Presentation on theme: "Regional Consultation Meeting Integrated Health Services Networks and Vertical Programs The HIV/AIDS/STI Experience MINISTRY OF PUBLIC HEALTH AND SOCIAL."— Presentation transcript:
Regional Consultation Meeting Integrated Health Services Networks and Vertical Programs The HIV/AIDS/STI Experience MINISTRY OF PUBLIC HEALTH AND SOCIAL WELFARE Dominican Republic 11-12 November 2009 Cuzco, Peru Dr. Ydelsi Hernández Technical Coordinator Office of Development and Strengthening of the Regional Health Services
Population: 9,224,428 inhabitants in 2007 Area: 48,670.82 km 2 (31 provinces and a national district) Health regions: 9 health regions Population: 9,224,428 inhabitants in 2007 Area: 48,670.82 km 2 (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)0.40.2 5. Women 15-24 years (DHS)0.70.4
Groups with highest prevalence GroupPrevalence 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 Frequency National EstimatesCaptured in the Program
Number of persons receiving ARV drugs in comprehensive care services. August 2009. PLHA receiving antiretroviral therapy (August) PLHA in ARV 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 Political level and leadership Regulatory level Surveillance and reporting Care management level General population and special groups Voluntary testing Promotion and prevention ART
Estimated funds to finance HIV/AIDS/RN*, US$. SOURCES OF FINANCING NATIONAL SOURCES EXTERNAL SOURCES Loans Internal 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. Global Fund donation USAID Other 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 services 1.Financing and i nsurance 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 The new legislation requires:
Two functionsOne commitment 1.L eadership 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 must be changed as follows: According to the new legislation, SESPAS must be changed as follows:
The strategies used to comply with the 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
Country Areas (provinces) UNAP UNAP The structure of health services for the population respects the geopolitical situation and the population 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 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 MODEL Responsibilities by levels HIV tests Adult care for both sexes and children/adolescents STI Coordination and strengthening of HIV/AIDS/STI services Supply management Warehouse Monitoring and evaluation Management of administrative resources DDF-SRS Regional health service
PROPOSED MODEL Responsibilities by levels HIV tests Adult care for both sexes and children/adolescents STI National program for reduction of vertical transmission (PNRTV) Regional and provincial facilities Test promotion Referral to HIV test Performance of HIV tests Counseling Zone centers and municipal facilities Supplementary tests Delivery of infant formula Prenatal visit CESAREANCESAREAN Sampling for DNA PCR, CD4, viral load Delivery of antiretroviral drugs
PROPOSED MODEL Responsibilities by levels HIV tests Adult care for both sexes and children/adolescents National program for reduction of vertical transmission (PNRTV) STI Test promotion Referral to HIV test Counseling Home visit Visit, referral, ensure referral of PLHA Treatment follow-up Nutritional support Family planning Appointment reminders for DNA PCR, CD4, viral load Palliative care Follow-up of pregnant women and children Infant formula Vaccines 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 Primary care unit (UNAP) 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 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