USAID CBJ FY 2002: Dominican Republic

Summary: This activity works to improve preventive and primary health care services by addressing both structural and systemic weaknesses within the health care system. USAID works closely with governmental and non-governmental organizations to improve access to quality basic health services. The Strategic Objective supports activities to increase access to HIV/AIDS/STI prevention and care services by at-risk and affected populations; increase access to reproductive health services for target populations; increase access to selected child survival interventions; and increase efficiency and equity of basic health services at decentralized levels.

Child Survival funds support programs which: reduce HIV/AIDS transmission through behavior change strategies and control of sexually transmitted infections (STIs); reduce the impact of HIV and AIDS in affected populations; improve immunization coverage through long term strategic planning; improve child health through community-based integrated management of childhood illnesses (IMCI); and increase access to rural potable water. DA funds support programs that increase access to and quality of public sector reproductive health programs and improve the sustainability of non-governmental organizations (NGOs) that provide family planning services. Both fund types help advance health policy reforms that increase equity in delivering quality, integrated health services at decentralized levels.

This activity supports the U.S. national interest "global issues" in the environment, health, and population. It also contributes to the strategic goal of economic development and equitable access to basic health services, a key Summit of the Americas initiative.

Key Results: USAID met the target for increased access to HIV/AIDS/STI services (98%) and the objective for Couple Years of Protection, a proxy for Contraceptive Prevalence Rate, reached 98% of the target. USAID-funded public sector services and NGOs provided a full range of preventive and curative care interventions, reaching over 177,000 males and 344,000 females, a total of over 521,000 persons. As a result of HIV/AIDS prevention and control activities, recent studies show an increase in condom use, an important behavior change (46.7% in 1999 vs. 9.1% in 1996 among women of reproductive age). USAID continues to contribute significantly to this important trend through behavior change communication interventions targeted at vulnerable groups, including adolescents and youth.

USAID supported the implementation of a pilot program to reduce mother-to-child HIV/AIDS transmission in four public maternity wards: 90% of HIV-positive women and their babies received treatment. Preliminary results are promising. A pre-packaged therapy pilot project for STI treatment was successfully completed in three public hospitals. Preliminary results indicate high levels of acceptance and satisfaction (88% completed treatment) by both male and female clients. The Government of the Dominican Republic (GODR) is interested in expanding this program to the national level.

Selected child survival interventions also produced important results in 2000. A community-level integrated management of childhood illness (IMCI) program was implemented jointly with the Pan American Health Organization (PAHO), the Secretariat of Health and partner NGOs. Five provinces have incorporated IMCI into their health care delivery systems, one more than the target. According to a 1999 study, only 36% of children 12 to 23 months were fully vaccinated. The recent polio outbreak has demonstrated the need to increase coverage through program efficiency. To contribute to the strengthening of the Expanded Program of Immunization, USAID, jointly with PAHO, helped draft a legal framework and operations manual.

The past year was also important for health sector reform initiatives. The frequently quoted, USAID-funded study, "Equity and Health," enriched the debate and draft of the Social Security Law. The approval of this law by the congress is imminent. USAID's assessment of the advances in decentralization provided key input to the new Secretariat of Health's decentralization policy. USAID-funded NGO certification norms were approved and launched last August and the certification process for nearly 200 NGOs has begun and will be completed by year's end. USAID support to strengthen the management capacity of one municipal and three provincial health directorates was also a key contribution to the decentralization process. Assistance included studies on the feasibility of organizing service networks as a strategy for rationalization and increased efficiency of service supply. To complement the study, a census of public and private providers was conducted in four provincial directorates that will be used to form public-private service provider networks. The Secretariat approved a USAID-supported monitoring and evaluation plan for the reform.

Performance and Prospects: USAID continues to raise GODR awareness regarding the importance of HIV/AIDS as a development problem and not simply a health problem. A presidential-level HIV/AIDS Council was appointed to oversee multi-sector involvement and participation. USAID's support enabled Council members to participate in observational trips and regional forums that were critical in identifying key issues. USAID is also assisting the GODR to develop policies and norms in establishing a national, voluntary HIV/AIDS counseling and testing program. USAID will support the expansion of the vertical transmission program to the country's maternal hospitals. A recent HIV/AIDS mid-term evaluation confirmed that the pro0ram remains on track.

The seven-year Family Planning and Health Project ended in September 2000. Key results include the introduction of injectables and the low dose pill, improved post-partum/post-miscarriage reproductive health services, the integration of HIV/AIDS into reproductive health services provided by NGOs, and the development and dissemination of reproductive health norms. Technical assistance and training bolstered institutional development and sustainability. NGO cost recovery/income generation and funding diversification progressed significantly: cost recovery for one NGO increased from 61% in 1994 to 88% in 1999. The ratio of international/local sources of funding for this NGO went from 64%/36% in 1993 to 38%/62%, respectively.

Based on a favorable national Contraceptive Prevalence Rate report, a activity for reproductive health/family planning will incorporate a five-year phase-out of USAID direct support to family planning through NGOs. This strategy will emphasize the financial sustainability of NGOs that currently receive direct USAID funding and will include: 1) improving the financial sustainability of partner NGOs while maintaining services to target populations; 2) improving the quality of public sector reproductive health/family planning services; and 3) fostering public/private partnerships. A key part of the phase-out strategy is enhancing the public sector's role in reproductive health/family planning services provision. So far, the new GODR administration has not indicated that this is a priority area, which may mean that progress will be slow in achieving sustainable, national coverage, especially for poor women residing in remote rural areas.

The Vice-President and Secretary of Education is requesting USAID assistance in developing a new reform strategy and more directly involving the private sector and communities in improving educational quality. A recently approved 416(b) program under the Global Food for Education Initiative will complement USAID efforts to incorporate the private sector, NGOs, and Dominican communities in education improvement initiatives.

Both the president and the congress support the health reform process. USAID's new health sector reform activity, REDSALUD, was launched in August 2000. REDSALUD will strengthen local and Health Secretariat management capacity and improve the policy environment that supports the health reform process. Prospects for continuing progress in program implementation are favorable.

FY 2001 DA funds will improve NGO family planning/reproductive health (FP/RH) sustainability ($.990 million); help develop the 2002 demographic health survey ($.600 million); support health sector reform ($2.1 million); and strengthen the capacity of NGOs and public sector institutions to provide quality FP/RH services ($.800 million). FY 2001 CSD funds support ongoing NGO programs to prevent and control the spread of HIV/AIDS ($3.0 million); assist the Ministry of Health AIDS Directorate and the Presidential Commission for AIDS develop HIV/AIDS reduction policies that include voluntary counseling and testing and treatment of sexually-transmitted diseases ($1.2 million); support a PAHO grant for HIV/AIDS-related tuberculosis treatment ($1.2 million); and provide vaccinations for childhood diseases and maternal and child health programs in select communities ($.400 million).

FY 2002 DA funds will continue support to RH/FP NGOs ($1.2 million) and technical assistance for public sector institutions providing RH/FP services ($.400 million). FY 2002 CSD funds will help NGOs raise awareness on AIDS prevention ($2.3 million); strengthen public and private sector capacity to develop and implement policies that reduce HIV/AIDS transmission ($.700 million). Other FY 2002 CSD funds will support health sector reform ($1.8 million); maternal health services through NGOs ($.800 million); and public sector vaccination programs ($.100 million).

Possible Adjustments to Plans: To improve the family planning method mix (60% sterilization), interventions will focus on postponement of sexual activity and the introduction of child spacing methods among youth, and the promotion of a broader choice of temporary methods for voluntary contraception as a quality issue in public hospitals. USAID will initiate a program to implement direct observance of tuberculosis treatment nationwide and will support a study of children and families affected by HIV/AIDS that will inform strategy design to address these issues.

Other Donor Programs: The Inter-American Development Bank, the World Bank, the European Union, UNAIDS, UNICEF, Germany, and the Pan American Health Organization.

Principal Contractors, Grantees or Agencies: U.S. organizations include: Abt Associates, Academy for Educational Development, Family Health International, Population Services International, John Snow, Inc., University of North Carolina, and Deloitte Touche. Local organizations include: The Dominican Association for Family Well-Being (PROFAMILIA), the Dominican Family Planning Association, Women in Development, the Secretariat of Health, and the Dominican Social Security Institute.

Dominican Republic 517-002

Indicators have been changed from recent Congressional Notifications to better reflect program results.

U.S. Financing

(In thousands of dollars)

	Obligations		Expenditures		Unliquidated
Through September 30, 1999	41,857	DA	39,532	DA	2,325	DA
	5,097	CSD	1,755	CSD	3,342	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA
Fiscal Year 2000	2,800	DA	3,904	DA
	3,300	CSD	2,600	CSD
	0	ESF	0	ESF
	0	SEED	0	SEED
	0	FSA	0	FSA
	0	DFA	0	DFA
Through September 30, 2000	44,657	DA	43,436	DA	1,221	DA
	8,397	CSD	4,355	CSD	4,042	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA
Prior Year Unobligated Funds	0	DA
	0	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Planned Fiscal Year 2001 NOA	4,490	DA
	5,885	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Total Planned Fiscal Year 2001	4,490	DA
	5,885	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
			Future Obligations		Est. Total Cost
Proposed Fiscal Year 2002 NOA	1,632	DA	6,085	DA	56,864	DA
	5,700	CSD	4,100	CSD	24,082	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA

Dominican Republic

Activity Data Sheet

Dominican Republic 517-002

U.S. Financing