Reflection and vision: a systems perspective

In the Dominican Republic, chronic diseases like heart disease, cancer, diabetes, and chronic respiratory illnesses are the leading cause of death, accounting for 70% of all deaths nationwide. Nearly 10% of the Dominican adult population suffers from diabetes, one out of every three people has high blood pressure, and more than one quarter struggle with obesity – but, only about half of these individuals receive treatment that could help them to live healthy, full lives. These numbers reflect a global trend: over the last two decades, the overall burden of disease has been shifting from infectious to non-communicable diseases, or NCDs. However, this burden is not distributed evenly — today, 86% of NCD-related deaths globally occur in low- and middle-income countries, like the Dominican Republic.

At Health Horizons International (HHI), we know that the fight against NCDs requires strengthening primary health care, providing essential medicines, and promoting healthy behaviors – and, we recognize there is a larger challenge. The conditions and norms that describe the places where people are born, live, work, and age have a major impact on health, including but not limited to NCDs. Globally, between 45% and 60% of variation in health outcomes is explained by environmental and socioeconomic factors, as opposed to health behaviors, genes, or even medical care. To reduce disparities in health, the policies and social structures that shape the distribution of power and resources are just as important as the quality of health care services and the health behavior choices that people make.

As a co-founder of HHI and now as Chair of the Board of Directors, I think about this context constantly as it relates to our organization’s work in the Dominican Republic – and, I continue to listen to our patients, community health workers, partners, and team to better understand how these root issues play out in their lives and experiences. What I hear is that we must consider the social and political factors that determine who can access health care, education, and employment, and who cannot. We must address how lack of reliable access to clean water and sanitation creates a double burden of infectious illness and NCDs in poor communities, which can be masked by national or provincial level data showing overall declines in infectious disease. We must consider what it looks like to have safe, inviting places to play and to exercise for people of all ages, gender identities, races and ethnicities. We must recognize that there are just over 1,700 unidades de atención primaria (primary health care centers) in the country and only 20 physicians for every 10,000 people on average, a fraction of what is necessary to adequately serve a population of 11 million – and these resources are not equitably distributed between rural and urban areas. We must wrestle with the reality that despite major legislation in 2001 having reformed the nation’s health care and social security systems, the promise of universal health care, minimum essential benefits, and long-term economic security continue to be challenged by lack of investment and coordination. And, we must acknowledge the additional barriers faced by community members who are of Haitian descent, including in access to education, health care, employment, and legal rights. While HHI has become recognized for our work in NCD prevention, treatment, and management, we are compelled to broaden our perspective in order to address NCDs systemically.

HHI’s mission is to improve community health in the Dominican Republic. In reflecting on our origins and our trajectory over the last nine years, I believe that our greatest strength as an organization is our willingness to listen authentically, to develop meaningful, trust-based partnerships, and to appreciate the construct of “community health” in the broadest sense of the term. Too often, people and communities can be reduced to specific diseases or problems, but our approach intentionally sees the whole person, the whole community, in all of their complexity and humanity. In this context, we recognize the importance of quality primary health care, health systems strengthening, and the social determinants of health as inextricably connected to our mission. That’s why, earlier this year, our Board of Directors committed to four big priorities to guide our work over the coming year:

  1. Optimize the scope and purpose of our Community Health Workers (CHW) program, to fulfill its potential in improving community health.
  2. Expand our community and public health programming, while continuing to promote clinical excellence.
  3. Connect our individual- and community-based work to strengthening the health system.
  4. Explore sustainable funding strategies to strengthen our revenue model.

We aim to double down on our commitments to clinical excellence in NCD management, to programs focused on nutrition and physical activity, and to health education at the individual and community levels. But, we are also building new partnerships and programming, such as working with the newly formed Asociación para el Desarrollo de Villa Montellano (Development Association of Montellano) to align with its efforts in community socioeconomic development, and collaborating with the local public school system to introduce health education activities to kids and teens. We are leveraging the growing body of evidence showing the positive impact that well-designed, well-supported Community Health Worker (CHW) programs can have on improving physical, mental, and social well-being in vulnerable populations – and, the impact a strong workforce can have on the opportunities for CHWs to exercise their power and create change. With the continued support of the World Diabetes Foundation, we are growing and strengthening our collaboration with local hospitals, primary care centers, and the Ministry of Health to support education and training of front-line providers, as well as to strengthen the systems, tools, and processes necessary to deliver excellent primary care, with NCDs as a point of entry. It is only through building relationships, strategic partnerships, and shared vision that we are able to carve out HHI’s place and value – we are part of a greater whole.

We know that the challenges and opportunities we are facing are interconnected, and our revenue strategy will need to support the creation of non-traditional partnerships and flexible approaches. Ever since the 2008 World Health Report emphasized that a renewed commitment to primary health care would be critical to address global health challenges, donor funding for strengthening primary health care systems has begun to increase; however, it is still overshadowed by disease-specific funding, and is far from meeting per capita targets. Similarly, per capita health expenditures in the Dominican Republic have been rising, but still lag behind the level of need – and, the majority of all health expenditures in the country are from private, domestic sources, such as individual households (out-of-pocket), businesses, or non-profits, rather than international aid or the Dominican government. At the same time, there is renewed attention on the importance of addressing NCDs in achieving the Sustainable Development Goals, which we wholeheartedly agree with and support integrated, horizontal funding mechanisms to advance. We must be creative in how we think about sustaining this work. We hope to partner with foundations, donors, and investors who are eager to bring their skills and knowledge to the table and help our team make change happen.

Without excellent primary health care services, infrastructure, and practitioners, and without ensuring that people have the ability, right, and capacity to access health care, even the greatest economic and community development efforts will not be enough to promote community health. Likewise, without employment opportunities that pay a living wage, equitable access to education and jobs, access to healthy food and spaces to play or exercise, and social norms that encourage and reinforce health for all, even our best efforts to provide treatment and access to health care will not be enough. We are committed to collaborating and thinking across sectors, power structures, and borders. The significance could not be greater: in 2008, the year before HHI was established, the World Health Organization’s Commission on Social Determinants of Health raised the alarm that “social injustice is killing people on a grand scale.” Our dedication to improving community health is driven by a commitment to changing this reality: to demonstrating and working towards equity and social justice in all of our actions.

Laura McNulty is the President and Chair of the Board of Directors of Health Horizons International.

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