Mapping CSO Funding Options for HIV & Tuberculosis in the Dominican Republic

This report maps out and provides detailed analysis of the domestic financing mechanisms available to civil society organizations (CSOs) in the Dominican Republic that are involved in the national responses to HIV and tuberculosis (TB). It identifies the barriers CSOs face when attempting to access and execute public and private domestic funds, as well as highlighting areas of opportunity and providing specific recommendations for government and international donors to support expanded grant-giving to CSOs. The report’s annexes contain step by step training materials to guide CSOs through the at times complex and confusing processes required to access public funding.

Aceso Global completed this report for The Global Fund to Fight AIDS, Tuberculosis and Malaria as part of the country’s ongoing efforts to ensure the sustainability of the Dominican Republic’s national disease programs. CSOs play a critical role in ensuring access to prevention and treatment services for HIV and TB, especially for vulnerable and marginalized groups, but are largely reliant on international support. In the context of reduced external funding, this report positions CSOs to better compete for domestic resources.

DOWNLOAD THE REPORT HERE (SPANISH)

Ensuring the Long-term Sustainability of the National HIV Program in the Dominican Republic: Civil Society Organizations are the Answer!

Building on a previous transition readiness assessment, Aceso Global recently worked with civil society organizations (CSOs) in the Dominican Republic on understanding the public funding landscape, and building their capacity to compete for public grants and other funding. Anna Bonfert, Health Economist, summarizes our main findings and suggestions for moving forward.

The Dominican Republic has made important strides towards an AIDS-free generation . While HIV prevalence in the Dominican Republic continues to be almost double the average for the Latin America and Caribbean countries, it has fallen rapidly over the last 15 years from the peak in the early 2000s.

A key success factor has been the active engagement of CSOs. Since many of these organizations are born out of the very communities that are affected by HIV, they have evolved to be at the heart of the national response. The Dominican Republic has seen the rise of specialized CSOs working with vulnerable and marginalized groups, those that are often disproportionally burdened by the HIV epidemic and face stigma. Because they can build trust and work on the ground with their peers, CSOs have access to communities that would otherwise not be reached by the national HIV program, such as sex workers, trans people, gay and other men who have sex with men, injecting drug users and Haitian migrants. CSOs serve as an interface between public services and these groups, and use differentiated approaches that reflect their diversity.

Over the last 15 years, the civil society space has flourished as donor funds for HIV-related activities abounded. These funds have often been contingent on CSO engagement and advocacy to ensure that the voices of affected communities are being heard, and their needs effectively addressed. Combating stigma and defending human rights are core competencies of CSOs, but many of them also engage in outreach, prevention and access to treatment.

At the same time, the government of the Dominican Republic has started to recognize the important work performed by the more than 200 CSOs currently involved in the HIV response. This recognition came in the form of updates to the legal code as well as financial commitments to fund CSO operations. In fact, there are now more than a dozen sources of public funding available to CSOs working on HIV. These range from the Center for CSO Promotion, a government institution dedicated to grant-making to CSOs, to agreements with Provincial Governments, to co-management arrangements with the Ministry of Health

Despite these positive strides, the country is still grappling with how to put the work of CSOs on a sustainable path moving forward. This question is increasingly pressing as several international donors currently supporting the national disease program have announced their gradual withdrawal, potentially leading to disruptions in HIV programming and services provided by the CSOs, who thus far have benefitted from, and in some cases relied on, external monies. At the same time, despite the numerous public funding sources that have emerged, access can be difficult.

As CSOs explore ways to stay afloat, they find themselves scratching their heads: if all of these public funding sources are available, then why is it so hard to actually receive funding from the government? And why is there no guidance on how to compete for public funding? To address these challenges, Aceso Global in partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria worked with CSOs in the Dominican Republic on understanding the public funding landscape, and building their capacity to compete for public grants and other funding.

