connections with outside markets are essential.
In other words, Haiti must export, both externally and internally.

Nationally, Haiti's productive apparatus is constrained by the low level of effective demand --
that is, purchasing power -- within the country. As a practical matter, therefore, Haiti has no
choice other than to look to external markets for buyers of its goods and services -- and to make
its investment climate one that is oriented outward rather than inward. Looked at another way,
setting up free trade zone enclaves is not enough. The challenge is to encourage and open the
entire economy to trade.

The same argument has validity at the local level. Despite their heavy dependence on markets,
poor people, especially those in isolated areas, typically enjoy only limited access to them. To
break out of the low-level equilibrium trap in which they find themselves, it is essential that they
enjoy access to a broader range of market opportunities.

In Haiti, the best public investment for expanding market access is roads.

In principle, there are a variety of policy and program actions that can tie markets together and
tie currently poor people into those markets. In Haiti, however, there is little doubt that the
appalling state of roads both trunk and access roads -- is the major impediment to integrating
domestic markets and linking them in turn with international markets. As a result, the
rehabilitation of the country's road network must be public investment priority number one.


The place one finds a problem is not necessarily the best place to attack it. As a case in
point, the location of the majority of Haiti's most food insecure people in rural areas
does not necessarily make rural areas the best place to attack their food insecurity.

There appears little doubt that the majority of Haiti's most food insecure people live in rural
areas and engage -- among other pursuits -- in agriculture. One programmatic response to the
plight of such people might be to focus primarily on raising agricultural productivity. Such a
response could be second-best. Existing population-land ratios, especially in Haiti's hills, are
too high for a productivity-increasing strategy by itself -- to generate sufficient incomes to lift
significant numbers of poor rural households above the poverty line. In addition, the resource
base of the areas in question is too fragile to support much additional population pressure in any
case. Such considerations suggest that it may be advisable to consider program responses
outside the areas of extreme food insecurity themselves. Haiti's rural poor appear to have
internalized that lesson themselves, as the diversity of their income sources bears witness.

The logical place to focus public investments is the country's principal secondary cities
and their respective countryside.

In one sense, promotion of growth in Haiti's secondary cities and neighboring countryside is
the country's only reasonable development choice. On the one hand, the current pattern of mass
migration to Port-au-Prince is neither desirable nor sustainable. On the other hand, Haiti's rural
areas are overpopulated now, and will continue to be so, even with conceivably dramatic
increases in agricultural productivity. Moreover, and as painful as it may be to acknowledge,
reaching all of Haiti's most food insecure people-- and Haiti's most food insecure people are, t
almost by definition, its most isolated physically -- lies beyond the country's budgetary grasp
Hard choices therefore must be made. As a matter of relative priority, focusing public
investment on the country's principal secondary cities is the sensible choice -- not only to service
a substantial portion of Haiti's currently poor population, but also to furnish relatively attractive
places for currently isolated poor people to migrate in the future.'

SA secondary cities strategy is an agricultural and rural development strategy. .

A strategy of decentralization to secondary cities not only is a way to deflect growing population
pressures in Port-au-Prince; it also is a logical outgrowth of thinking through what "rural"

'Secondary cities often have been the first haven of poor people leaving rural areas for gainful
employment. During the embargo, these migrants were referred to as "internal boat people." Internal
boat people may become "external boat people" once again unless, between them, secondary cities and
Port-au-Prince step up the pace of generating jobs.


development must entail in coming years. There are two ways of thinking of agricultural and ,
rural development, as a supply-push process and as a demand-pull process. If one thinks of
agricultural and rural development in supply-push terms, one focuses on productivity concerns
and how much additional product can be "pushed" from the countryside. If one conceives of
development more as a demand-pull process, then one shifts one's focus to look at overall
effective demand in the economy and the potential role that cities and market towns can play in
"pulling" agricultural production out of rural areas. Both development theory and programmatic
experience in a variety of countries including Haiti -- suggest that the latter perspective is the
more appropriate of the two. When the development process is looked at in that way, city and
countryside are not rivals, but allies. The two demand goods and services from each other: in
the city, industries with backward and forward linkages with agriculture grow and mature, and
absorb the continuing exodus of rural dwellers; in the countryside, increases in effective demand
in the city furnish real incentives to invest in primary agriculture and make it more productive,
modern, and profitable.

