The Puerto Rico Department of Health (PRDOH) is the state agency responsible for all matters related to public health including the administration of programs funded through the Title V Block Grant.

PR Title V consists of the Maternal, Child and Adolescent Health Program (MCAHP) housed in the Maternal, Child and Adolescent Division and the Children with Special Heath Care Needs Program (CSHCNP) located in the Children with Special Medical Needs Division. PR Title V provides services and implements initiatives in the seven PRDOH Health Regions.

To place Title V efforts in context one must first understand the general conditions of Puerto Rican society that play a crucial role in the health and wellbeing of populations.

Puerto Rico (PR), a territory of the US, is divided in 78 jurisdictions known as municipalities, each headed by a mayor. Vieques and Culebras are offshore municipalities whose residents travel to the Great Island (PR) in small planes and/or ferry for secondary and tertiary health care and other services.

Every four years, a governor, 28 senators, and 51 House members are elected to serve in the PR government. A non-voting delegate to the US House of Representatives is also elected. Puerto Ricans are US citizens, serve in the US military, and contribute to Social Security and Medicare, but since they do not pay federal taxes, are not eligible to receive the Earned Income Tax Credit that gives refunds to low-income workers. PR residents do qualify for the Child Tax Credit only if they have three or more children, whereas in the states it is applicable to working families with one or more children.

The governmental structure has three major branches: the executive (called Central government), the legislative and the judicial. Each major state agency is divided into a Central office and Regional offices distributed across PR.

Health Care System

In the 1990’s public healthcare was transferred from the government to contracted private insurers to provide health care services on a capitated payment plan. The PR Health Insurance Administration (PRHIA) oversees and negotiates contracts with private insurers.

The Government Health Plan (GHP) integrates physical and mental health in one facility, expands preventive medicine and screening, and provides direct access to specialists without need for referral within a Preferred Provider Network. The GHP is financed by a combination of state, municipal and federal funds (Medicaid and SCHIP). Medicaid funding to PR is limited to a fixed amount regardless of the eligible population medical needs, unlike the states that are set based on per capita income. ACA funds (non-recurrent) were added to the GHP for Medicaid assigned funds. Through ACA a number of benefits such as family planning and contraception methods services were added to the GHP’s coverage.

In FY 2017-2018 there were 1,238,042 persons covered by the GHP through five   insurance companies. Vital Statistics 2018 data show that 67.1% of mothers’ health insurance at the time of birth was the GHP which means that it pays for a majority of births in PR.

GHP has a Special Coverage Registry (SCR) for CSHCN. Enrollees have the option to choose the providers for services within the Preferred Provider Network of their PMG or their Health Plan’s General Network. Medications, laboratory tests, diagnostic tests and other related procedures specified are part of this coverage. In 2018, there were 40,426 children enrolled in this SCR. The GHP also has a SCR for ASD. When ASD is suspected, children are enrolled in a temporary coverage for up to 6 months for the diagnostic interventions. If the diagnosis of ASD is certified by one of the following GHP providers: neurologist, psychiatrist, developmental pediatrician or clinical psychologist the child is included in the ASD Special Coverage Registry. In 2018, there were 1,279 children enrolled in the ASD-SCR.

Since there has been a large migration of physicians to the US, Puerto Rico passed Act   No. 14- 2017 known as the “Incentives Act for the Retention and Return of Medical Professionals” aimed at retaining practicing physicians in PR as well as attracting those who already had left through tax incentives. This act establishes a 4% fixed rate of income contribution on all income generated by the medical provider by a term of fifteen years. 

To address the problem of the use of opioids in Puerto Rico, the Prescription Monitoring Program for Controlled Substances (under Law 70 of 2017 for Monitoring the Prescription of Controlled Substances) opened for physician’s registration on June 2018. This program aims at maintaining a system of electronic prescription monitoring of controlled substances dispensed in the island.

Population

Puerto Rico is an area of about 3,500 square miles and a population of 3.3 million (PRCS 2017 1YR) that tend to cluster in urban areas. The PRCS 2018 estimate places the population at 3.2 million.

Puerto Rico is mainly a Spanish speaking country where the majority of its residents are Puerto Ricans (95.4% in the 2010 Census) followed by other foreign Hispanic ethnic groups like Dominicans and Cubans. According to the 2017 PRCS 1-YR estimates, the Dominicans that make up 1.7% of the total population and Cubans (0.48%).  As these groups come from the Caribbean they share certain sociocultural characteristics with Puerto Ricans.  Dominicans, Cubans and any other group can access health and other types of services. Regarding racial composition, 75.8% of people in PR identified themselves as white, 12.4% as black, 7% as some other race, and 3.3% as two or more races in the 2010 Census.

