Regional Consultation Meeting Integrated Health Services Networks and

Vertical ProgramsThe HIV/AIDS/STI Experience

MINISTRY OF PUBLIC HEALTH AND SOCIAL

WELFAREDominican Republic

11-12 November 2009Cuzco, Peru

Dr. Ydelsi HernándezTechnical CoordinatorOffice of Development and Strengthening of the Regional Health Services

Population: 9,224,428 inhabitants in 2007Area: 48,670.82 km2 (31 provinces and a national district) Health regions: 9 health regions

Population: 9,224,428 inhabitants in 2007Area: 48,670.82 km2 (31 provinces and a national district) Health regions: 9 health regions

Situation of the HIV Program

Prevalence of HIV

Generalized epidemic with most prevalent foci

POPULATION GROUPS

Prevalence (%) 2002

Prevalence (%) 2007

 

1. General population 15-49 years (DHS) Men 1.1; Women 0.9

0.8 (no differences between sexes)

2. Rural population (DHS)Men 1.3; Women 1.0 1.0 (no differences

between sexes)Total 1.2

3. Urban population (DHS)

Men 1.0; Women 0.9 0.7 (no differences between sexes)

Total 0.9

4. Men 15-24 years (DHS) 0.4 0.25. Women 15-24 years (DHS) 0.7 0.4

Groups with highest prevalenceGroup 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 2008

FrequencyFrequency

FrequencyFrequency

National EstimatesNational Estimates Captured in the ProgramCaptured in the Program

Number of persons receiving ARV drugs in comprehensive care services. August 2009.

Number of persons receiving ARV drugs in comprehensive care services. August 2009.

PLHA receiving antiretroviral therapyPLHA receiving antiretroviral therapy

(August)(August)

PLHA in ARVPLHA in ARV

Comprehensive care services are offered to PLHA in 72 health centers and reduction of maternal-infant transmission in 122 health centers.

Comprehensive care services are offered to PLHA in 72 health centers and reduction of maternal-infant transmission in 122 health centers.

Social networks(GOVERNMENT ORGANIZATION, NGO, FBO, CBO, OPLHA)

CARE MANAGEMENT IN THE HIV PROGRAM

SESPAS

Department of Public Health

DIGECITSS

UAI UAI UAI UAI UAI UAI UAI UAI

Political level and

leadership

Regulatory levelSurveillance and

reporting

Care management

level

General population and

special groupsVoluntary

testing

Promotion and

prevention

ART

Estimated funds to finance HIV/AIDS/RN*, US$.Estimated funds to finance HIV/AIDS/RN*, US$.

SOURCES OF FINANCINGSOURCES OF FINANCING

NATIONAL SOURCESNATIONAL SOURCES

EXTERNAL SOURCESEXTERNAL SOURCES

LoansLoans

Internal resourcesInternal resources

*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.

*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.

Global Fund donationGlobal Fund donation

USAIDUSAID

Other donorsOther donors

Health sector reform

Legal basis for health services networks in the Dominican Republic

Law that defines the new Dominican Social Security system (SDSS)

General Health Law and its regulations

Strategic agenda of health sector

Regional health services network model

Separate functions

Delivery

of services1. Financing and

insurance

2. Leadership and delivery of services to the population

1. In SESPAS and IDSS, organized in regional services networks by levels of care under the PHC strategy, becoming as a result the PSS for the SDSS

Law 87/01 transforms the SDSS Law 87/01 transforms the SDSS

The new legislation requires:The new legislation requires:

Two functions One commitment1. Leadership of the

national health system

2. Public health service provider

1. Separation of leadership and delivery of health services to the population

According to the new legislation, SESPAS According to the new legislation, SESPAS must be changed as follows:must be changed as follows:

The strategies used to comply with the The strategies used to comply with the legal measures are:legal measures are:

Develop regional health services such as the

public social protection in health (PSS) centers, which provide care for

the population: decentralization

Develop leadership and the delivery of

public health services functions in SESPAS:

deconcentration

La Otra Banda

L. Lagunasde Nisibón

La Otra Banda

L. Lagunasde Nisibón

CountryCountry

Areas (provinces)

UNAPUNAP

The structure of health The structure of health services for the population services for the population respects the geopolitical respects the geopolitical situation and the situation and the population population