As a practical matter, when one talks about the economic potential of a secondary city, much
of the discussion revolves around the economic potential of its surrounding, rural areas. It may
be that processing activities take place in the city, but the products processed typically have their
origins in the countryside.

Agriculture will continue to be a significant sector of the economy for the foreseeable I
future, but it cannot be looked to as Haiti's lead engine of dynamic growth.

There is ample evidence available that returns on investment in agriculture can be high, both on
the plains and in the hills. For that reason, investment in agriculture will continue to make
sense. That said, it is difficult to believe that agriculture in Haiti, even with substantial
investments in lowland irrigation, can be the lead engine of the eight- to ten-percent growth rates
required to lift substantial numbers of Haitians out of poverty and food insecurity.

SGeographically, the appropriate unit for investment in agriculture is the watershed.

In Haiti, it is common to debate the relative priorities to be given to hillside agriculture and to
plains agriculture. As a practical matter, the two ecosystems are related intimately and cannot
be divorced from each other. Rather than thinking in horizontal terms, therefore, it is preferable
to think in vertical terms, that is, of watersheds.

The sector most likely to provide the dynamism for high rates of overall economic
growth is light manufacturing.


In the last 45 years, Haiti has enjoyed only one brief period in which growth in Gross Domestic
Product approached levels that lift substantial numbers of people out of poverty. That period
was the late 1970s and early 1980s. The principal engine of growth during the period was light
manufacturing assembly, textiles, agroprocessing, etc. In a negative vein, the principal losers
from the economic embargo were workers in precisely those kinds of industries. Although these
glimpses into recent Haitian economic history are not definitive, they certainly are suggestive.2
Specifically, they suggest that a likely place to start to put Haiti back on the path to buoyant
economic recovery is the light manufacturing sector. Furthermore, as intimated above, the ideal
location for firms in that sector is not Port-au-Prince alone, but secondary cities as well.

The role of government is to encourage private sector activity. It is not to pick winners,
to make productive investments, or to produce. Those responsibilities lie with the
private sector. -

The government does not have the wherewithal, by itself, to create permanent jobs for the
majority of Haiti's poor people. Nevertheless, government policies have much to do with the
degree to which private economic activity flourishes and the degree to which those relatively
poorly endowed participate in that activity. In essence, the government has two fundamental
roles to play: first, to set clear and transparent rules for market activity and to enforce
compliance with those rules; and, second, to invest in public goods -- physical infrastructure,
primarily -- essential for the conduct of private economic activity. Of all the actions t it a
government can take, these are the most basic -- and those that typically will have the bi est
impact in lowering transaction costs in the economy and making it more competitive.

Roads probably are the most common example given of public goods tat reduce ma ket
transaction costs. There also are other, less obvious examples of public goods that govern nts
and donors can invest in for the same end. The partial underwriting of deal-oriented pri ate
business promotion offices in secondary cities discussed below is a case in point.

Emergency food assistance has dominated much of USAID's attention in recent years.
The time has come to shift its focus to the prevention of malnutrition and, thus, reduc
Haiti's need for emergency assistance in the future.

The economic crises of recent years, coupled with drought in the Northwest, demanded at
USAID act reactively rather than proactively. Starvation was in the offing, and action ne ed
to be taken. As the country slowly emerges from that emergency, the time has come to ad pt

'Also suggestive is what appears to be a gradual acceleration of light manufacturing activity since e


a more long-term developmental posture and focus on the means for preventing malnutrition in
the future.