It must be noted that race is a historically and culturally grounded concept that varies from one society to another. Race taxonomies in PR are constructed on the basis of phenotype traits such as texture of hair, skin tone, and lip and mouth shape and intermediate categories exist between white and black that are not represented in the US Census. Some examples are: “indio’’ (literally Indian, light brown and brown skinned with straight hair), “jabao’’ (fair skinned with kinky hair), and “trigueño’’ (light to dark brown skinned). According to PR cultural standards, a person is white if he/she has light skin color (fair and light brown) and straight and/or curly hair, regardless of ancestry.

People in PR may opt to report their race as white (despite skin tone) due to an unstated contempt for everything associated with being dark or black skinned. For example, in PR people make a distinction between “bad hair’’ (kinky hair linked to being black) and “good hair’’ (straight hair linked to white and Indio). Although new generations are identifying themselves as black, the euphemism “de color’’ (literally of color) is commonly used as the word black is seldom used as a direct term of reference, There is also a generalized denial of racial prejudice and discrimination in the island. While it is not possible to explain in depth the manifestation of racism in PR, suffice is to say that it takes a covert form exemplified by sly comments and racial jokes (often seen as harmless) in day-to- day interactions. On an institutional level, dark/black skinned people are underrepresented in the main media outlets and high status positions in both the corporate world and government, according to the PR Civil Rights Commission.

The population in PR fell from 3.7 million in 2010 to 3.2 million in 2018, a decrease of 14%, according to an analysis of the PR Institute of Statistics.

Two main factors are linked with population decline. First, the natural population growth continues to decrease due to declining natality and fecundity rates. Second, the migration of people to US mainland in search of better job opportunities and living conditions. From 2005 to 2016 about 525,769 people left PR, equivalent to 14% of its population. This trend continued and 69,343 people migrated between July 2016 and July 2017. The migration from PR to the US intensified after Hurricane María and approximately 130,000 people left the island between 2017 and 2018, according to Census estimates.

The MCA population constituted 45% of the total 3.3 million population in 2017. The MCA population composition was as follows: 0.8% infants; 8.9% children 1-9 years of age; 12.6% adolescents aged 10-19 (6.5% males and 6.2% females) and; 19.8 % reproductive age women between the ages 20-49.

Education

The 2017 PRCS (1YR estimate) reports that people 25 years and over with less than 9th grade was 15.8 % and those with a high school diploma was 27.9%. Of those 25 years and over with post-secondary education, 22.6% had some college or associate’s degree; 18.3% a bachelor’s degree and; 7.4% a graduate or professional degree.

Student enrollment in the public system diminished greatly from 544,076 in 2006 to 319,422 in 2017, a decline of 41%. The decline of students led to the closing of public schools. Between 2006 and 2017 a total of 243 public schools were closed, a number that increased in 2018. A total of 265 (24%) public schools closed while 855 remain open in the 2018-2019 academic year.  According to the report “Population Decline and School Closure in Puerto Rico”  (Center for PR Studies, May 2019), 65% of public schools in the rural areas closed down compared to 35% in the urban areas, meaning that rural areas were the most impacted by the closures.

Socioeconomic Conditions

In the last decade, PR has experienced a reduction in employment in the private and public sectors. Between 2006 and 2016 employment fell by 28.6% according to the Bureau of Labor Statistics (BLS). Concomitantly, the labor force participation rate declined from 47% in 2007 to 41.6% in 2017.

Lack of employment is accompanied by income levels that in PR are still far behind from the states. The per capita income for PR in the 1YR 2017 PRCS was $12,279 compared with the US $32,397. The 1YR 2017 PRCS median household income was $19,343, less than half of Mississippi ($43,529), the state with the lowest US median household income.

There is also an alarming number of families facing the possibility of losing their homes. According to the non-profit organization “Ayuda Legal de Puerto Rico” (Legal Help of Puerto Rico) more than 250,000 homes are at risk of foreclosure this year. A problem with being at risk of foreclosure is that people tend to face the process alone due to inadequate orientation from banks, lack of education on their rights, and insufficient family economic resources for legal representation.

Poverty is a significant problem in PR affecting women, children and families. In 2017, the poverty rate in PR (44.4%) was higher than the US (12.3%) and higher than the poverty rate in Mississippi (19.8%). Children under 18 years of age living in poverty in PR were 58.7% in 2017. Family structure influences poverty rates as single female-headed families tend to be poorer than married-couple families. While the percent below poverty level in 2017 PRCS in married-couple families with children was 28.1%, the percent of families with children headed by a female with no husband present was 59.2%.

