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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Un mensaje del Dr. Craig Czarsty: Renovación en Horizontes de Salud

Estimados amigos y colaboradores de Horizontes de Salud:

Este otoño ha sido una temporada de nuevas direcciones para HHI, todas positivas.

Como saben, después de una búsqueda exhaustiva de un nuevo Director Ejecutivo, contratamos a Edgar Castillo. Él se está estableciendo en la vida de la costa norte y está ocupado haciendo planes para mover a HHI hacia adelante. Estoy encantado de que nuestra visión para el Director Ejecutivo de HHI coincide con su deseo de marcar una diferencia en la vida y la salud de la gente en su país. Estoy muy entusiasmado con las perspectivas de HHI con Edgar a la cabeza.

La Junta Directiva de HHI se reunió el sábado y como parte de una transición pensada y planificada, finalicé mi mandato como Presidente y Presidente de la Junta. Soy uno de los cofundadores de HHI y he sido presidente desde el día en que firmé los documentos de incorporación en 2009. Me enorgullece enormemente lo lejos que ha llegado HHI como organización y en las vidas que hemos tocado. Solo recibo un crédito parcial porque HHI es un esfuerzo de equipo y es el producto de innumerables horas de trabajo arduo por parte del personal y la Junta Directiva. Sin embargo, no creo que sea saludable para una persona permanecer en el papel de Presidente durante tiempo prolongado. HHI se ha expandido más allá de la provisión directa de atención médica (algo de lo que sé mucho), hacia el ámbito de la salud pública con el que estoy menos familiarizado. Es hora de un nuevo líder que esté equipado con conocimientos y habilidades en salud pública. Para mí, la buena noticia es que realmente no voy a ir a ningún lado. La Junta fue lo suficientemente amable como para crear el puesto de “Presidente Emérito”, y elegirme para ello. Continuaré sirviendo en la Junta de HHI y haré todo lo que pueda para avanzar la causa. Liderar HHI durante sus primeros ocho años ha sido un honor y una alegría, y un punto culminante de mi vida profesional. No puedo agradecer lo suficiente a la Junta por confiar en mí, así como  a los amigos y seguidores de HHI por su confianza en todos nosotros.

Para HHI la buena noticia es que la nueva Presidente y Presidente de la Junta es Laura McNulty. Laura también es cofundadora y fue nuestra primera Directora Ejecutiva. Laura aporta una gran cantidad de conocimiento, savoir faire y experiencia. Ella ha sido la Tesorera desde que comenzamos, y solo exagero un poco cuando digo que aprendió contabilidad por sí misma para administrar nuestras finanzas. Recientemente se mudó de Boston a St. Louis para comenzar estudios de posgrado en salud pública y trabajo social. Cuando termine, no solo tendrá dos maestrías, sino que dominará esas áreas temáticas. Cuales dos grados podrían ser más relevantes para el trabajo que HHI hace? Laura es una líder nata que siempre está preparada y siempre tiene no solo un análisis cuidadoso de una situación dada, sino recomendaciones claramente definidas para cualquier acción requerida. No podría dejar a HHI en mejores manos que las de Laura y no puedo esperar para ver a HHI prosperar bajo su liderazgo.

No puedo cerrar sin mencionar a Brad Wilkinson. “Dr. Brad “es otro cofundador que ha sido el vicepresidente desde que comenzamos, y es la piedra angular de nuestro programa clínico. También dimitió para dar paso a un nuevo liderazgo, y fue sucedido por Chris Meelia. Brad tampoco irá a ninguna parte, y permanecerá en la Junta. Brad ha sido mi “compañero de ala” durante todos estos años, y he dependido de él por su sabio consejo en tiempos de problemas. También he dependido de él cuando fue necesario reducir mi ego, hasta el tamaño justo con el insulto correcto. Se ha convertido en mi “hermano de otra madre” y no puedo agradecerle lo suficiente por todo lo que ha hecho por HHI.

