To provide T/A to USG partners, including COPRESIDA, in order to establish a one monitoring and

evaluation system in the DR.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18417

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18417 11907.08 U.S. Agency for University of North 8092 6012.08 Measure/TA for $225,000

International Carolina M&E

Development

11907 11907.07 U.S. Agency for University of North 6012 6012.07 Measure/TA for $75,000

International Carolina M&E

Development

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $440,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

18-OHSS Health System Strengthening

Note: Due to late initiation of the new USAID contract with AED, FY07 USG funds were partially used to extend the CONECTA

project one more year so that the two projects would overlap and the transition to the USG HIV/AIDS program to Region V and

the border areas would be smoother. CDC and DOD also experienced delays in starting implementation. Therefore, FY09 is the

first year for the majority of USG support to be concentrated in Region V and the border areas. The border areas lack the basic

infrastructure needed to support a comprehensive HIV/AIDS program, and hence FY08-09 funding will focus on improving

infrastructure and strengthening NGOs.

Program Area Context/Services

The DR's public health infrastructure is extensive, with approximately 1,370 local clinics, 104 municipal hospitals, 32 provincial

hospitals, 12 regional hospitals and 16 national reference hospitals. Despite enormous growth in the supply of services, relatively

high levels of total spending, and institutional efforts to implement a new Social Security system, including 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 health reforms to address barriers to accessing quality services and to improve efficiency and equity. Key

changes included decentralizing service provision, introducing national health insurance coverage and demand-side financing.

Implementation of these reforms has been gradual and slow. For over five years USG has supported health sector reforms and

implementation of the new Social Security system with a focus on Region V. GODR has 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 covered currently

by health insurance.

System strengthening is critical for effective and sustainable programs and is a key focus of our regional strategic approach. USG

supports institutional strengthening of partner NGOs, CBOs and FBOs, public sector institutions and MOH service providers, and

is providing TA to develop essential systems, e.g., information systems, supply chain management, health communication

messages, and referral systems.

Health sector reform success depends on trained and competent human resources. Frequent replacement of qualified staff affects

all programs and underscores the need for ongoing training. This is particularly critical as each change in GODR administrations

tends to lead to the replacement of many trained 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 funding from external sources and the availability of HIV/AIDS resources is not currently an issue. The critical

challenge now is for the MOH to take on its overall stewardship role, coordinate within the decentralized health system and 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 to fighting the disease. Existing

non-discrimination laws prohibit testing without consent or as an employment screening measure are frequently violated. PLH are

particularly affected, as they are often discriminated against with impunity. Many employers violate this law openly and with

impunity, screening potential employees for HIV and then denying employment to those who test positive, without revealing test

results. Likewise, employees are often dismissed when their employers find them to be HIV+. The economic consequences for

the PLH 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 women who disclose positive HIV status, is a growing problem, and 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 regional 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.

Leveraging/Linkages

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 and 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. There is no civil service, in the DR, even though a civil service law was approved in the early 1990s. The Health

Sector Roundtable, noted above, includes major international partners who have discussed various ways to improve the structure

and functioning of the GODR health system. USG will continue to promote development of a common donor policy agenda, so

partners can speak to GODR in one voice. This includes, for example, engaging the government in dialogue and advocating for

systems that retain technical managers and personnel through political changes such as developing a civil service system. It also

includes appropriately implementing stigma and discrimination, child protection and other laws which have an impact on fighting

HIV/AIDS in the DR. PAHO and UNAIDS will work with USG to ensure quality laboratory tests are easily accessible. USAID/CSH

funding is leveraged to improve maternal-child health, especially in relation to PMTCT services. About eight corporations have

developed and implemented an AIDS in the Workplace policy to combat stigma and discrimination in the workplace.

FY09 USG Support

With FY09 resources, USG/USAID will work in two major areas: continuing and expanding health system strengthening; and

improving policy-making and implementation. During the past few years, USG has worked in Region V to strengthen the health

systems functioning in a number of hospitals. This has included improving the management of service providers and provincial

and regional health directorates. During FY09, based on the lessons learned from that experience, USG/USAID partners will

begin organizing a regional service provider network to ensure an integrated approach to HIV/AIDS, with gradual expansion to an

additional eight hospitals, including at least two in the provinces along the DR-Haiti border. This work emphasizes strengthening

health systems to improve maternal-child health, especially in relation to PMTCT services. USG will continue to invest in human

capacity development through training on health service management and quality of care. USG will also promote training on

gender-related violence and girl/women's empowerment to help women avoid putting themselves at risk for HIV. To address staff

turnover, and as a wraparound activity, USG will continue to work with other donors to promote the development and

implementation of a civil service, at first via demonstration projects in the selected focus geographic areas. USG will continue to

facilitate the MOH in policy discussions to encourage minimum standards and quality of care in its services

In FY09, USG will continue to work on cross-border and bi-national matters with Haiti, including engaging GODR in policy

discussions. USG will continue to support GODR in developing a DR-Haiti bi-national agreement including a framework/strategy

for prevention, care and treatment of populations crossing the border in either direction. This agreement is expected to address

HMIS and other surveillance issues, PMTCT, access and adherence to ART, and possible sharing of laboratory services.