High poverty rates and low-income levels leads families to rely on public assistance programs for survival. The 1YR 2017 PRCS reports that 37.9% of households in PR received nutritional assistance (food stamps) benefits compared to 11.7% in the US.

In many municipalities, mass transportation is unavailable and people rely on private transportation services (12 passenger vehicles) called “carros públicos’’ (public cars) that may not be available after 2 PM or even earlier. Those who have their own private cars, may have to drive a long distance from and to their homes to work, study and receive services. To cover gaps in transport, there are municipalities that provide transportation mainly to the Greater Metropolitan Area to people in need of specialized health services. While mass transportation in San Juan municipality, - capital of PR - is available, there are limitations as the waiting time in some routes can be anywhere between one to two hours. The Urban Train only covers San Juan and Bayamón municipalities and lacks sufficient connecting buses to and from its 16 stations.

Like families, the PR government has been experiencing severe economic difficulties for almost a decade: a public debt of more than $70 billion, revenue loss, high GHP expenditure, depletion of pension funds, and insufficient liquidity to operate and meets its obligations.

To face the crisis, the PR government has taken measures to reduce costs and increase revenues over the past years. Some of the measures are: budget cuts to state agencies, school closings, reduction in subsidies to municipalities and NGO’s, and tax increases. Measures related to government employees include lay-off of public workers (Law 7, 2009), increases in employees’ contributions and retirement age (Law 2013) and fringe benefit reductions and mobilization across agencies (Fiscal Compliance Act of 2017).

In 2016 the US Congress enacted the PR Oversight, Management and Economic Stability Act (PROMESA), installing the Financial Management and Oversight Board (FMOB) with decision-making power on all fiscal matters. In May 2017, the Oversight Board filed in the federal district court for debt relief under Title III of PROMESA, a form of bankruptcy to restructure PR fiscal liabilities. Presently, the court proceedings are underway while the FMOB is mandating a reduced government budget, a 10 percent cut in pensions for retired public workers, reduced fringe benefits for public workers, and drastic changes to PR labor laws that will affect workers in the private sector. In May 2018, the FMOB approved to include Puerto Rico 78 municipalities under its jurisdiction, a process that will be initiated with a pilot of ten municipalities.  The FMOB also filed more than 200 lawsuits against government suppliers, most of which are local small businesses, claiming that suppliers were either paid without a written contract or received payments in excess of the value of the goods and services provided to the government. According to experts, the financial burden of the lawsuits on small businesses, that may have not the resources needed for legal representation, could lead to the closure of operations and thus, more people could be out of work. 

In the midst of the fiscal crisis, Hurricane Maria, with 155 mph winds struck PR on September 20, 2017. The hurricane caused billions of dollars in damages leaving behind widespread destruction to homes, businesses, energy grid, roads, highways, and public and private institutional facilities. Research on the deaths related to the hurricane place the death toll at approximately 3,000 people.  Presently, there are many damaged roads in the rural areas, a significant number of damaged traffic lights in the Metro Area, and many closed small businesses all over PR. As it was mentioned above, the hurricane also pushed people out of PR to the US mainland. The recovery from the devastation caused by the hurricane will take years according to experts.

Beyond economic costs, the hurricane caused sadness, distress, anguish, uncertainty and frustration as people’s lives were completely disrupted. Almost two years after the hurricane, people in Puerto Rico still speak of “before María” and “after María” referring to how life was before the hurricane struck the island and how life has been afterwards. Through these phrases people mean how the society they once knew changed drastically overnight.

PR society strengths

The people of PR despite economic hardships and stressful social conditions have strengths and resiliency seldom publicly recognized.

Culturally, great value is placed on seeking a post-secondary education to better one’s life which accounts for the skilled or semi-skilled labor force that has been and still is sought after in the US for its capacity to work.

There is a wide variety of informal and formal organizations (about 11,000 formal non-profits) geared to improve life through cultural promotion (arts, music, dance), neighborhood revitalization, environmental protection, youth development, and community development (may include micro enterprises, health promotion and community/home vegetable gardens). There are NGO’s that has been successful – such as Nuestra Escuela and Sor Isolina - in providing alternative education to school drop outs to attain a high school diploma. A strong and economically sound cooperative movement is another important asset in PR society. There is also an ecological movement to protect the environment and the health of people.

