HIV/AIDS

Panama Transition Readiness Assessment Country Report

This report summarizes the findings of the Transition Readiness Assessment for Panama 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 Panama’s transition planning as the Global Fund scales down its financial support for the national tuberculosis and HIV/AIDS responses. To produce a complete report, the Aceso Global team used the Guidance for Global Fund Transition to inform the analysis and consulted with numerous local stakeholders, including government officials at the Ministries of Health and Finance, Global Fund staff members and local civil society organizations. 

The report summarizes the Global Fund's financial and non-financial support to the country, analyzes the epidemiological situation as well as the national response in Panama and provides a background on the institutional and enabling environments, human rights and gender situation.  

Based on a thorough analysis of the Panamanian health system, the Aceso Global team identified the most pressing opportunities and threats to be considered during the transition process. Recommendations included the following: increasing the outreach to high risk communities to improve the identification of TB patients, particularly among indigenous groups and communities with weak links to primary care clinics; merging the HIV and TB programs of the Ministry of Health and the Social Security Fund to avoid duplication of effort and reduce inefficiencies; and committing to anti-discriminations actions. In addition, the report underlined civil society organizations’ urgent need for assistance in sustainability planning.

DOWNLOAD THE REPORT IN ENGLISH HERE

DOWNLOAD THE REPORT IN SPANISH HERE

Asegurar la sostenibilidad a largo plazo de la respuesta nacional contra el VIH en República Dominicana: ¡Asociaciones Sin Fines de Lucro son la solución!

Basándose en un previo Análisis de la Preparación para la Transición en el proceso de salida del Fondo Mundial, Aceso Global trabajó con asociaciones sin fines de lucros (ASFL) en la República Dominicana para comprender los mecanismos de financiación pública y desarrollar las capacidades de las organizaciones para competir por subvenciones públicas y recursos de otra procedencia, Anna Bonfert, economista de la salud, resume nuestros principales hallazgos y sugerencias para continuar un trabajo que se muestra muy promisorio.

La República Dominicana ha logrado importantes avances hacia una generación sin VIH. Mientras que la prevalencia del VIH en la República Dominicana sigue siendo el doble de la media en América Latina y el Caribe; en los últimos 15 años, los casos nuevos de infección por año han disminuido rápidamente desde su punto máximo en el principio de los años 2000.

Uno de los factores de éxito ha sido el compromiso activo de las ASFL. Dado que muchas de estas organizaciones fueran creadas en las mismas comunidades afectadas por el VIH, pasaron a ser el centro de la respuesta nacional. La República Dominicana ha visto un surgimiento de ASFL especializadas, que trabajan con grupos vulnerables y marginados, los mismos grupos que son desproporcionadamente afectados por el VIH y el estigma. Debido a que pueden establecer y mantener una relación de apertura y confianza mutua que les permite trabajar en el terreno, las ASFL tienen acceso a comunidades que no serían alcanzadas por programas oficiales a nivel nacional, provincial o local. Entre esas comunidades y colectivos se encuentran los de trabajadores sexuales, personas trans, gay y otros hombres que tienen sexo con hombres, usuarios de drogas inyectables e inmigrantes haitianos. Las ASFL sirven como una interfase entre los servicios públicos y estos grupos, y utilizan enfoques diferenciados que reflejan la diversidad de las comunidades.

En los últimos 15 años, la sociedad civil ha florecido gracias al apoyo recibido con los fondos de donantes para actividades relacionadas con la prevención y control del VIH y la protección de los derechos y la dignidad de las poblaciones y grupos clave. Las subvenciones externas a menudo han sido entregadas con la condición de que los fondos se ejecuten con la participación de las ASFL, para así garantizar que se escuchen las voces de las comunidades afectadas por el VIH y se atiendan sus necesidades de manera efectiva, defendiéndose sus derechos y bienestar. La lucha contra el estigma y la defensa de los derechos humanos han sido quehaceres fundamentales de las ASFL, pero muchas de ellas también participan en actividades de divulgación, prevención y acceso al tratamiento.

Al mismo tiempo, el gobierno de la República Dominicana ha reconocido el importante trabajo realizado por las más de 200 ASFL que participan actualmente en la respuesta al VIH. El reconocimiento se ha expresado (y materializado) a través de actualizaciones de instrumentos legales y códigos, así como mediante compromisos financieros para subvencionar internamente  las operaciones de las ASFL. De hecho, ahora hay más de una docena de fuentes de financiamiento público disponibles para las ASFL que trabajan en el área del VIH. Estas incluyen: el Centro Nacional de Fomento y Promoción de las ASFL, una institución gubernamental dedicada a la concesión de subvenciones a las ASFL, acuerdos con los gobiernos provinciales y acuerdos de gestión conjunta con el Ministerio de Salud.

