Case study of the Dominican Republic

1. Regional Consultation MeetingIntegrated Health Services Networks, Vertical Programs and Global Initiatives Maximizing synergies for collaborative workCusco, Peru. 11 November 2009 Case study of the Dominican Republic Impact routes for segmentation/fragmentationof national system response to HIV Mario Cruz Penate, Adivsor on Health Systems Strengthening PAHO/WHO

2. Contents • Introduction • Background • Framework • Impact of segmentation/fragmentation on national health system response to HIV • Conclusions • Measures taken based on the evaluation

3. Results Performance • Universal coverage • Quality health care • Efficiency • Equity* • Improved health status • Protection from financial risk • Satisfaction Structure, organization and functions (input and processes) HEALTH SYSTEM What is expected from a health system? Context Are all of the changes in the system and all interventions related to the goals?

4. Background • External evaluation performed in the Dominican Republic from Dec 2006 to Apr 2007 • Objective: Analyze the relevance and adequacy of the national health system response to HIV/AIDS • The items discussed in this case study refer to the past. Some measures have been instituted since then. Therefore, it should not be inferred that the situation described herein exists at the present time. http://new.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=319&Itemid=

5. Framework • 13 attributes of the integrated health services networks • Main Components of a Health System • Essential values, principles and elements of a health system based on Primary Health care PAHO. Integrated Health Services Networks: Concepts, Policy Options and Road Map for its Implementation inthe Americas. Series: Renewal of Primary Health Care in the Americas. 2008. Available at: http: /www &.lachealthsys.org/index.php? &option=com_content&task=vie &w&id=305&itemid=377

6. Main impact points for segmentation/fragmentation of national health system response to HIV

7. Cross-cutting finding The reform processmoved in one direction and the response to HIV in another

8. Attributes ofthe integrated health services networks • Lack of direct responsibility for the population • “Targeting” of risk populations and vulnerable populations, but not precisely related to their needs and preferences Covered population/territory defined and extensive knowledge of its health needs and preferences, which determine the health services offered A network of health facilities that includes all levels of care and provides personal health as well as public health services • Organization of service supply almost exclusively at the hospital level (UAI and maternity) • Preventive and promotion services are not coordinated with the services network

9. Attributes ofthe integrated health services networks • Primary care does not participate in the response to HIV. The population must be transferred to provincial hospitals. Primary care that acts as gateway to the system, integrates and coordinates health care, and meets most of the health needs of the population. Delivery of specialized services in the most appropriate location, preferably in non-hospital environments • The UAI are located in third-level hospitals, even when their portfolio of benefits is not necessarily from that level of complexity. • In-patient hospital care for persons with HIV or other specialized services is not provided by the UAI and not included in DIGECITSS or COPRESIDA planning.

10. Attributes ofthe integrated health services networks • Unclear mechanisms for referral and return that vary with the initiative of the providers • No standards for hospital care There are mechanisms for coordination of care throughout the continuum of the health services. Health care is centered on the person, family and the community/territory • Inexplicit care model • Determined by the supply for the disease and not person-centered

11. Attributes ofthe integrated health services networks • Dual management • Coordination of care and clinical management are nearly nonexistent in the delivery of services. A single governance system for the entire network Broad social participation • Participation involving vested interests that creates conflict of interest and perverse incentives.

12. Attributes ofthe integrated health services networks • Insufficient data on sufficiency of personnel. • Distortions in human resources management due to differential levels of remuneration and limited responsibilities, as well as the creation of staffing categories not found in the public service. Sufficient, competent and committed human resources valued by the network Integrated information system that links all members of the network • Parallel information systems • Information gaps; managerial limitations, especially at the local and regional levels and, above all, failure to use information to improve the services.

13. Attributes of the integrated health services networks • High complexity and confusion in the definition of roles and functions. • Highly centralized nature of managerial processes without the links required to prevent gray areas. • High degree of duplication of mechanisms and coordination and management processes, particularly for management of the drug supply. Integrated management of administrative systems and clinical and logistical support Adequate financing and financial incentives aligned with the goals of the network • Extremely high out-of-pocket expenditure. • Segmentation of the population by labor status and ability to pay. • Insufficient allocation to achieve the goal of universal access, inefficient management of available resources for a sustainable response.

14. Attributes of the integrated health services networks Intersectoral action • Very limited (a sex education program in the education sector)

15. Some of the main functions of the system • COPRESIDA was created in 2001 for five years. Duplication of functions, management mechanisms and coordination and confusion of roles were observed. • Decision and control over assignment and use of resources in parallel structures without effective control mechanisms and accountability. • Weaknesses in regulatory function. Leadership and governance. Leadership and governance include ensuring the existence of strategic policy frameworks combined with effective supervision, the formation of coalitions, regulation, attention to system design, and accountability.

