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MINISTRY OF PUBLIC HEALTH AND SOCIAL WELFARE Dominican Republic Regional Consultation Meeting Integrated Health MINISTRY OF PUBLIC HEALTH AND SOCIAL WELFARE Dominican Republic Regional Consultation Meeting Integrated Health Services Networks and Vertical Programs The HIV/AIDS/STI Experience 11 -12 November 2009 Cuzco, Peru Dr. Ydelsi Hernández Technical Coordinator Office of Development and Strengthening of the Regional Health Services

Population: Area: Health regions: 9, 224, 428 inhabitants in 2007 48, 670. 82 km Population: Area: Health regions: 9, 224, 428 inhabitants in 2007 48, 670. 82 km 2 (31 provinces and a national district) 9 health regions

Situation of the HIV Program Situation of the HIV Program

Prevalence of HIV POPULATION GROUPS 1. General population 15 -49 years (DHS) 2. Rural Prevalence of HIV POPULATION GROUPS 1. General population 15 -49 years (DHS) 2. Rural population (DHS) Prevalence (%) 2002 Men 1. 1; Women 0. 9 Men 1. 3; Women 1. 0 Total 1. 2 Men 1. 0; Women 0. 9 Prevalence (%) 2007 0. 8 (no differences between sexes) 1. 0 (no differences between sexes) 0. 7 (no differences between sexes) 3. Urban population (DHS) Total 0. 9 4. Men 15 -24 years (DHS) 0. 4 0. 2 5. Women 15 -24 years (DHS) 0. 7 0. 4 Generalized epidemic with most prevalent foci

Groups with highest prevalence Group Prevalence Residents of bateyes (sugar cane plantations) (DHS 2007) Groups with highest prevalence Group Prevalence Residents of bateyes (sugar cane plantations) (DHS 2007) 3. 2 Women with low educational levels (DHS) 3. 7 Haitian immigrants (MOSCTHA) 7. 4 -13% (1996, 1998) Gays, transsexuals, others (USAID-MVV) 6. 4 (2008) Sex workers (sentinel surveillance) 2. 7 (2006) Pregnant women (sentinel surveillance) 1. 7 (2006) Drug users (CDC/USAID) 7. 6 (2008)

Ratio of estimated population with HIV vs. population that visited the services prior to Ratio of estimated population with HIV vs. population that visited the services prior to 2008 Frequency National Estimates Captured in the Program

Number of persons receiving ARV drugs in comprehensive care services. August 2009. PLHA receiving Number of persons receiving ARV drugs in comprehensive care services. August 2009. PLHA receiving antiretroviral therapy PLHA in ARV (August) Comprehensive care services are offered to PLHA in 72 health centers and reduction of maternal-infant transmission in 122 health centers.

CARE MANAGEMENT IN THE HIV PROGRAM SESPAS Political level and leadership Department of Public CARE MANAGEMENT IN THE HIV PROGRAM SESPAS Political level and leadership Department of Public Health DIGECITSS Regulatory level Surveillance and reporting Care management level General population and special groups UAI Promotion and prevention UAI Voluntary testing UAI UAI ART Social networks (GOVERNMENT ORGANIZATION, NGO, FBO, CBO, OPLHA)

Estimated funds to finance HIV/AIDS/RN*, US$. SOURCES OF FINANCING NATIONAL SOURCES Loans Internal resources Estimated funds to finance HIV/AIDS/RN*, US$. SOURCES OF FINANCING NATIONAL SOURCES Loans Internal resources EXTERNAL SOURCES Global Fund donation USAID Other donors *Does not include out-of-pocket expenditures, NGO internal funds, companies, or Social Security contributions. Source: Estimate by M. Rathe for Global Fund Project, Round 7.

Health sector reform Health sector reform

Legal basis for health services networks in the Dominican Republic General Health Law and Legal basis for health services networks in the Dominican Republic General Health Law and its regulations Law that defines the new Dominican Social Security system (SDSS) Regional health services network model Strategic agenda of health sector

Law 87/01 transforms the SDSS The new legislation requires: Separate functions Delivery of services Law 87/01 transforms the SDSS The new legislation requires: Separate functions Delivery of services 1. In SESPAS and IDSS, organized in regional services networks by levels of care under the 2. Leadership and PHC strategy, delivery of services becoming as a result to the population the PSS for the SDSS 1. Financing and insurance

 According to the new legislation, SESPAS must be changed as follows: Two functions According to the new legislation, SESPAS must be changed as follows: Two functions One commitment 1. Separation of national health leadership and system delivery of health services to the 2. Public health service population provider 1. Leadership of the

The strategies used to comply with the legal measures are: Develop leadership and the The strategies used to comply with the legal measures are: Develop leadership and the delivery of public health services functions in SESPAS: deconcentration Develop regional health services such as the public social protection in health (PSS) centers, which provide care for the population: decentralization

Country The structure of health services for the population respects the geopolitical situation and Country The structure of health services for the population respects the geopolitical situation and the population Regions (or SRS) Areas (provinces) Zones (municipaliti UNAP

