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.

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.

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. 



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

Aceso Global CTO Authors World Bank Call to Action for Chinese Health Care System

A new World Bank report, issued in collaboration with the Government of China and the World Health Organization, urges adopting “People Centered Integrated Care” in China as a way to reduce costs and place primary care at the heart of the country’s health system. Aceso Global CTO Gerard La Forgia led the study from its inception and joined Aceso Global just prior to the conclusion of the report. The World Bank released the report’s 200-page Policy Summary on July 22, 2016.


Over the past three decades, China has made significant improvements in health, including in child and maternal mortality. Also, Chinese citizens theoretically enjoy Universal Health Coverage. Yet, in the years ahead rising costs could limit further improvements in the Chinese health system. An aging population and a shift in the disease burden to non-communicable diseases such as cancer, cardiovascular disease and diabetes will place new strains on an already costly system. Current healthcare costs are growing unsustainably, and are projected to reach 9.1 percent of GDP by 2035. The People Centered Integrated Care model suggested in the report provides a potential means to making the system more effective while also containing cost escalation.

The existing Chinese system over invests in expensive hospitals and specialty care, while increasingly neglecting primary care service. Rising patient dissatisfaction with the quality of primary care has driven many Chinese to visit hospitals at the first sign of illness. Not only is this an inefficient use of expensive hospital resources, but it has also led to a decline in the number of health professionals seeking work in the primary care sector. This vicious cycle only further weakens the quality of the primary care system. In response to these challenges, the report recommends placing primary care at the core of an integrated health system to reduce costs and free up hospitals for more complex care needs, while simultaneously altering incentive systems so that hospitals and clinics are rewarded for quality of care rather than the volume of services provided. Finally, the report encourages greater private sector involvement to harness private sector efficiency for public healthcare. 

The challenges faced by China—from rising health costs, to an aging population, to a shifting disease burden away from communicable diseases—are not unique. OECD countries are already facing these issues, and Emerging Market countries will experience similar trends over the next decade and will be confronted with the need to rein in costs while expanding service equity and quality. Policymakers can consult the report for lessons as a step to solving these challenges. 


Find the report, Healthy China: Deepening Health Reform in China: Building High-Quality and Value-Based Service Delivery, here.

See the report in the news: 




Hospitals Are Key to Reaching Universal Health Coverage

The global commitment to universal health coverage (UHC)—target 3.8 of the Global Goals for Sustainable Development—is as ambitious as it is energizing. Ensuring that everyone, everywhere has access to quality health care without being forced into poverty will require stronger health systems that generate better patient services and improve patient health. To that end, investments in hospitals and their performance will be key.

UHC is about timely, appropriate, and high quality services available at an affordable price. Yet, in striving towards this aim, hospitals are often overlooked by governments and donors alike. This needs to change given the shift in disease burden, whereby cardiovascular disease, cancer, and trauma, rather than infectious diseases, now dominate the burden of disease even in the poorest countries. Cancer and cardiovascular disease each claim more lives in Sub-Saharan Africa than AIDS, tuberculosis and malaria combined—although the latter remain the focus of funders. Health investment priorities must shift to meet these changing disease profiles.

If we continue to give little attention to upgrading and integrating hospitals and their services, low- and middle-income countries will remain ill-equipped to meet their commitment to UHC. Sticking with the status quo leaves modernization and expansion of hospitals to the private sector, which typically skews investments towards the upper and middle classes and often increases inequalities within and across countries. For example, the boom in private hospital construction in many middle-income countries in East Asia compensates for the lack of public investment in hospital services. However, these private hospitals are used by the wealthy who can afford their services while the poor are relegated to seek care at public hospitals. The poorest citizens in low- and middle-income countries ultimately suffer the most.

Although bilateral and multilateral donors focus almost exclusively on primary health care to meet UHC goals, and philanthropic institutions like the Bill & Melinda Gates Foundation have followed suit, this strategy falls short of the needs and preferences of country governments and their citizens. And it undermines the quality of the evolving health care system.  

First, countries are clearly concerned by the lack of hospital investments. This is most evident in how countries are increasingly seeking support from the multilateral development banks and their private sector arms, such as the International Finance Corporation, to make new investments.

Middle-income countries moving towards UHC, such as China, Brazil and Nigeria, already spend 70 percent of their health budgets on hospital care. Improving hospitals’ efficiency and quality, as well as integrating with primary care, is critical to raising performance. It would also be cost effective. Without hospitals, primary health care services lack a point of reference and an effective referral network. If hospitals are dysfunctional, services at all levels suffer.

Second, the specialized expertise and support of hospital care remains central to the treatment of trauma, cancer, and other chronic diseases, which require new and more costly health care strategies. Although primary health care remains important, building integrated care networks that link hospitals to outpatient services can offer critical and cost effective services to the people who increasingly depend on them.

As countries and donors seek to manage the rise of chronic and non-communicable diseases, prioritizing the building of health system capacity and improving health system performance can bring healthy returns. As I’ve written about before, this means renewing their efforts to upgrade health care systems, investing in secondary and tertiary facilities, and integrating care across inpatient and outpatient services. Furthermore, investments should be made to improve hospital leadership, which is an indispensable tenet of quality hospitals, management, and health care.

Without putting efforts towards hospitals, UHC goals risk becoming a hollow exhortation rather than empowering targets. That’s why I’m helping host an event at the CGD on December 7 to launch a new report, Better Hospitals, Better Health Systems, Better Health. I hope you’ll join us for a discussion on the critical issues around, and importance of, improving and reforming health systems and hospitals in low- and middle-income countries, where it’s needed most. (Register here)

Global Insights Series: The Role of Healthcare Accreditation in Mexico

This is the first in a series of interviews with global experts on approaches to specific health challenges.

Sebastian Garcia Saiso, the General Director of Quality and Education in Health at the Mexican Ministry of Health, discusses the role of accreditation in Mexico with CEO Maureen Lewis at the International Foundation for Integrated Care Conference.

The Ministry of Health has an active accreditation process for healthcare providers that complements other initiatives aimed at raising quality and ensuring basic standards of care. The accreditation body’s enforcement has led to the sanctioning of hospitals and hospital departments. These facilities or departments are ineligible to receive public funding until their deficiencies are resolved. Dr. Saiso gives a comprehensive background to the accreditation policy in Mexico, explains the government role in accrediting both public and private hospitals, discusses quality of health and integrated care, and gives his views on enforcement.



ML (Maureen Lewis): Can you discuss the accreditation process for hospitals in Mexico, how it works, how you see this connecting to quality of care, and its importance in terms of healthcare delivery in the country?


SG (Sebastian Garcia Saiso): I am going to go slightly before that, before accreditation, because it’s important to understand where policy comes from. The health system in Mexico was officially established in 1943 with the creation of the social security system, and it has had several milestones along the way from 1943 to the moment.


The provision of services before 1983 was done through social security as a mechanism directly linked to labor. And it was in 1983 that we in Mexico changed the constitution, which reflected the right of health protection as a constitutional right, which later became a human right as established by the constitution. This is also linked to the decentralization of services in the ‘80s and ‘90s – all those services provided outside social security, provided by a network of providers at the national context, were given autonomy to each of the 32 states of the Mexican republic and that created a system comprised by social security on one side and 32 autonomous providers on the other side for those not enrolled in social security.


By 2000, there was a very important milestone in which Mexico carried out a study and detected that 50% of the population did not have access to a formal form of financing for health needs – meaning 50 million people did not have access to social security because of their labor status. That created a gap and inequities in different kinds of population.

In 2003, there was a very important reform pushed forward to establish Seguro Popular – it’s a financing mechanism based on general taxation for all those not enrolled in social security.  Parallel to that reform, the accreditation system was established to guarantee Seguro Popular enrollees the minimum standards in terms of quality and capacity at the local level. This was set up as a strategy acknowledging that there was a very important difference across the 32 different state providers and that the financing from the federation was going to be generally the same, meaning the federation was going to pay for services in all the states.


In 2004, we started the accreditation process. It was a very important challenge to start accrediting for a financing mechanism that was already in place. So there was a huge rush to accredit establishments so that we could have units providing services to match the financing that became available. What’s happened since then is that we have about 12,000 medical units accredited within the Seguro Popular financing mechanism. It becomes a need to evaluate what has happened with this accreditation mechanism and to set forward new regulatory mechanisms so we make sure that this surveillance mechanism, which will ensure the minimum standards of quality and safety are in place not just across Segura Popular but also across different services, including social security.


So this is one of our main concerns at the moment in which we have managed to balance or reduce the gaps in financing between different populations with a particular set of providers and those outside the public financing mechanism, which includes the private providers.


Thinking of this is a very comprehensive and ambitious reform that would set up a horizontal as much as a regulatory mechanism in which accreditation would be one mechanism to ensure minimum standards. This means making sure that through accreditation and surveillance mechanisms that standards are met, but then also measuring how performance changes with these mechanisms so that we make sure that those who are not performing as well can have incentives also to move into this direction. So, by accrediting, you make sure that no one below this standard exists in a market of provision, and then later, through incentives, you actually make innovation and promote change towards where the system should be.


In a context like Mexico in which the demographic and epidemiological transition is such an important role in what healthcare delivery will be in the next few years, you need to have very small mechanisms to steer the system in that direction. Accreditation is one of the tools you have in the regulatory framework, and then you have to create different incentives and different mechanisms to promote it.


ML: I am also wondering – are you responsible for accrediting all public and private across the board?


SG: We are responsible at the General Directorate to accredit establishments across all different providers, but only when they are linked to the financing mechanism provided by Seguro Popular. If we have interventions provided by social security, we would accredit them – such as maternal emergency care, where regardless of the insurer we provide services across the spectrum and that is accredited by us. We have accredited private providers that are part of a local network of services especially for those services under the fund for catastrophic expenditure protections which includes the most expensive and specialized interventions within Seguro Popular and, of course, those public providers owned by the state which are the main provisions under Seguro Popular financing.


ML: Because we have been talking about integrated care, how do you see the regulations and accreditation trying to play a role in promoting integrated care going forward?


SG: Quality of healthcare is a very important part of integrated care. You may have many of the other aspects defined as components of integrated care, but if you do not have a strong quality framework, its very hard to achieve this interaction between different areas of healthcare, and different mechanisms to achieve a patient centered health policy. So regulation is one of these areas that we can use to steer the system.


We are working with other governments – here I prefer the experience that France has developed on tracing patients to ensure that healthcare is provided in a continuous manner. That is something that we are incorporating in our accreditation system to make sure that we follow patients at different levels to make sure that care is provided when the patient requires it at the type of facility which is ideal for this and by a group of people that is required to treat this condition.


So this means, for example, in care for pediatrics of quality, the patient is diagnosed properly in primary care, but it refers also to units that have the resources to actually treat the condition so we have problems for example in rural communities in which patients may delay a very long time before they are diagnosed and referred to a higher level of care, and this creates an opportunity cost which is sometimes very important in trying to achieve better outcomes in healthcare.


ML: What about enforcement of accreditation and the accountability that comes within it - how does that work, and how do you manage that within the regulatory system?


SG: It is something vital to any system, and it has to be constant. You have to always work on accountability of any system and any tool that you have to actually reach results. This is the case of accreditation and regulation in general in which you can never lose sight of what you are trying to achieve, and you have to work towards that all the time. The case in Mexico is very important, with as you have seen a few minutes ago, we evaluated the number of units that provide pediatric care and we find a great range of performance results in these units. That creates concern whether accreditation is actually achieving its purpose, meaning greater homogeneity in the provision of services.


What we are trying to do now - and it’s a great step forward in our accreditation policy - is that we are trying to evaluate risk, by measuring performance in each of the units that are accredited, and then creating a mechanism to survey those that are actually show a greater risk of not showing results and help them. One would be if they have lost the accreditation standards to push them to achieve them again without actually creating a risk to the patient. The other one would be to incentivize that they not only maintain these standards but also improve them so that we can raise the standard across the entire system. This creates a moving forward policy in which you don’t only make sure they have the minimum at this moment but you also follow them and evaluate them periodically so that you move the standard slightly upwards every once in a while.


ML: Is there anything else you want to add?


SG: I want to make sure that the point gets across that regulation is only one of the things that the system has to contain. It’s only one thing; there are no silver bullets in any health system. It’s such a complex array of circumstances, actors, and mechanisms that have to interact and move in the same direction, that regulation is only one way to equalize to make sure that everyone knows their role, at their time, and towards a particular goal.