Human Resource Capacity Assessment: As stated above the DRMOH reports having over 50,000 employees, it is not clear the level of existing technical competency and future training needs. These funds will be used to provide technical assistance and support to the DRMOH in order to conduct a National Human Resource Capacity Assessment. Assessment results will be used to advocate with the Health Minister on reengineering of the existing human resource structure required to provide efficient and effective health services and the development of a human resource policy and system. If fully implemented, this initiative has the potential to create enormous savings which could be redirected to existing services and the procurement of much needed supplies.

The DR's public health infrastructure is broad, with approximately 1,370 local clinics, 104 municipal hospitals, 32 provincial hospitals, 12 regional hospitals and 16 national reference hospitals. In 2008 the DRMOH reported having 53,000 active employees in their payroll, of which: 12,071 are medical doctors, 11,927 are nurses, 1,230 are laboratory staff and 28,968 other health and administrative workers. Despite enormous growth in the overall provision of services, relatively high levels of total spending, and institutional efforts to implement a new Social Security system which includes a subsidized national health insurance system for the poor, the DR health system performs poorly in addressing health needs, ensuring quality of care, reducing the financial burden of health care on the poor, and providing adequate insurance coverage.

In 2001 the DR passed several laws to address barriers to accessing quality services and to improve efficiency and equity of health care. Key changes included decentralizing service provision, introducing national health insurance coverage and demand-side financing. Implementation of these reforms has been gradual and slow. GODR has already launched the family health insurance for 2,400,000 employees and their dependants, plus one million poor people, for a total of 3,400,000 Dominicans that could be covered currently by health insurance.

All partners agree that health sector reform success depends on trained and competent human resources, but frequent replacement of qualified staff affects all programs and underscores the need for ongoing training. This challenge is particularly critical as each change in GODR administrations tends to lead to the replacement of many trained and technical staff. As happened at the regional and provincial levels after the recent re-election of the current President. Through the Health Sector Roundtable, major international partners have discussed possible ways to engage the government in dialogue and advocate for systems that retain technical managers and personnel through political changes such as enforcing the civil service law approved in the early 1990s.

The success of the on-going health system reform will enhance the DR's ability to provide an effective HIV/AIDS response. The DR receives significant funding from external sources. The critical challenge is now for the MOH to take on its overall stewardship role, increase the national investment in health and coordinate within the decentralized health system to ensure efficient investment of resources to achieve maximum results. Recently, with broad stakeholder participation, DR developed a seven-year National Strategic Plan (PEN) and a framework for a single national M&E plan. These plans will form the basis for annual reporting meetings on PEN progress, joint program reviews, and shared program reports among GODR, stakeholders and donors, leading to increased accountability for all HIV/AIDS funding and program monitoring.

The DR's HIV/AIDS legal framework is based on a national AIDS law enacted in 1993. Over the last seven years the country has seen an increase in funding for HIV/AIDS, but stigma and discrimination are still a major barrier. Existing laws prohibit testing without consent or as an employment screening measure, but are frequently violated without penalties. PLWH are particularly affected, as they are often discriminated against with impunity. Likewise, employees are often dismissed when their employers find them to be HIV+. The economic consequences for the PLWH and their families are devastating. The AIDS law was reviewed by GODR in FY2008 but has not yet been sent to Congress.

Gender issues continue to be a significant concern in the DR. Cross-generational sex is common and young girls/women often do not feel empowered to abstain from sex or negotiate condom use. Men often report having multiple partners, sometimes including other men, so partner reduction and other prevention messaging and efforts to change social norms are critical. Violence against women, including against those who disclose positive HIV status, is a growing problem. National laws/policies against gender-based violence require revision and enforcement.

System strengthening is critical for effective and sustainable programs and is a key focus of our strategic approach. USG supports institutional strengthening of partner NGOs, CBOs, and FBOs so that these organizations will be accredited as health service providers and have access to financing by the, public sector. USG is also providing technical assistance to MOH service providers in order to improve quality of care, strengthen information and management systems, implement supply chain management and referral systems.

USG-supported health sector reform has now been taken over by GODR, with financial help from the World Bank (WB) and the Inter-American Development Bank (IDB). Nonetheless, USG and other donors will continue to monitor the GODR progress in this effort. The USG will continue to model improved health systems strengthening and appropriate HIV/AIDS policies to ensure appropriate implementation. The World Bank loan supporting health sector reform and social security complements USG efforts. WB and GF also leverage funds for human resource development and job stability within the civil services, as well as system strengthening. Although a civil service law was approved in the early 1990s in the DR, it is not implemented.

Recognition of HIV/AIDS as a priority concern in the uniformed services is paramount to the success of HIV prevention efforts. We will continue to provide technical assistance for the development and implementation of an HIV policy. This policy will support the strategic priorities addressed by the National Strategic Plan (NSP) and provide a favorable context for the prevention, care and treatment of HIV by addressing key concerns for the uniformed services. Some of these concerns include increase access to and use of prevention services through information, education and communication (IEC) for behavior change, VCT and condom support, implementation of improved sexually-transmitted infection (STI) control measures, and strengthened networks and support for PLWHA. Individuals who can support the quality of HIV/AIDS prevention, care and treatment in the FFAA are crucial. Capacity building to train, mentor, and supervise staff necessary for prevention, care and treatment will be addressed.

Indicators: Monitoring policy reform and development of PEPFAR supported activities.