Regional Health Services • Public provider of health care services for the population • Regional Health Services • Public provider of health care services for the population • Aspires to be an autonomous and highly professionalized entity • Articulated as a network by levels of complexity • Seeks to make a significant contribution to improvement of all health indicators directly and indirectly related to delivery of individual health services with the resources allocated • Capacity to provide at least the care indicated in the Basic Health Plan in cost-effective manner

 The new network model uses modern forms of organization and management, replacing the The new network model uses modern forms of organization and management, replacing the vertical, unipersonal forms of management considered essential to the operations of the institution Regional hospital General hospital Structure of services Regional management Management structure General hospital Area management Primary care center UNAP UNAP Area hospital director General hospital director Health area coordinator

Regional Health Services STEP 1 ESTABLISHMENT OF REGIONAL HEALTH SERVICES STEP 2 TRANSFER OF Regional Health Services STEP 1 ESTABLISHMENT OF REGIONAL HEALTH SERVICES STEP 2 TRANSFER OF RESPONSIBILITIES: DECONCENTRATION STEP 3 CONSTITUTION AS AUTONOMOUS PSS: DECENTRALIZATION

Integration of Programs in RHS Background: Legal framework and management contracts Integration of Programs in RHS Background: Legal framework and management contracts

Proposed integration of the HIV/AIDS/STI program through SRS • Priority is given to the Proposed integration of the HIV/AIDS/STI program through SRS • Priority is given to the two health regions that have entered into contractual agreements (regions 6 and 7) • An intervention model is designed according to the structure and functions of the SRS, development of primary care, laboratory network, experience of other internal and external actors (e. g. PAHO, USAID, Clinton Foundation, MSH, UNAIDS, UNICEF, Global Fund, COPRESIDA, Cicatettelli, PLHA networks) • Review/validation of this model is introduced in health region 8.

Budget model validation process • Integration of technical personnel in areas of discussion and Budget model validation process • Integration of technical personnel in areas of discussion and decision-making. • Participation of other actors for the transfer of competencies.

What is missing? • Organization of services according to the model • Strengthening the What is missing? • Organization of services according to the model • Strengthening the link between SRS and facility directors to ensure that the interventions are carried out, establishing levels of responsibility • Guaranteeing exercise of the roles by the DDFSRS through the SRS and DPS programs without creating conflicts

PROPOSED MODEL Responsibilities by levels Regional health service DDF-SRS HIV tests Adult care for PROPOSED MODEL Responsibilities by levels Regional health service DDF-SRS HIV tests Adult care for both sexes and children/adolescents Coordination and strengthening of HIV/AIDS/STI services Supply management Warehouse Monitoring and evaluation Management of administrative resources STI

PROPOSED MODEL Responsibilities by levels Regional and provincial facilities HIV tests National program for PROPOSED MODEL Responsibilities by levels Regional and provincial facilities HIV tests National program for reduction of vertical transmission (PNRTV) Sampling for DNA PCR, CD 4, viral load Delivery of antiretroviral drugs Test promotion Referral to HIV test Zone centers and municipal facilities Adult care for both sexes and children/adolescents Performance of HIV tests Counseling Supplementary tests Delivery of infant formula Prenatal visit C E S A R E A N STI

PROPOSED MODEL Responsibilities by levels HIV tests Adult care for both sexes and children/adolescents PROPOSED MODEL Responsibilities by levels HIV tests Adult care for both sexes and children/adolescents National program for reduction of vertical transmission (PNRTV) STI Home visit Visit, referral, ensure referral of PLHA Primary care unit (UNAP) Treatment follow-up Test Nutritional support promotion Family planning Referral to HIV test Appointment reminders for DNA PCR, CD 4, viral load Counseling Follow-up of pregnant women and children Infant formula Vaccines Palliative care After pregnancy, HIV+ women should visit a HIV service If the child is HIV+, after verifying his virologic status, his admission to a HIV service should be ensured D I A G N O S I S T R E A T M E N T TPE

WEAKNESSES The need for planning of the transition process with the actors was not WEAKNESSES The need for planning of the transition process with the actors was not identified.

OPPORTUNITIES • We have been able to respond to the known weaknesses of the OPPORTUNITIES • We have been able to respond to the known weaknesses of the system such as the drug and supply management process. • Strengthen primary care as the gateway to the services. • It has been possible to develop and strengthen levels of coordination with the DAP and other agencies in the SESPAS. • The commitment by the SRS to increase assignment of the population to the UNAPs, including the PLHA, ensures their future inclusion in Social Security. • Establish levels of coordination with the international financing agencies to prioritize and support the SESPAS agenda. • The DR is a member of the 2006 PAHO Strategic Fund and is our current procurement agent for antiretroviral drugs and supplies.

CHALLENGES • Strengthening primary care (especially in the urban area) • The DAP is CHALLENGES • Strengthening primary care (especially in the urban area) • The DAP is giving priority to these areas (sectorization and zoning) • Strengthening management links between the SRS and the services • Strengthening the leadership capacity of public health programs.

There is no need to wait for ideal conditions [. . . ] Better There is no need to wait for ideal conditions [. . . ] Better conditions will come because we have begun. . . Petra Kelly, Thinking Green