Demonstration and twinning projects will identify and test appropriate means and venues for collaboration along the border.

Policy dialogue will aim at improving enforcement of the AIDS law, particularly in terms of stigma and discrimination. USG will

support the network of PLH who have been providing legal support to those discriminated against by employers so that their rights

to employment are respected or companies who discriminate are fined or otherwise punished. USG and local partners will

continue to engage GODR to either prohibit any testing as a condition of employment or, barring that, ensure enforcement of the

existing law, particularly to prohibit hiring and firing practices based on the results of an HIV. USG will also engage the GODR to

ensure that the child protection laws are implemented effectively.

USG will also promote a national condom policy stipulating responsibilities of both GODR and the commercial sectors in providing

access to condoms for MARP. USG will engage GODR to revise legislation to allow provider-initiated counseling and testing, opt-

out testing (particularly for pregnant women), and same-day test results. USG will also engage the MOH in policy discussions to

encourage evaluation and priority for palliative care services as a foundation for building long-term sustainability. Demonstration

projects in the geographic focus areas will provide evidence-based data. USG will initiate policy dialogue to study the economic

impact of adding ARV treatment and related testing into the basic health package. USG will also try to ensure that the Social

Security system is implemented in the USG focus regions with the most vulnerable populations, including those living with

HIV/AIDS.

USG will also continue to collaborate with PAHO to advocate with COPRESIDA and DIGECITSS to procure rapid and

supplemental testing supplies and facilitate policy development of a national validation and procurement of tests to be used

nationally. USG/CDC will provide current technical background scientific information in order to inform policy and decision makers

on policies for procurement and validation of rapid tests and other supplies to ensure the use of quality products. In collaboration

with PAHO and UNAIDS, USAID will oversee implementation of these policies. USG will continue to collaborate with PAHO to

advocate with COPRESIDA and DIGECITSS to procure rapid and supplemental testing supplies. USG and its local partners also

will continue to advocate for the family health insurance to cover the costs of tests needed by PLH, including CD4 and viral load

that are not currently included in that insurance.

USG will also work with GODR to ensure appropriate implementation of TB/HIV diagnoses and services throughout the country to

ensure early diagnosis and treatment services are available. Current protocol calls for sputum smears, X-Rays and cultures. USG

will work to ensure that the whole package of services, including clinical and community ones, are offered and referrals are made

for ARV and TB treatment.

In FY09, USG/DOD will continue working with the DR Armed Forces (FFAA). Strengthening leadership and the policy

environment to reduce stigma and discrimination and ensure access to HIV care and treatment services among members of the

FFAA is crucial. The FFAA's decision-making authority agrees with the strategic plans and assumes leadership over the officers

and other ranks of the FFAA. In FY09, USG/DOD will support sensitization trainings on HIV, and integrating prevention activities

into military curricula/trainings for senior leaders to ensure HIV program sustainability. USG/DOD will continue to support the

efforts of the Committee for the Prevention and Control of HIV/AIDS in the Armed Forces and National Police of Latin America

and the Caribbean (COPRECOS-LAC). Senior leaders will attend HIV policy development training at the annual Defense Institute

for Medical Operations (DIMO) "International HIV/AIDS Strategic Planning and Policy Development" course or similar meetings

where capacity-building efforts, leveraging funds, cross-fertilization of best practices and HIV program sustainability are discussed

by military leaders across the region.

For more information on this, see the following sections: Sexual Prevention, Laboratory Infrastructure, PMTCT, Counseling and

Testing, OVC, TB/HIV and Pediatric and Adult Care and Treatment.

Sustainability

Systems strengthening, human capacity development, and implementing the civil service law are important elements of

sustainability. Implementing national health insurance and priority enrollment of vulnerable populations, particularly PLH, will

guarantee access to subsidized quality health services including treatment for opportunistic infections. USG will continue to

increase local capacity and improve sustainability by supporting the development and operations of an increased number of

indigenous NGOs and FBOs.

Table 3.3.18: