HEALTH CARE DEVELOPMENT IN LATIN AMERICA & CARIBBEAN COUNTRIES Focus: DOMINICAN REPUBLIC

1. HEALTH CARE DEVELOPMENT IN LATIN AMERICA & CARIBBEAN COUNTRIESFocus: DOMINICAN REPUBLIC Y. Reyes Columbia University School of Social Work April 11, 2011

2. Latin American & Caribbean Health Trends Tug between the role of government and the role of nonstatutory welfare institutions in providing care Are taking a progressive agenda in the development of social welfare Nonstatutory welfare institutions have in essence been forced to be key service providers (Midgley, 1997) New initiative: producing health outcomes as stated in the United Nations Millennium Development Goals Takes on a reconstructionists approach, which is highlighted in many welfare pluralists states (Midgley, 1997; Mkandwire, 2007) Government has involvement but rebuilding of welfare states should accept increased privatization and some budgetary reduction of expenditures (Midgle, 1997; Figuiera, 2002)

3. Research Study • Descriptive research study design, non probability sampling method • 90 day study in mental health needs of a clinic in Monte Plata, Dominican Republic • Patient observations in the HIV/AIDS clinic • Interview of medical and administration teams • In-depth interviews with the following organizations: • Fundación Global Democracia y Desarrollo (FUNGLODE) and Global Foundation for Democracy and Development (GFDD) • Colegio Dominicano de Psícologos (Dominican College of Psychology) • Universidad Iberoamericana (Iberoamericana University) • Colegio Medico Dominicano (Dominican College of Medicine) • Instituto Nacional de la Salud (National Institute of Health) • Batey Relief Alliance (BRA) Dominicana • Presidential Public Health Advisor, Dr. Alberto Fiallo

4. Dominican RepublicInternational Human Development Indicators - UNDP

5. Dominican Republic Health Model • Transitionary period to separate functions and decentralize services (2007) • Modeled after Chilean Health Model • 2007 review, PanAmerican Health Organization (PAHO) • showing strides with regards to providing coverage to its' population (18%) • general health law no. 42-01 and the social security system law no. 87-01 have been created which establish that health coverage is a government responsibility • Recently Established: • SENASA, the national health insurance authority • SESPAS, the Ministry of Public Health and Social Assistance, is the systems lead agency

6. Source: PAHO, 2007

7. Currently in development… Policy implementation at the ground level is encountering difficulties due to the social and political culture of the country Creation of new financial steering agencies within SESPAS to process funds from the central government (2007) Regional Health Services agency, whose sole mission is to provide access to health based on geographical distribution in three levels of care 1. primary health strategies 2. specialized care that may require hospital stays 3. regional and specialized hospitals covering delivery of more complex services

8. POLICY NEED IDENTIFIED Decentralization still needs to occur Increased need for transparency between agencies to identify different functions of public health agencies (2007) Currently no methodologies are in place for analysis which leaves policy makers at a standstill on best practices needed to reduce the high level of in equitability. Forms skewered numbers that lead many agencies to under-report their findings which establishes ill-defined causes for public health issues Need in human resource administration was defined as a necessity in government strategizing Shortage of medical personnel, particularly in rural areas (2007)

9. NEEDS CONTINUED… Preventive health services, a major necessity in lowering health disparities, are not included in the basic health plan. basic health plan administration feels that this responsibility solely relies on the state Population over use public hospitals, which consumes 40% of the health budget, as a method of treating acute illnesses Currently, the country is in an epidemiological transition, noted decline in infectious diseases and a noted increase in chronic non-communicable diseases (2007). Preventive health models can assist in self management of illnesses and can include populations that absorb direct services from government without contribution, such as the disabled and elderly populations

10. BRA Dominicana, Monte Plata • Humanitarian agency that coordinates local efforts to alleviate the plight of sugarcane workers in bateyes • Using internal resources, international grants, specialized volunteers, and partners with other humanitarian institutions to implement projects that provide assistance in finance management, health care/education, agriculture and sustainability, and community development • Current Projects: • Unit of Integral Attention to HIV/AIDS • Prevention of Malnutrition • Medical Missions in Opthalmology and Disaster Management

11. Bra Dominicana Findings • Normative Need • Difficulties in understanding problem, no registry of services given, establishing which resources are available to medical staff • Expressed Need • More time was needed to establish concrete findings in this area. System to track services not the culture in the country • Perceived Need • Patient profile symptoms expressed: • Recurrent nightmares of death, feelings of loss, emptiness, abandonment, remembering difficulties, little motivation, low level all daily living skills, difficulties with treatment adherence

12. Recommendations for Bra Dominicana • Recommendations to incorporate Mental Health services • Identify indicators with regards to service monitoring for use in future evaluations. This is critical to identifying any underlying trends found in patients that might impede successful implementation of care • Create system of tracking services administered, especially as care becomes highly individualized between doctor and patients • Open dialogue within the community regarding mental health and the types of assistance available • Establish a mental health component to assist patients experiencing difficulties with medication adherence due to alcohol and substance abuse • Educate on alcohol and substance abuse, and effects of medication, individual counseling, family group sessions, and community open forums to educate on the occurrences of mental illnesses

13. Suggestions from other Caribbean Models • Cuban Health Model • Focuses mainly on community practice as a way to understand the social causes of diseases • Prioritizes at-risk individuals, as identified through neighborhood outreach and development social welfare projects • Chilean Health Model • Progressive law enactments that combat severe health disparities • Laws established had a two-fold agenda: 1. economic and policy creation and 2. reinforcement. • Laws made were with the intent to strengthen the authority of the health ministry

14. Use a very practical and in depth approach, when faced with extreme resource constrictions, of understanding inequalities as diseases that have a cause and a cure Develops the role of social workers as a key agent within the system. Social workers use a multi-dimensional approach in which income is only one factor in defining poverty Cuba experienced an enormous diminution of infectious diseases and sweeping improvements of socio-economic conditions (Spiegel et al, 2005) Chilean system elevated country to second rank, contains a dual system approach, the private and public sector Established integration of cash transfers with service provisions, overseeing means of subsistence by using multiple indicators to assess level of income and consolidation of administration procedures (Mesa-Lago, 2008) Principles from other Caribbean Health Care Models:

15. References Health Financing and Sustainability Project. (1990). Health Services for Low-Income Families: Extending Coverage Through Prepayment Plans in the Dominican Republic. Bethesda, MD: La Forgia, G.M. Jane-Llopis, E. (2004). La Eficacia de la Promocion de la Salud Mental y la Prevencion de los trastornos mentales. Rev. Asoc. Esp. Neuropsiq., 89, 67-77. Mesa-Lago, C. (2008). Social Protection in Chile: Reforms to Improve Equity. International Labour Review, 147 (4), 377-402. Pan American Health Organizatoino. Health Systems Profile: Dominican Republic 2007 [Data file]. Retrieved from http://www.lachealthsys.org/index.php?option=com_content&task=view&id=373&Itemid=450 (accessed, 1, February, 2011). Santana, I. & Rathe, M. (1994). Setting a New Agenda for the Dominican Republic. In Aedo, C. & Larrannaga, O. (Eds.), Social Service Delivery Systems: An Agenda for Reform (91-126). Washington, DC: Inter-American Development Bank. Saracostti, M. (2003). The Chile Solidario System. The Role of Social Work. International Social Work, 51 (4), 566-572. Saracostti, M. (2010). Constructing Chile’s Social Protection: From Early Childhood to Old Age. International Social Work, 53 (4), 568-574. Strug, David. (2006). Community-oriented Social Work in Cuba: Government Response to Emerging Social Problems. Social Work Education, 25 (7), 749-762.

16. REFERENCES United Nations. Contexto General y Determinantes de la Salud [Data file]. Retrieved from http://www.who.int/whosis/database/gis/salb_home.htm US Agency for International Development. Dominian Republic: Country Health Statistical Report [Data file]. Retrieved from http://pdf.usaid.gov/pdf_docs/PNADO678.pdf. US Agency for International Development. Sustained Improvement in the Health of Vulnerable Populations in the Dominican Republic [Data file]. Retrieved from http://www.usaid.gov/dr/strategies.htm. World Health Organization. Disease Control Priorities Related to Mental, Neurological, Developmental and Substance Abuse Disorders [Data file]. Retrieved from http://www.dcp2.org/file/64/WHO_DCPP%20mental%20health%20book_final.pdf. World Health Organization & Pan American Health Organization. Dominican Republic: Health Situation Analysis and Trends Summary [Data file]. Retrieved from http://www.paho.org/english/dd/ais/cp_214.htm World Health Organization. Prevention of Mental Disorders Effective Interventions and Policy Options.(2004).[Data file]. Retrieved from http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf . World Health Organization and Pan American Health Organization. (2009). WHO-AIMS Report on Mental Health Systems in Central America and Dominican Republic [Data file]. Retrieved from http://www.who.int/mental_health/evidence/WHO-AIMS/en/.