Food is a necessary but not sufficient condition for good nutrition.

Malnutrition is not just a disease, and food is not its cure. Rather, malnutrition is a state that
results from a number of interrelated variables. In Haiti available evidence suggests that the
principal determinants are infections, limited maternal knowledge, meager use of health services,
and fertility factors. Although food can be useful as an income transfer and in luring vulnerable
mothers and children to health services -- and, in fact, recompensing mothers for the difficulty
in getting to them, food pr se typically is not the key variable at work.

Food insecurity is too scattered in Haiti to use geography as a criterion for targeting.
This suggests the desirability of self-targeting interventions --food for work, for

Despite political sensitivity and anecdotal evidence to the contrary, food insecure people
apparently are open to -- and, indeed, would welcome -- food-for-work programs. Food for
work offers a number of advantages: first, those willing to accept food for work typically need
it; second, food-for-work programs can create productive and social capital **- roads and potable
water systems, for example; third, food for work is flexible -- if necessary, it can be
programmed to meet seasonal fluctuations and emergency requirements.

Safety nets mean different things to different people. Clarity of definition is in onfer.

In Haiti it is common to refer to at least three different kinds of programs as safety net
programs: first, programs that attend to otherwise defenseless indigent people in institutions set
.up expressly for that purpose -- orphanages and old-age homes, for example; second, programs
directed to populations at nutritional risk -- maternal-child health programs, for example; and,
third, programs that provide jobs for those temporarily unemployed. In the policy and program
recommendations given below, reference is made to these programs separately, not


In recent years, the United States Government has played a major role in Haiti's affairs. It led
the economic embargo that finally returned the country to democratic role, and, both during and
since, has given generously of its resources to ease Haiti's food insecure people through very
trying times. Precisely because its humanitarian response has been so robust, the popular mind
has come to identify food security in Haiti with USAID's food aid program. This perception
is unfortunate on two counts. First, it confuses food security with food aid. And, second, it
place USAID in the awkward position of taking on responsibility for Haiti's food security
problem. As a final principle for consideration, therefore, the strategy team suggests that the
role of the United States Government assume proper perspective. As daunting as Haiti's food
security challenge looms for the future, it is Haiti's challenge to respond to. USAID can help
Haitians in that task, but it neither can nor should it attempt to do the job for them.


During the development of the strategy, a number of significant choices surfaced for
consideration. In one sense, the choices are the strategy's "metachoices." Before presenting
the policies and program actions that make up the practical meat of the strategy, therefore, this
section summarizes the strategy team's positions on what are logically prior, broader questions.
The summary appears in Table 5.1.


Question Answer

To what extent If Haiti is to move substantial numbers of poor people out of
should the strategy poverty, it has no choice but to tilt its development attention more
focus on safety aggressively toward growth. The shift can not be done wholesale
nets, economic from one day to the next, however.
stabilization, and
economic growth?
Should the strategy No matter what the government and donors do, outmigration from
focus primarily on rural areas is likely to continue unabated for years to come. The
rural or urban development of cities tied in with external markets is essential for
areas? buoyant economic growth. The choice therefore comes down to
going with the flow and directing it preferentially to secondary
cities, supporting more decentralized development.
Should Haitian In the final analysis, this is not a question for'the government,
agriculture produce donors, or the strategy team to answer. Picking winners (and,
primarily for the quite possibly, losers) is the prerogative of producers. That said,
domestic market or producers typically need information on markets, appropriate
for export? technology, sources of financing, etc., to make informed choices.
Often the costs of obtaining such information can be prohibitive.
As experience under the PLUS Project illustrates, external support
can play an important, facilitative role here.
What specific Although plenty of ideas abound, this is a question, again, that
agricultural falls more appropriately to producers to answer. The same goes
products should for selecting among specific light manufacturing industries as well.
Haiti produce?
Should USAID Other donors have expressed interest in lending major support to
continue to focus on the government to improve irrigated agriculture or. the plains.
agriculture in the Continuation of the implicit division of labor currently in force
hills or support the therefore appears in order, subject to the proviso that USAID
government on the continue to focus on strategic watersheds and coordinate with
plains? parties working downstream.
Should USAID Now that the crisis of recent years is receding, it is time to tilt the
focus on treating or pendulum to prevention.