First, we examined how the qualification and application processes for public funding actually work in the Dominican Republic. Which documents do CSOs need to submit, when and where? What are the different steps involved, and their timelines? Where can CSOs go for additional information? Ask government officials, and you will likely get different answers. As we soon discovered, the necessary information exists, but is scattered across different websites, departments within the Ministry of Health and even individuals in charge of specific processes. Often, relevant information is not available in a user-friendly format at all. We also noticed that there are many repetitive steps required to apply for funding, and that some guidelines are contradictory.

Our Mapping document and its accompanying factsheets (in Spanish) organized the scattered information in one readily accessible location, and streamlined existing guidelines into an easily digestible format. It provides the CSOs with a clear picture of the administrative steps required to qualify for public funding.

During the process, we also became keenly aware that CSOs range considerably in their experience and capacity. While some already compete successfully for public funding, others are just beginning to set up the systems and structures required to comply with public funding requirements. Further capacity building can improve CSOs’ competitiveness for public funds. How do you write a compelling proposal? What are do’s and don’ts in project planning and execution? How do you set up the M&E systems to show what you have accomplished through government funding? Is there a more effective way to promote your services, both to government entities and other domestic funders? These are some of the questions CSOs are facing, and training in these areas based on our material will allow CSOs to move from being passive recipients of donor funding to active promoters who can effectively sell their services to the government and other sources of support.

These organizations provide valuable services in healthcare and human rights, beyond what government is able to provide on its own. They are critical to the long-term sustainability of the national response to HIV/AIDS and deserve a boost from training and support to strengthen their leadership role in the Dominican Republic.

 

Innovative Financing and its Role in Global Health

There is often confusion surrounding discussions on innovative financing in the context of global health. This summary of a past CUGH conference session on the subject clarifies what is meant by global health specialists when they debate “innovative payment mechanisms” and challenges associated to it. Aceso Global’s CEO Maureen Lewis opened the session with a presentation on the emergence of new actors in global health financing and the shifts in donor priorities away from disease specific programs towards more integrated programs, which could be financed by innovative financing mechanisms. Click here for the full post.

Webinar: JLN Vertical Integration tool

This webinar, organized by the JLN’s Vertical Integration and New Roles for Hospitals learning exchange team, presents the Vertical Integration Diagnostic and Readiness Tool, a survey instrument that helps countries assess and implement vertical integration policies, programs, and pilots.

JLN Vertical Integration/Network Diagnostic and Readiness Tool

The Vertical Integration/Network Diagnostic and Readiness Tool is designed to help stakeholders in low and middle-income countries to successfully assess readiness and review current policies and initiatives relating to vertical integration. The tool is also designed to collect data and information on existing vertical integration pilots.

The Vertical Integration/Networks Diagnostic and Readiness Tool is divided into three instruments, each targeted at different stakeholders:

Instrument 1 is addressed to policymakers, payers and regulators and it covers system-wide policies, regulations and leadership supporting (or inhibiting) vertical integration at the national or federal level. It focuses on broad policy and institutional attributes of vertical integration at the national level.

Instrument 2 is addressed to healthcare facilities and front-line practitioners. It seeks to understand the degree to which vertical integration has been introduced and incorporated into the delivery system as well as the supporting institutional and financial environment. In addition to assessing capacities and nuts-and bolts features of vertical integration (or the lack thereof), it also assesses organizational environments in terms of policies, leadership and support for the same. It also gathers information on four types of patient transitions from the perspective of the respondents: PHC-hospital, specialist-PHC, hospital-home, and community-PHC-hospital for MNCH.

Instrument 3 is addressed to practitioners and implementers of vertical integration pilots and initiatives. It covers the major enablers or disablers in the broader institutional and financial environment as well as vertically integrated care practices implemented by these initiatives. Each initiative will probably cover a single type of patient transition.

To facilitate implementation, an online version of the tool is also available using through the Survey Solutions software. Find instructions on how to access the Survey Solutions version by downloading the tool below.

The tool builds upon findings from a March 2018 Join Learning Network coproduction workshop in Manila facilitated by Aceso Global. 

Please email jln.vi@acesoglobal.org if you need more information on the tool.

DOWNLOAD THE TOOL HERE

LINK TO A WEBINAR PRESENTING THE TOOL

The Revolution in Quality of Care: What Will it Take?

The recent WHO/OECD/World Bank report on Delivering Quality Health Services fills a much needed gap in defining and explaining the importance of quality of care in the attainment of Universal Health Care (UHC). Essentially, the message is: without quality, what is the point of health care investments? Along with access, quality is the sine qua non of health services.

The report’s careful explanation of quality of care and requirements for achieving progress in this area lay out imperatives for countries choosing to take on the challenge of raising quality of care in health care delivery. And while the list of actions is long, it reflects both gaps in data and evidence, and the hard road ahead in closing the gap. Unfortunately, the summary of available evidence and data is thin and limited largely to South Asia, specifically India, and a handful of African countries, complemented by OECD examples on the quality front. Finally, while not mentioned in the report, quality improvement initiatives have often been partial, focusing on one part of the system, such as maternal and child health, while ignoring the need for a culture of quality, a set of core indicators and, critically, some means of ensuring sustainability of initiatives.

As articulated by the OECD (Francesca Colombo remarks), while quality is complicated, some initiatives can be simple and straightforward. Building blocks, such as checklists for surgery or tracking selected adverse events in hospitals, offer a path toward quality improvement that are straightforwardly simple and worth adopting. Others, such as a quality culture and robust data systems, entail greater investments and longer time frames. But all of the requirements and suggestions entail a shift in the way that health care is delivered, and a greater reliance on data. More importantly, and absent in the report, are the roles of incentives and accountability in health care.

The importance of incentives, both financial and non-financial, cannot be underestimated in driving toward a quality culture. Similarly, without accountability, change is unlikely and, where it occurs, unsustainable. Multiple experiences suggest as much. The seminal Institute of Medicine report, To Err is Human, outlined the abysmal state of US health care quality, despite virtually universal hospital accreditation, highly trained staff and significant resource investments. Quality isn’t automatic. In response to the report findings, the weight of public payers, mainly Medicare, forced change through setting clear incentives, and ensuring accountability, e.g., defining performance, rewarding good results and following through on consequences for not meeting data, process improvements and outcome targets. Much progress has been achieved as a result.

Similarly, Atul Gwande’s project on a surgical checklist for “essential birth practices” in India implemented a 28-item checklist accompanied by hands-on collaboration with providers over an eight-month period to test the benefits of using a simple tool for reducing medical errors associated with childbirth. Despite valiant efforts, the checklist system showed no impact.  However, there was no incentive for providers to consistently use the method and, more importantly, they were not being held accountable for outcomes.

The quality agenda remains imposing, but as the WHO/OECD/World Bank report makes clear, embracing quality at the national level offers the only serious route to achieving UHC. And while the report reflects a tour de force on a policy and technical level, implementation issues raise the stakes further. Many of the report’s recommendations offer a menu of options, and countries will need to determine what to prioritize. However, the importance of structuring quality initiatives to ensure adoption and sustainability on a national scale calls for specific actions to drive shifts towards quality, specifically:

  • defining, collecting and using data to capture progress in improving quality in service delivery at all levels of the system;
  • establishing incentives to encourage collection of (correct) data, analysis of performance and use of the data at all levels to monitor performance and measure quality improvements; 
  • financial and non-financial incentives aimed at providers to encourage adoption and mainstreaming measures to raise quality in service delivery; and
  •  harnessing the data to allow supervisors across the system to hold providers and staff accountable for the quality of services.

While simple to describe, these shifts translate into dramatic changes in how health care is delivered, financed and monitored. That part of the quality agenda remains far from simple and straightforward, but captures the essence of quality improvement in context of low- and middle-income countries.

Dominican Republic Transition Readiness Assessment Country Report

This report summarizes the findings of the Transition Readiness Assessment for the Dominican Republic carried out by Aceso Global and APMG Health, with financial and technical support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. It aims to support the Dominican Republic to undertake transition planning as the Global Fund winds down its financial support for the national tuberculosis and HIV/AIDS responses.

Specifically, the report: 1) summarizes the Global Fund's financial and non-financial support to the country; 2) describes the epidemiological situation as well as the national response in the Dominican Republic; 3) provides a background on the institutional and enabling environments, human rights and gender situation; 4) overviews the Dominican Republic's health system and analyzes healthcare financing and fiscal space issues; 5) analyzes delivery system enablers and barriers to transition, including supply chain, information systems and the health workforce; and 6) assesses the current and future role of civil society organizations in the national disease responses. The report concludes with recommendations on the pathway forward to facilitate a smooth and sustainable transition.

DOWNLOAD THE REPORT IN ENGLISH HERE

DOWNLOAD THE REPORT IN SPANISH HERE

Bloomberg's Call to Action - Broadening the Agenda for Action

Aceso Global CEO Maureen Lewis explores the new health agenda laid out by Michael Bloomberg in his Annual Letter on Philanthropy mandated by the rapid shift in disease prevalence from infectious to non-communicable diseases (NCDs) in low- and middle-income countries. She argues that while prevention will be critical to the future fight against NCDs, as laid out by Bloomberg, a robust agenda remains for treating and managing patients currently suffering from these conditions. Effectively meeting this agenda will require not only restructuring the healthcare delivery system to meet the needs of the chronically ill, but also a shift in the international donor community's focus to concentrate on the emerging challenge of NCDs. 

 

READ THE BLOG HERE

Combating Corruption in Global Health

In the past 20 years, the international community has begun to fully recognize the devastating effect of corruption on global health. Poor governance, marked by weak institutions, absence of rule of law, and lax enforcement of health policy, creates conditions for corruption to thrive. This can contribute to health system failure and deprive citizens of access to even basic health services. This paper explores the extent of corruption in health services, as well as  emerging anti-corruption tools and inter-agency frameworks that could prove effective in limiting corruption in global health. While corruption has gained attention in the international sphere, more action is needed in the specific context of global health. This paper was co-written by Maureen Lewis (CEO of Aceso Global), Tim K. Mackey, Jillian Kohler and Taryn Vian.

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Measuring Public Hospital Costs: Empirical Evidence from the Dominican Republic

This paper presents a methodology and analysis to determine the actual costs of inpatient, emergency and outpatient services in a Dominican hospital. By developing and applying a set of survey instruments to a large sample of patients, the authors were able to measure and cost all hospital staff time, in-kind goods, overhead and the depreciated value of plant and equipment related to the treatment of each patient. The study finds that the hospital budget was 50 percent higher than actual costs of services. Further, while spending on personnel comprised the vast majority of the total hospital budget, actual personnel costs for patient treatment were low. Based on these results, the authors suggest that the hospital suffers from gross inefficiency, chaotic medical care organization and poor management.

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Guidance for Analysis of Country Readiness for Global Fund Transition

Aceso Global was tasked by the Global Fund to develop a tool to help countries through the transition process as Global Fund contributions wane and consequently national governments and other in-country stakeholders are expected to shoulder an increasing burden of disease financing and programmatic responsibilities. This Guidance is the culmination of these efforts. It aims to help countries identify financial, programmatic and governance gaps, bottlenecks and risks in the health system that might affect transition.

Specific areas of investigation include service delivery, procurement and supply chain management, human resources, information systems, monitoring and evaluation (M&E), community systems and responses, and health financing, among others. A modular approach allows for flexibility and analysis tailored to country-specific context.

The Guidance was refined following a pilot in Paraguay led by Aceso Global in January 2017, and has since been successfully implemented in Panama and the Dominican Republic.  

 

DOWNLOAD THE GUIDANCE HERE (ENGLISH)

DOWNLOAD THE GUIDANCE HERE (SPANISH)

Health Investments and Economic Growth: Macroeconomic Evidence and Microeconomic Foundations

Improvements in health status over the last 50 to 100 years have been nothing short of spectacular. Vaccines, antibiotics, and other pharmaceutical developments have drastically reduced the incidence of illness and death. Economic growth has also helped: richer people are better nourished and educated, and richer countries are more able to afford the public goods (such as supply of clean water and sanitation and control of disease vectors such as mosquitoes) that reduce the transmission of disease.

Do improvements in health themselves help to boost economic growth? A resolution of this debate could boost the urgency of the quest for growth, inform that quest, or both. For example, a finding that economic growth reduces infant mortality could hasten the adoption of potentially growth-enhancing policy reforms. To help inform decision making on public policy, this review aims to: i) examine the routes by which improvements in health might indeed increase incomes and growth, and the related evidences; and ii) investigate the determinants of health itself, particularly evidence on the impact of public expenditure policies on health.

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Better Hospitals, Better Health Systems, Better Health

Despite their central role in healthcare delivery and their consumption of the lion’s share of national health budgets, hospitals in many emerging markets remain poorly governed, underfunded, and unevaluated. Hospitals have long been neglected by external stakeholders such as donors and multilateral institutions, and considered “black holes” by government ministries that fund facilities but provide limited governance or accountability. Historically, patients have borne the brunt of this negligence, shouldering high costs for poor quality of care.

This report proposes a Global Hospital Collaborative to transform the emerging market hospital landscape by promoting knowledge sharing, research, and cooperation between global experts and stakeholders in hospital governance, management, financing, and related fields. It was produced by the Hospitals for Health Working Group housed at the Center for Global Development, in collaboration with Aceso Global CEO Maureen Lewis and CTO Gerard La Forgia.

The proposed Collaborative would synthesize and centralize the vast but fragmented knowledge, research, and best practices related to hospital management and financing, as well as integration with the broader health system, and add to this knowledge base through additional research. The Collaborative is imagined as a forum for exchange that can lead to concrete improvements in health on the ground. Potential projects and products could include a web-based knowledge clearinghouse, conferences and webinars, data measurement and analysis, peer-to-peer learning exchanges, and in-country technical assistance. 

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Health and Growth

This volume, comprising six articles and related commentary, examines the relationship between economic growth and investment in health. It emerged from the Commission on Growth and Development, which convened from 2006 through 2008 to discuss the diverse causes and impacts of economic growth.

While evidence clearly shows that positive economic growth contributes to better health outcomes, as measured by better nutrition, longer life expectancy, and lower communicable disease rates, among other indicators, the extent of the reverse relationship—that is, whether improved population health directly contributes to economic growth—is less clear. The lack of comprehensive metrics to measure health makes determining the degree of this causation challenging, as do other potential compounding factors; for example, countries with more effective health systems often benefit from greater institutional strength overall, complicating the identification of individual causal relationships. The articles in this volume explore existing evidence around this relationship, which is tenuous.

The final article explores the impact of early childhood investment in health and nutrition on future individual and household earnings. On this topic, the scientific evidence demonstrates clearly that investing in health and nutrition at an early age can lead to higher incomes, help break cycles of intergenerational poverty, and contribute to long run economic growth.

 

Co-editor Michael Spence is a senior fellow at the Hoover Institution and Philip H. Knight Professor and Dean, Emeritus, at Stanford University. He was awarded the Nobel Memorial Prize in Economic Sciences in 2001. 

 

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Parallel Systems and Human Resource Management in India's Public Health Services

Increasingly, evidence in India suggests that the delivery of health services suffers from not only a shortfall in trained health professionals, but also from unsatisfactory performance of existing service providers working in the public and private sectors. This study focuses on the public sector and examines de facto institutional and governance arrangements that may give rise to well-documented provider behaviors such as absenteeism, which can adversely affect service delivery processes and outcomes.

The paper considers four human resource management subsystems: postings, transfers, promotions, and disciplinary practices. The four subsystems are analyzed from the perspective of frontline workers, that is, physicians working in rural healthcare facilities operated by two state governments. Physicians were sampled in one state that has instituted human resource management reforms and one state that has not.

The findings are based on quantitative and qualitative measurements. The results show that formal rules are undermined by a parallel modus operandi in which desirable posts are often obtained through political connections and side payments rather than merit. The evidence suggests an institutional environment in which formal rules of accountability are trumped by a parallel set of accountabilities. These systems appear so entrenched that reforms have borne no significant effect.

 

This working paper was co-authored by Gerard La Forgia, Shomikho Raha, Shabbeer Shaik, Sunil Kumar Maheshwari, and Rabia Ali. 

 

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Aceso Global CTO Cited in Bloomberg Article on Healthcare Access for China’s Rural Poor

Gerard La Forgia, Aceso Global’s CTO, was cited in a Bloomberg Business article regarding China’s rural poor and the high cost of healthcare access in the country.

La Forgia, the lead author of Healthy China: Deepening Health Reform in China stated that the average cost of a hospital is 1.3 times the annual income of rural residents, compared to only 50% of the annual income of city residents. According to the article, nearly 60% of senior citizens in China live in rural areas marked by poverty and poor healthcare.

The Chinese government instituted a rural medical insurance scheme over a decade ago; in 2009 it introduced a pilot rural pension program. La Forgia points out that “On paper it looks great—90-some percent of the rural population is covered, and that is probably true.” However, both of these programs are limited and impose high out-of-pocket payments and copayments.

Read more: China’s Rural Poor Bear the Brunt of the Nation’s Aging Crisis

Case Studies: White Paper on Hospital Autonomy Potential in India

These case studies supplement Aceso Global’s White Paper on Hospital Autonomy Potential in India and assess hospital autonomy reforms in Brazil (Sao Paulo), Hong Kong, Vietnam, Portugal, Spain, the UK, and the US (NYC). Each case study introduces the country- or city-specific context leading to reforms, then details how the governance model functions in terms of operational and organizational autonomy, financial management, and accountability. Finally, each case study concludes with an analysis of the model’s strengths and weaknesses, and lessons learned. 

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Preparing for Transition from Donor Funding: Developing a Stakeholder Engagement Tool for the Global Fund in LAC

This presentation introduces Aceso Global’s work for The Global Fund to Fight AIDS, Tuberculosis and Malaria, conducting Transition Readiness Assessments in Latin America to help middle-income countries transition away from reliance on donor funding for these diseases. The work, as outlined in the presentation, includes the development and testing of a transition tool comprised of specific modules that will help assess whether countries are ready – financially, managerially, and politically – to shoulder a greater share of disease funding and program oversight. The findings will inform analytical reports and country-specific recommendations on this topic.  

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White Paper: Hospital Autonomy Potential in India

Public hospital autonomy reforms emerged out of frustration over poor hospital performance, citizen distrust of public care and evidence from other sectors of the benefits of delivery models that incorporate or build on private sector incentives. Hierarchical bureaucracy, limited managerial decision-making authority and nonexistent accountability have resulted in poorly performing hospitals, and driven the search for alternative models of health care delivery.

This paper takes up three major organizational forms of hospital autonomy reforms – autonomization, corporatization, and public-private partnerships – and the underlying components necessary for their successful implementation. International examples of hospital autonomy reforms in both OECD and emerging market countries serve as a foundation for analyzing potential opportunities, as well as pitfalls, of autonomy reforms in different contexts.

The paper concludes with an evaluation of the possible application of public hospital autonomy reforms in India. A brief overview of existing autonomy reforms in non-hospital settings is followed by recommendations for the Indian government on the applicability of specific models to the Indian public health sector.

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