Strategies (2002-2007)

Sustained Improvement in the Health of Vulnerable Populations in the Dominican Republic

Health and Population -- Development Hypothesis

Sustained Improvement in the health of vulnerable populations in the Dominican Republic will not be attained by USAID efforts alone. However, USAID will make clear and major contributions in attaining this goal. USAID will focus on three major areas of health risks in the Dominican population: HIV/AIDS prevention and care; child survival; and reproductive health/family planning (RH/FP). A fourth area of emphasis, and one which provides the organizational underpinnings for the other three, is health sector reform. The strategy will target vulnerable population groups defined generally as those living under the poverty line, with a focus on children, adolescents and women of reproductive age. HIV/AIDS interventions will be focused on the population groups most vulnerable to the HIV/AIDS epidemic.

The priority technical areas (as identified in the four Intermediate Results) are mutually reinforcing. HIV/AIDS prevention has an impact on infant and maternal health. Reproductive health and family planning services have an impact on child survival, and incorporating HIV/AIDS prevention counseling and voluntary testing into the reproductive health package will result in fewer HIV infections. These three major areas support the reform effort, through demonstration programs that (we postulate) will demonstrate the tangible benefits of decentralized health care services. Health sector reform, on the other hand, provides the structural and management justification for such decentralization to take place. Once the service decentralization demonstration programs involving public/private partnerships are shown to be effective, they can be replicated with Government and other donor resources in other parts of the country.

The combined results of these four areas will help the Mission reach the objective of sustained improvement in the health of vulnerable populations in the Dominican Republic.

Increased Use of HIV/AIDS Prevention and Care Services

While the HIV seroprevalence rate in the DR has maintained at approximately 2.5 percent of the adult population, the threat of an increase is always present. The rate of HIV infection is about equal in males and females. However, infection rates in young women are rapidly escalating and are of great concern in pregnant women who can pass the virus to their unborn child. HIV/AIDS prevention efforts will focus on the establishment of public and private sector networks. It is important to link the public sector (i.e. the Ministry of Health, with its broadly established network of health centers) with the private sector (with its experience with specific target groups and emphasis on quality of care). The purpose of such a linkage is to achieve complementarities in use of resources and approaches, so that the "quantity" variable, represented by Ministry network, and the "quality" variable of the Non Governmental Organization (NGO) converge, thus, increasing availability of quality services. USAID will help empower women, especially young women, with respect to their sexual health. Activities that focus on both men and women promote effective prevention measures such as condom use as well as help develop systems to improve public and private sector management through partner notification and treatment options. USAID will also continue NGO initiatives that provide support groups. These support groups frequently have a higher level of women participation due to HIV diagnosis associated with pre-natal healthcare visits. Activities will also encourage health-seeking behaviors (i.e. more use of safe sex practices) among target populations: men that have sex with men, commercial sex workers, adolescents, hotel employees, and bateys (communities of sugar plantation workers). Thus, our focus will emphasize the involvement of both public and private sectors and increased personal responsibility for healthy (or at least reducing high-risk) behavior. And we will design programs to reduce the number of new Tuberculosis (TB) infections using the DOTS treatment regime nationwide. TB is a major opportunistic infection of HIV/AIDS and the Dominican Republic has one of the most virulent drug resistant strains. Thus, our focus will emphasize the involvement of both public and private sectors and increased personal responsibility for healthy (or at least reducing high-risk) behaviors.

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Sustainable, Effective, Reproductive Health/Family Planning Services Provided by the Public and Private Sectors

While the percentage of institutional births in the Dominican Republic is high and the majority of women have at least one prenatal examination, the high incidence of maternal mortality indicates that quality of care is seriously deficient. The Strategic Objective's initiatives in reproductive health/family planning will increase the sustainability of family planning services, that will enable the Mission to phase out of general institutional support to family planning NGOs over the strategy period. It is expected that NGOs will have attained the capability to continue provision of quality services to vulnerable groups with their own or national resources. The RH/FP activities will also have a public/private sector focus, with quality of attention being an important component of the strategy. Our intent is to involve the public sector more in RH/FP services, again taking advantage of the Ministry network of health centers and hospitals. The challenge is to improve the quality of services, at selected facilities among the largest healthcare establishments, so that the extensive Ministry of Health network becomes a quality, reliable reproductive healthcare provider. At the same time, the three major family planning NGOs will continue to receive technical assistance to fine tune and implement financial sustainability plans allowing them to reduce dependence on USAID and develop local public/private partnerships to address the most difficult target populations. An important part of the sustainability strategy will be an endowment fund, which will be made available to those NGOs positioned to take advantage of such a resource. Adolescents and the rural poor are priority target groups for both public and NGO service delivery, given their special needs in terms of access to and use of services. Consistent and in coordination with our work in health sector reform, we will focus on policy advocacy to achieve the institutionalization of RH/FP programs in the Ministry of Health and its inclusion in the basic package of services to be offered under the reform.

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Increased Use of Selected, Effective Child Survival Services

Vaccination coverage is low in the Dominican Republic and in the year 2000 there was an outbreak of polio in the country, even though the Dominican Republic had been declared polio-free by PAHO. The country has traditionally depended upon vaccination campaigns. Our child survival strategy will support the strengthening of the routine vaccination program in the Ministry of Health. Continuing our work in promoting the adoption and implementation of locally managed rural water and sanitation systems as standard public policy of the Government water authority, will contribute to the health of children and families through the increased availability of clean drinking water. We will also continue to encourage increased community participation in the Integrated Management of Childhood Illness (IMCI) program that improves the capacity of mothers to responsibly care for their children. These efforts will be linked to the decentralization pilot programs to be carried out under health sector reform activities and to the school focused community activities to be implemented under the Global Food for Education Initiative. These initiatives will be supported by the formation of public/private/community partnerships and will leverage other donor funds for additional water and sanitation infrastructure.

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Increased Efficiency and Equity of Basic Health Care Services at the Local Level

The three technical focus areas will be supported with the foundation of health sector reform. The Mission will continue to support the decentralization of the health system by strengthening provincial and municipal capacity to respond to their own health issues. Demonstration local public/private service provider networks carried out in conjunction with local health authorities will help formulate new ways to improve service quality and equity at reasonable costs. Decentralization and the active participation of civil society and local communities in the management of their own health care services are important goals of this component. When achieved, local communities will be better positioned to support and sustain improved services to support child survival, reproductive health and HIV/AIDS prevention initiatives. Activities under the three previous intermediate results will utilize a service delivery system that is decentralized and managed through local public and private partnerships.

Finally, through policy dialogue in conjunction with other donors, and by supporting public debate on health sector reform issues, the Mission will promote health policy changes that address system inequities and inefficiencies and encourage the formation of public/private health care delivery networks. The health reform process is a crucial aspect of the health sector development hypothesis. The reform process, which began in earnest with the Mejia Administration (August 2000) and is supported by USAID, the multilateral banks and several other bilateral donors, will lead to important positive changes in the Ministry of Health's and the Social Security System's management practices and service delivery structure. These changes will lead to improved effectiveness of service delivery and efficiency in the use of health sector resources. The larger multi-donor supported reform process will help the Government shift resources to increase public sector funding for primary and preventive health care, particularly for the lowest income groups. USAID's contribution will be to assure civil society participation in the policy debate so that the reform reflects the desires of the citizens and to provide some models for decentralized, public/private service networks providing quality basic primary and preventive health services that can inform the reform process. USAID will support advocacy groups that will work to ensure that the new Social Security laws and implementing regulations on gender equity are adopted, publicized and enforced.

In sum, USAID proposes a strategy which will result in an HIV prevalence rate that is either maintained at its current rate or reduced; in sustainable, effective provision of RH/FP services provided by the public and private sectors to the target populations; in an increased vaccination rate and availability of clean potable water to target communities, all supported by the health sector reform initiative. The result of this six-year effort will be sustained improvement in the health of vulnerable populations in the Dominican Republic, USAID's primary customers and beneficiaries.

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Health and Population -- Five Cross-Cutting Themes

The health strategy supports Mission cross-cutting themes of poverty reduction, policy reform, civil society, local government, and strategic partnerships. It will contribute to poverty reduction because a healthy workforce loses less productive time to illness19/05/05t or medicines. Therefore, family incomes rise. Proposed activities, especially under the health sector reform intermediate result, will involve civil society and local governments, including provincial and municipal governments. Policy dialogue and reform is key to all components of the health strategy and is the specific thrust of the Health Sector Reform program. Public/private partnerships are at the heart of the health sector reform efforts as well as each of the three health intervention focus areas: HIV/AIDS, RH/FP, and selected child survival interventions. These partnerships will be linked to international alliances where opportunities exist. For example, the Mission has supported HIV/AIDS awareness education in the hotels of popular tourist destinations of the country. We will dialogue with the managers of local and international hotel chains to establish a partnership among participating NGOs, USAID, and the hotels themselves, to continue these activities under a cost-sharing basis. In addition, USAID will link efforts with other donors and international financial institutions to achieve the Objective.

Health and Population -- Prior Strategic Objective Activities Continued

The technical areas of the new health strategy will be essentially the same as those of the current strategy. The unattenuated health challenges of the current strategy include: improving HIV/AIDS prevention and mitigation, including treatment of TB, a major opportunistic infection of HIV/AIDS; increasing the sustainability of family planning services that will enable the Mission to phase-out of general institutional support to family planning NGOs; ensuring that adolescents and the poor have access to NGO-provided reproductive health programs which will be done in tandem with expanding Ministry of Health (MOH) capacity to provide reproductive health services; improving vaccination rates and locally-managed rural water and sanitation infrastructure programs; and assisting the Government to move its health sector reform agenda from policy to implementation. USAID assistance will be more focused (based upon previous development advances and achievements), and the program's successes will be sustainable beyond USAID's assistance.

Health and Population - Development Environment Assumptions

Important assumptions underlay the USAID strategy in health and population. One key assumption is that the programs of the other donors and international financial institutions, particularly the WB, IDB and the EC will continue without major delays or disruptions. Other assumptions are that reforms made during the Mejia Administration will be sustained through successive Government administrations; and that nature will spare the Dominican Republic of future disasters, such as hurricanes or earthquakes, which would inevitably result in a reallocation of resources and delay the implementation of health sector reforms. Another assumption is that key GODR technical staff, whose professionals skills have been developed through training, are not replaced after national elections.

Health and Population -- Ultimate Customers

Generally, the poor and underserved populations of the Dominican Republic constitute USAID's ultimate customers in the health sector. It is the health of these vulnerable populations that we strive to improve in a sustainable way. Specifically, ultimate customers for our HIV/AIDS interventions will be the general population, since the epidemic is now established in the general population, and not only in high-risk groups. Poor rural women, adolescents, and residents of bateys are the ultimate customers of our reproductive health/family planning initiatives. Poor rural children will be our ultimate customers for our vaccination and water programs. The rural poor, bateys and adolescents will also be the ultimate customers of our health sector reform efforts, although we will work through the MOH and the Social Security system to promote the management changes that will lead to improved services for these target groups.

The majority of the activities under this Strategic Objective target women. Women in the Dominican Republic have primary responsibilities for traditional tasks (household maintenance, childcare, nutrition and healthcare), especially in the rural areas. In addition, women constitute an increasing proportion of the HIV-positive population, which positions women as a critical target group within the health and population strategy.

For information on our previos strategy, click here.

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Last updated on May 20, 2005