This section presents the key elements of the proposed strategy to improve food security in
Haiti. In general, it recommends a conscious shift from a "welfare" to a developmental
perspective. Specifically, it argues for a change in policy and program priorities to nudge Haiti,
over time, to growth rates high enough to lift substantial numbers of food insecure people out
of poverty. In addition, it argues for a focus on secondary cities and their surrounding

Strictly speaking, the focus on secondary cities is not a necessary condition for growth. In'
principle, Haiti's future growth could take place without it. Nevertheless, the current pattern
of growth, in which the Gulliver of Port-au-Prince lords it over the Lilliputians of the rest of
the country, is neither sustainable economically nor desirable socially. Some will argue that
development resources are simply too scarce at this time to "divert" them away from pressing
needs in Port-au-Prince. Migration to secondary cities is not a fad, however. It has been going
on for some time, and, if anything, it will accelerate. The public policy question, therefore, is
whether it makes sense to go with the flow, so to speak, and accommodate what, by all
accounts, is a socially desirable evolution of demographic trends. The strategy team argues that
the time has come not only to accommodate it, but to encourage it.3

In developing the strategy, the proposed focus on secondary cities generated a variety of
reactions. Like beauty, what a focus on secondary cities means appears to lie in the eye of the
beholder. For that reason, it is important to make explicit what is proposed here is and what
is not.

For some, the proposal of a secondary cities strategy harks back to the development thinking of
the 1970s and 1980s that emphasized urban-rural linkages, the role of market towns, and the
creation of "growth poles." Much of that thinking continues to have relevance today. As a
practical matter, though, many programs that emerged from that thinking suffered from two
major drawbacks, both of which are to be avoided here. First, designers of secondary city
programs often tried to lead -- not to say, preempt -- the market. In short, the underlying
philosophy was, "if you build it, he will come." Frequently, economic activity did not come,
and white elephants resulted. In the strategy proposed here, the approach is explicitly pro-
market: look to those cities where economic dynamism already is taking place, build on it, and
expand it. Haitians already are voting with their feet and migrating to secondary cities. The
challenge is to make those cities permanent homes of economic dynamism and, thus, minimize
further onward migration, either to Port-au-Prince or abroad.

'In fact, donors have been and are likely to continue to be the predominant source of Haiti's
.investment finding To a large extent, therefore, a decision to shift public investments toward secondary
cities would involve primarily donor funds.


The second drawback of much urban development in the past has been the almost exclusive
emphasis given to industrial development as the motor of regional growth. Although potential
linkages between city and countryside were acknowledged in principle, the practical application
often was enclave in character. Although the benefits of industrial growth were seen as rippling
out somehow to the countryside, the countryside largely was ignored as a source of raw
material. Thus, the natural symbiotic relationship between city and countryside described in
textbooks did not pan out in full. The strategy proposed here would not ignore the potential of
jndustrielying on imported inputs --such industries do create income after all and do set in
motion derived demand for food and fiber. But the strategy would not cocoon itself in that
approach. In- Haiti, the major constraint to the growth of agriculture is lack of effective demand.
Secondary cities are a logical place to look for the generation of that demand, not only through
the multiplier effects that result from higher urban household incomes, but also, more directly,
through agroindustries that process primary agricultural products for both domestic and export