16. Some of the main functions of the system Health financing/risk pooling. A good health financing system collects sufficient funds for health to ensure that the population can use the services needed and is protected from catastrophic expenses or poverty associated with the obligation to pay for such services. Provides incentives for providers and users to be efficient. • National health insurance was created to cover different systems (prevent joint risk and financial solidarity among them). • The guarantee of antiretroviral therapy was not addressed through the insurance plan but rather, was defined as a State responsibility (without specific sources of financing).

17. Values, principles, and essential elements of PHC Universal access and coverage 33% 21%

18. Values, principles, and essential elements of PHC Optimal organization and management • Important barriers to access “It takes us a lot of time and resources, because sometimes we do not have the means to go to the hospital. We have to take transport that costs 40 Pesos, and then pay for the tests.”

19. Conclusions • Implementing a health systems strengthening approach to analyze the response to HIV/AIDS in countries helps to identify areas of improvement and reformulate interventions, in order to achieve betterproducts and outcomes in disease prevention and management. • It would be ideal to consider this approach when designinginterventions and defining theinstitutionalarrangementsfor their implementation, even when they areimplemented through programs. This approach can help obtain better results, make more efficient use of resources, and improve coordination of the interventions required at different levels. • Better health system performance can not be expected if the intervention is not based on thissystemic approach.

20. Conclusions • One of the main impact routes occurs at the level ofgovernance. If the management andcoordination mechanismsused to respond to disease are not the same as those of the system in general, or these are not at least functionally compatible, thecapacity of the national health authority to maintaineffective oversight and consider the contribution of specific disease-related efforts in the construction of a system based on a single design will probably be weakened. • It will also be difficult to ensure effectiveaccountabilityand for the efforts of all the actors involved to contribute to the national goals and priorities, eliminating potential distortions and conflicts of interest insofar as possible.

21. Conclusions • Disease-based interventions can contribute to strengthening the health systems, but this will not happen automatically. One of the main areas of opportunity is the organization and management of services. • The goal of universal access cannot be met if disease-based interventions do not contribute to building or strengthening integrated health services networks,starting with thelevel closest to the people. • Use of theintegrated health services networks modelcan help identify ways of optimizing thearrangements for implementing actions, so thatthe objectives related to disease and strengthening of health care networks can be met.

22. Measures taken based on the evaluation Taken from the TAC presentation 19 October 2009Dr. Cristina Nogueira, PAHO/WHO Representative,Dominican Republic

23. Unclear roles and duplication of functions Low investment priority for prevention and active case-finding, particularly in vulnerable groups Practices that are not conducive to the goal ofuniversalaccess. The health sector reform process has begun, and roles and functions are being clarified. There have been few changes, since 7.8% of public spending is currently allocated to prevention. Strategies such as zero tolerance have been implemented, and universal access has improved. SITUATIONFOUND IN THE EVALUATION CURRENT SITUATION

24. Limited analysis and lack of strategic use of the available information. Evidence of a trend with the migration of patients to second- line and rescue treatment regimens, which increases the cost of ARVs. There are no drug surveillance or therapeutic drug monitoring activities. Specific advances in some regions of the country, since there is 40% data analysis. Others regions have still made little progress. HIVDR studies are being conducted to obtain real information about this subject. This is part of drug surveillance and the monitoring of current therapy regimens. SITUATIONFOUND IN THE EVALUATION CURRENT SITUATION

25. Management of drug and supply delivery functions operates parallel to PROMESE/CAL Need for ARV drugs is planned, based on forecasts and inventories PROMESE/CAL are currently in charge of distribution and storage of ARV drugs. DIGECITSS and COPRESIDA are in charge of planning and management. PAHO/COPRESIDA agreement for use of the strategic fund has resulted in considerable savings, which helps improve the quality of expenditures The same planning method is still being used at this time. SITUATIONFOUND IN THE EVALUATION CURRENT SITUATION

26. Existence of a parallel health care system that does not respond to service planning criteria Deficiencies in recording, monitoring, and controlling of HIV/AIDS/STI drugs Transitional period in which the UAI will be eliminated. Integration with the regular services provided at the hospitals is beginning. PAHO supports updating the information system, which validated all of the information about the services, including the drug surveillance and early warning indicator modules. SITUATIONFOUND IN THE EVALUATION CURRENT SITUATION