I

II III

IV

V

VI

VII

VIII

0

Regions (or SRS)

Zones (municipalities)

Regional Health Services

• Public provider of health care services for the population

• Articulated as a network by levels of complexity

• Capacity to provide at least the care indicated in the Basic Health Plan in cost-effective manner

• Aspires to be an autonomous and highly professionalized entity

• 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

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

General hospital

Primary care

center

Primary care

center

Primary care

center

UNAP UNAP UNAP UNAP UNAP

Structure of services

Management

structure

Regional management

Area management

Area management

Area hospital director

General hospital director

Health area

coordinator

Regional Health Services

STEP 1 STEP 2 STEP3

ESTABLISHMENT OF REGIONAL HEALTH

SERVICES

TRANSFER OF RESPONSIBILITIES:

DECONCENTRATION

CONSTITUTION AS AUTONOMOUS PSS:

DECENTRALIZATION

Integration of Programs in RHS

Background:

Legal framework and management contracts

• 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.

Proposed integration of the HIV/AIDS/STI program through SRS

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 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 DDF-SRS through the SRS and DPS programs without creating conflicts

PROPOSED MODELPROPOSED MODEL

Responsibilities by levelsResponsibilities by levels

HIV testsHIV tests Adult care for both sexes

and children/adolescents

Adult care for both sexes and children/adolescents STI

STI

Coordination and strengthening of HIV/AIDS/STI servicesCoordination and strengthening of HIV/AIDS/STI services

Supply managementSupply management

WarehouseWarehouse

Monitoring and evaluationMonitoring and evaluation

Management of administrative resourcesManagement of administrative resources

DD

F-S

RS

DD

F-S

RS

Reg

ion

al h

ealt

h s

ervi

ceR

egio

nal

hea

lth

ser

vice

PROPOSED MODELPROPOSED MODEL

Responsibilities by levelsResponsibilities by levels

HIV testsHIV tests Adult care for both sexes

and children/adolescents

Adult care for both sexes and children/adolescents STI

STINational program for reduction of vertical transmission (PNRTV)

National program for reduction of vertical transmission (PNRTV)

Reg

ion

al a

nd

pro

vin

cial

fac

ilit

ies

Reg

ion

al a

nd

pro

vin

cial

fac

ilit

ies

Test

promotion

Referral

to HIV test

Performance

of HIV tests

Counseling

Test

promotion

Referral

to HIV test

Performance

of HIV tests

Counseling

Zo

ne

cen

ters

an

d

mu

nic

ipal

fac

ilit

ies

Zo

ne

cen

ters

an

d

mu

nic

ipal

fac

ilit

ies

Supplementary tests

Supplementary tests

Delivery of

infant formula

Delivery of

infant formula

Prenatal visit

Prenatal visit

CESAREAN

CESAREAN

Sampling for DNA PCR, CD4, viral loadSampling for DNA PCR, CD4, viral load

Delivery of antiretroviral drugsDelivery of antiretroviral drugs

PROPOSED MODELPROPOSED MODEL

Responsibilities by levelsResponsibilities by levels

HIV testsHIV tests Adult care for both sexes

and children/adolescents

Adult care for both sexes and children/adolescents

National program for reduction of vertical transmission (PNRTV)

National program for reduction of vertical transmission (PNRTV) STI

STI

Test

promotion

Referral

to HIV test

Counseling

Test

promotion

Referral

to HIV test

Counseling

Home visitHome visit

Visit, referral, ensure referral of PLHAVisit, referral, ensure referral of PLHA

Treatment follow-upTreatment follow-up

Nutritional supportNutritional support

Family planningFamily planning

Appointment reminders for DNA PCR, CD4, viral loadAppointment reminders for DNA PCR, CD4, viral load

Palliative carePalliative care

Follow-up of pregnant women and children

Follow-up of pregnant women and children

Infant formulaInfant formula

VaccinesVaccines

After pregnancy, HIV+ women should visit a HIV service

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

If the child is HIV+, after verifying his virologic status, his admission to a HIV service should be ensured

Pri

mar

y ca

re u

nit

(U

NA

P)

Pri

mar

y ca

re u

nit

(U

NA

P)

DIAGNOSIS

TREATMENT

TPE

DIAGNOSIS

TREATMENT

TPE

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 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 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 conditions will come because we have begun...

Petra Kelly, Thinking Green