A medida que el otoño da paso a la temporada de vacaciones, me gustaría hacer un llamamiento a los amigos y colaboradores de HHI, para que apoyen generosamente nuestra misión de fortalecer la prestación de la atención primaria, y mejorar la salud pública en la República Dominicana. Continuamos brindando atención directa a través de nuestro programa de Enfermedades Crónicas. Estamos fortaleciendo la prestación de atención primaria en asociación con el Ministerio de Salud Pública y la Fundación Mundial contra la Diabetes. Estamos mejorando la salud pública a través de nuestro programa “Sano y Feliz”. Estamos haciendo lo que decimos que haremos, y en esta próxima temporada de donaciones espero que hagan una donación que nos permita seguir haciéndolo.

Atentos Saludos,

Dr. Craig W. Czarsty

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A Message from Craig W. Czarsty, M.D.: Renewal at Health Horizons

Dear Friends and Supporters of HHI:

This autumn has been a season of new directions for HHI, all of them positive.

As you know, after a comprehensive search for a new Executive Director, we hired Edgar Castillo.  He is settling into life on the north coast and is busily making plans to move HHI forward.  I am thrilled that our vision for the E.D. of HHI matched his desire to make a difference in the lives and the health of people in his country.  I am very excited about HHI’s prospects with Edgar at the helm.

The Board of Directors of HHI met on Saturday and as part of a thought-out and planned transition, I ended my tenure as President and Board Chair.  I am one of the co-founders of HHI and have been President since the day I signed the incorporation documents in 2009.   I take tremendous pride in how far HHI has come as an organization and in the lives we have touched.  I only take partial credit because HHI is a team effort and is the product of countless hours of hard work by the staff and the Board.   I don’t think it’s healthy for one person to stay in the President’s role for too long however.   HHI has been expanding beyond the direct provision of health care, something I know a lot about, into the public health realm with which I am less familiar.   It is time for a new leader equipped with knowledge and skills in public health.   The good news for me is that I am really not going anywhere.  The Board was gracious enough to create the position of “President Emeritus” and elect me to it.   I will continue to serve on the HHI Board and do whatever I can to advance the cause.  Leading HHI for its first eight years was an honor and a joy and a highlight of my professional life.  I cannot thank the Board enough for placing its trust in me and I can’t thank you friends and supporters of HHI for your trust in all of us.

The good news for HHI is that the new President and Board Chair is Laura McNulty.   Laura is also a co-founder and was our first Executive Director.   Laura brings a wealth of knowledge, savoir faire and experience.   She has been the Treasurer since we started and I am only slightly exaggerating when I say she taught herself accounting in order to manage our finances.   She recently moved from Boston to St. Louis to begin graduate studies in public health and social work.   When she is done, she will not just have two master’s degrees, she will be a master of those subject areas.  What two degrees could be more relevant to the work HHI does?   Laura is a born leader who is always prepared and always has not only thoughtful analysis of a given situation but clearly defined recommendations for any action required.   I couldn’t possibly leave HHI in better hands than Laura’s and I can’t wait to see HHI thrive under her leadership.

I can’t close without mentioning Brad Wilkinson.  “Dr. Brad” is another co-founder who has been the Vice President since we began and is the bedrock of our clinical program.  He also resigned to make way for new leadership and was succeeded by Chris Meelia.  Brad is not going anywhere either and will remain on the Board.  Brad has been my “wing man” all these years and I have depended on him for his sage advice in times of trouble.  I have also depended on him when needed to whittle my ego down to size with just the right insult.  He has become my “brother from another mother” and I can’t thank him enough for all he has done for HHI.

As autumn gives way to the holiday season, I would like to appeal to the friends and supporters of HHI to give generously to support our mission to strengthen the delivery of primary care and improve the public health in the Dominican Republic.  We continue to provide direct care through our chronic disease program.   We are strengthening the delivery of primary care in partnership with the Ministry of Public Health and the World Diabetes Foundation.  We are bettering the public health through our “Sano y Feliz” program.   We are doing what we say we will and in this upcoming season of giving, I hope you will make a donation that will allow us to continue doing it.


Craig W. Czarsty, M.D.

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