The overriding objective of the focus on secondary cities and their respective countryside
proposed in this document is to increase the incomes of currently food insecure people,
primarily through the generation of jobs. The principal instruments to bring that objective
about will be the combination of conducive policies and investment programs. To the extent
that those policies and programs require geographic focus and often they do, secondary
:ities furnish it. Looked at from that perspective, therefore, the strategy proposed here is
:nabashedly an economic development strategy. It is not, per se, an urban development or
Political decentralization strategy -- though, as incomes rise in secondary cities and their
surrounding areas, both urban development and political decentralization naturally can be
expected to take place. For purposes here, however, they are ancillary objectives to the main
sk at hand.

able 5.2 presents Haiti's current hierarchy of cities. It includes all settlements with more than
),000 inhabitants, a cutoff point that, with one exception, identifies what most observers would
gard as the country's "cities." The exception is Jacmel, which has a population slightly less
ian 20,000 people.

:aiti has the most pronounced urban primacy in the hemisphere. By official estimates, the Port-
u-Prince metropolitan area contains at least 15 times the population of Cap Haitien, the
country's second largest city. Actually, that ratio may understate the difference. Many
observerss believe that the population of Port-au-Prince metropolitan area is considerably higher
than the official estimate. If so, the "true" ratio could be greater than 20:1.

Empirically, when this document refers to "secondary cities, it is referring to the four
"intermediate cities" and the four "market and district towns" contained in Table 5.2. The
strategy team would not be averse to including Jacmel in the list as well, which would give a
total of nine. It is in a limited number of these cities and their neighboring countryside that
the strategy team recommends priority be given in future investment programs. The location
of the cities can be seen in the map below.


Types of cities Cities Population
Metropolitan areas Port-au-Prince 1,651,000
Intermediate cities Cap Haitien 102,000
Gonaives 61,000
Saint Marc 47,000
Les Cayes 47,000
Market and district towns VWrettes 28,000
Jdr6mie 27,000
Port-de-Paix 26,000
Limb6 21,000

The remainder of this section, Section 5.5, and the following section, Section 5.6, define the
principal policy and program priorities that the strategy team sees as essential to improve food
security in Haiti. The following section talks explicitly to what the team recommends that
USAID do. This section,.in contrast, lays out policy and program priorities across the board,
and thus, ideally, at least, has implications both for USAID and for the Government of Haiti,
as well as for other donors and non-governmental organizations. Since the strategy team is
preparing this strategy exclusively for USAID, the reader is cautioned to view the policy and
program priorities presented here not as prescriptions for others, but as the major items of the
overall food security policy dialogue agenda that the team would propose USAID take up with
the government and other parties involved in Haiti's development. 1n the final analysis,
enhancin food security in Haiti is Haiti's job, not USAID's. The role of USAID is to support
Haiti in that task and, ideally, act as a catalyst in helping think through what will work and what
will not. It is in that spirit that the recommendations below are offered.

The priorities recommended by the team are summarized in Tables 5.3 and 5.4. Table 5.3
presents recommended policy measures, while Table 5.4 presents recommended program actions.
In each case, a phasing of the implementation of the recommendations is suggested over two
periods, from 1996 to 2000 and from 2001 to 2010. As one might expect, the recommendations
for the latter period are more generic than those for the former.


Cap Haitien



Saint Mai




1996-2000 2001-2010
Rationalize and make investment incentives Refine and maintain investment incentives
Institutionalize procedures for resolution of Refine and maintain procedures
business disputes
Reduce tax exemptions and improve Expand tax base and improve enforcement
Privatize electricity, telecommunications,
and ports
Implement current tariff policy Adopt uniform tariff policy
Make support to agriculture evenhanded Continue evenhanded and transparent
and transparent policy
Make family planning a clear national Continue to make family planning a clear
priority national priority
Government assumption of responsibility Continuation of government responsibility
for orphanages, old-age homes, etc. for orphanages, old-age homes, etc.;
funding of greater portion of FAES and
minimum package of health services
Explore options for regularizing property Regularize and refine property rights,
rights, water, and finance policies water, and finance policies
Institutionalize joint government-donor Continue joint programming of local
programming of all local currency currency generations; as the economy
generated under food aid programs improves, gradually phase out food aid


1996-2000 2001-2010

Rehabilitate and maintain major trunk roads Complete rehabilitation' of trunk roads;
rehabilitate major access roads; maintain
all roads rehabilitated
Develop private business promotion centers Expand private business promotion centers
in four major secondary cities to additional secondary cities; gradually
phase out external support
Increase focus of social sector activities in Continue to focus social sector activities in
secondary cities secondary cities
Expand current focus on microenterprises Maintain expanded focus
to promote business activity across the
Improve quality of primary education Raise primary school efficiency; improve
quality of secondary and technical
Increase UCS coverage to 60% Gradually increase UCS coverage to 95%
Target PLUS-like interventions in strategic Continue to target PLUS-like interventions
watersheds; expand commercial orientation in strategic watersheds; continue
of program commercial orientation of program

On the policy front, the proposed priorities are:

* Rationalize and make investment incentives uniform. At the moment, Haiti's
investment "regime" is an amalgam of ad hoc measures, including sweetheart deals
granted to individual companies during previous governments. The introduction of a
uniform code of non-exorbitanl, time-limited, monitorable tax incentives clearly is in
order. Unfortunately, the government's recent attempt to develop an investment code
did not meet these conditions. The government needs to cultivate a pro-business
image, but without giving away the store.

* Institutionalize procedures for resolution of business disputes. A major constraint to
investment in Haiti, both by Haitians themselves and by foreigners, is the absence of
protection for private property and legal recourse in the event of contract disputes.


The institutionalization of transparent, expeditious, and enforceable procedures for
resolving business disputes merits high priority attention.

+ Expand tax base and improve enforcement. By taking difficult structural adjustment
measures, the government willy-nilly has put itself in a tax revenue bind. In the short
run, it probably -is unrealistic to look for major new sources of tax revenue, but
substantial progress still can be made in eliminating loopholes and improving
enforcement. In the longer run, that is, after the termination of the current ESAF,
expansion of the authority of secondary cities to tax and spend will be in order. So
too will the expansion of their capability to do so.

Privatize electricity, telecommunications, and ports. For private investment to
increase, functional electricity, telecommunications, and port services are essential. It
is unrealistic to expect the Haitian government to provide these services efficiently.
Consequently, transfer of operational responsibility to the private sector -- by direct
sale, by "capitalization," or by other means -- is imperative. Privatization currently is
a major item on the policy dialogue agenda of international donors. Until the torch is
passed, it will need to continue to be.4

Adopt uniform tariff policy. The government has made great strides in trade policy in
recent years, though implementation of the reforms in question has been somewhat
uneven. The levels of tariffs have fallen, as has the dispersion among them. It is
unrealistic to expect tariffs to become more uniform in the next five years. Other
policy reforms also are more important. As Haiti enters the next century, however,
the removal of this lingering trade distortion will warrant attention.

Make support to agriculture even-handed and transparent. In its frustration at the
stagnation of the country's agriculture and in its desire to satisfy more of Haiti's food
needs with domestic production, the government often is tempted to administer prices -
tariffs, for example -- to favor certain products over others. Such policies can be
risky. By distorting the relative prices producers face, the government can wind up
making the preferred commodities artificially and unsustainably attractive and, in the
end, skewing the country's pattern of production against its comparative advantage.
None of this is to say that the Government of Haiti does not have the right to promote
crops like rice for strategic reasons. It certainly does. The question is how to do so
in a way that minimizes the likelihood that farmers will stay out of' other, potentially
more profitable commodities. All other things being equal, the best way to promote
production of a given commodity is directly and transparently -- for example, by
expanding the irrigation of lands apt for production and investing in applied research

'One intriguing option to consider is the privatization of public utilities by region. For example,
the national electric concern need not be transformed into a single private company; it might be split


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