A pesar de estos avances positivos, el país todavía aún está en vías de identificar mecanismos asegurar que el trabajo de las ASFL se encuentra en un derrotero sostenible para avanzar sin contratiempos ni interrupciones. Esta inquietud es cada vez más apremiante porque varios donantes internacionales que actualmente apoyan el programa nacional de VIH y tuberculosis han anunciado su retiro gradual, lo que podría provocar interrupciones en el programa contra el VIH y los servicios proporcionados por las ASFL, que hasta el momento se han apoyado en recursos externos y, en algunos casos, han dependido exclusivamente de estos. Al mismo tiempo, a pesar de las numerosas fuentes de financiamiento público que han surgido, el acceso a estas puede ser difícil.

A medida que las ASFL exploran formas de mantener su trabajo y sus actividades de gestión, se encuentran peguntándose: si todas estas fuentes de financiamiento público están disponibles, ¿por qué es tan difícil recibir financiamiento del gobierno? ¿Y por qué no hay una guía sobre cómo competir para obtener fondos públicos? Para enfrentar estos desafíos, Aceso Global, en asociación con El Fondo Mundial para la lucha contra el SIDA/VIH, la tuberculosis y la malaria, trabajó con las ASFL en la República Dominicana para comprender el panorama de financiamiento público y desarrollar la capacidad de asociaciones para competir por subvenciones públicas y otros fondos.

Primero, examinamos cómo funcionan en la República Dominicana los procesos de calificación y solicitud de financiamiento público. ¿Qué documentos deben presentar las ASFL, cuándo y dónde? ¿Cuáles son los diferentes pasos involucrados, y cuáles son las fechas límite para cumplir con esos pasos? ¿Dónde pueden ir las ASFL para obtener información adicional? Si se pregunta a diferentes funcionarios del gobierno es probable que obtengan diferentes respuestas. Como pronto se pudo constatar existe toda la información necesaria, pero está dispersa en diferentes sitios web, departamentos dentro del Ministerio de Salud e incluso personas a cargo de procesos específicos. A menudo, la información relevante no está disponible en un formato fácil de usar. También se constató que hay muchos pasos repetitivos necesarios para solicitar financiamiento, y que algunas pautas son contradictorias.

Nuestro documento de Mapeo y las hojas informativas que lo acompañan (en español) organizaron la información dispersa en una ubicación de acceso fácil y simplificaron las pautas existentes en un formato fácilmente comprensible. Los documentos proporcionan a las ASFL una imagen clara de los pasos administrativos necesarios para calificar para la financiación pública.

Durante el proceso, también se pudo observar que las ASFL varían considerablemente en su experiencia y capacidad. Mientras que algunas ya compiten con éxito para obtener financiamiento público, otros apenas están comenzando a establecer los sistemas y las estructuras requeridas para cumplir con los requisitos para competir por este y conseguir obtenerlo. Un mayor desarrollo de la capacidad podría mejorar la competitividad de las ASFL para los fondos públicos. ¿Cómo se escribe una propuesta persuasiva? ¿Qué es lo que se debe y no se debe hacer en la planificación y ejecución de proyectos? ¿Cómo configurar los sistemas de monitoreo y la evaluación para mostrar lo que ha logrado a través del financiamiento gubernamental? ¿Existe una manera más efectiva de promover servicios ofrecidos por las ASFL, tanto a entidades gubernamentales como a otros financiadores nacionales? Estas son algunas de las preguntas que enfrentan las ASFL, y la capacitación en estas áreas basada en nuestro material educativo, que permitirá a las ASFL pasar de ser receptores pasivos de fondos de donantes a promotores activos que pueden ofrecer y vender sus servicios al gobierno y otras fuentes de subvención.

Estas organizaciones brindan servicios valiosos en salud y derechos humanos, más allá de lo que el gobierno puede proporcionar por sí solo. Son fundamentales para la sostenibilidad a largo plazo de la respuesta nacional al VIH / SIDA y merecen un impulso en la forma de capacitación y el apoyo para fortalecer su papel de liderazgo en la República Dominicana.

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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, and also highlights areas of opportunity, 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 organization’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!

Aquí para la versión en español de esta publicación.

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.

 DOWNLOAD THE REPORT HERE (SPANISH)

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)

Sustainability of Global Fund Supported Programs: Brazil Country Case Study

This report summarizes the policies, programs and levels of investment in malaria, tuberculosis and HIV/AIDS in Brazil, linking these to broader Brazilian healthcare initiatives and to both general and specific investments. It provides the background necessary to understanding the contribution of the Global Fund, and the country’s transition away from that support once funding for malaria and tuberculosis ended. Brazil’s strong commitment to health, early establishment of excellence, its depth of technical expertise, and its ability to implement complex health programs has translated into a level of independence that relies on outside support for only part of its agenda. That in turn facilitates adapting to declining external transfers, and an understanding that transition means establishing functioning and funded institutions.

DOWNLOAD THE FULL REPORT HERE

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)