In PR, most of the activities of women and families revolve around kinship and neighborhood networks. In general, relations among neighbors in low-income communities are highly personal and reciprocal despite any internal conflicts. This is most evident in times of crisis, deaths, fires and other emergencies. Kinship ties provide emotional and financial support (may include housing) to women and children as resources are pooled, borrowed and shared. Grandparents (as well as other kin) are very influential in parent’s and children’s lives. It is common for grandparents to provide unpaid childcare to working mothers and/or at times of need. Grandparents also enjoy taking their grandchildren out and having them stay in their homes overnight.

The strengths and resiliency in PR became most evident in the aftermath of Hurricane María. NGO’s were highly instrumental in helping people as they distributed food, water, water filters, solar lights and other supplies in shelters and communities. Very importantly, people themselves displayed generosity and resourcefulness. Neighbors shared food, (in some places cooked together and established community kitchens), water, ice and even power from generators through extension cords. Neighbors also organized where and how to put damaged items in communities and in many instances took them to the landfill. In some communities, neighbors shared their own money to pay private electricians to restore energy while in others its members joined retired workers of the PR Electric Power Authority to raise power poles and cables.

All over the island, people turned to cultural practices like music, songs, phrases (like “Puerto Rico se Levanta” - Puerto Rico Rises) and the Puerto Rican flag as symbols of strength and resolve to help overcome the pain and desolation caused by the hurricane.

PR Title V Roles, Challenges and Strengths

Understanding the devastation and suffering due to Hurricane María in the midst of the socioeconomic crisis is crucial for public health. First, the storm exacerbated certain conditions like job loss, income, poverty and housing conditions. Second, low-income people in rural areas face geographic disparities in accessing health care due to very limited transportation and shortage of specialists and facilities. Indeed, HRSA categorized 72 out of 78 municipalities as medically underserved areas. Last, the distress endured by residents brought about and/or exacerbated mental health conditions in populations.

Given these conditions, a challenge of PR Title V is to balance the needs of populations with existing internal and external resources amidst an unprecedented economic crisis and shrinking public resources. In decision-making strategies, PR Title V uses the following overreaching principles to assess the importance, value and priority of competing factors:

• Community health promotion
• Health literacy and empowerment

• Family and youth inclusion
• Collaborative networks
• Understanding the impact of the Social Determinants of Health (SDH) on populations

PR Title V has played a lead role in several important health related initiatives and public policies propounded by the DOH and the state. Examples include:

• Law 186 (2016): PR Maternal Mortality Epidemiologic Surveillance System (PRMMESS). The MCAH Program is responsible for its implementation as well as providing leadership to the Maternal Mortality Review Committee.
• Administrative Order 336 (2015): Compels all hospitals to establish a Breastfeeding Support Program as requirement for hospital operation licensed by SARAFS. This policy facilitates compliance with the 10 steps for a Baby Friendly hospital that supports breastfeeding initiation post-partum and mother- newborn bonding.
• Administrative Order 357 (2016): Requires all hospitals to change their measurements for pediatric patients to the metric system and to change their weighing equipment so to only measure grams and kilograms. MCAH worked jointly with the CSHCN and the Medical Pediatric Emergency services to develop this policy to improve pediatric medication dose security.
• Administrative Order 359 (2016): Establishes Positive Youth Development as the main approach for adolescent health and creates the Youth Advisory Council (YAC) that integrates youth as advisors and allies of health initiatives and policies within the DOH.
• Administrative Order 366 (2017): Requires all birthing hospitals in PR to establish a Hard Stop Policy for non-medically indicated labor inductions before 39 weeks - consistent with the recommendations of the American College of Obstetricians and Gynecologists - to reduce neonatal morbidities and mortality.
• Administrative Order 369 (2017): establish the policy for testing symptomatic and asymptomatic pregnant women for ZIKA, including the PRDH Guidelines for the Evaluation and Management of Pregnant Women with Laboratory Evidence of Possible Zika Virus Infection.
• Administrative Order 388 (2018): PRDH Guidelines for the Evaluation and Management of Infants Born to Mothers with Laboratory Evidence of Possible Zika Virus Infection During Pregnancy.

An important asset of the MCAH Program (MCAHP) is leadership through committees and coalitions such as the PR Breastfeeding Promotion Collaborative Group, the Fetal and Infant Mortality Review Committee, the Maternal Mortality Review Committee, the Perinatal Care Guidelines Review Committee, the Youth Advisory Council and the Regional Boards. The Regional Boards are MCAHP sponsored committees – located in each of the 7 DOH Health Regions - composed of representatives from government and non-government entities that meet regularly to address maternal, child and adolescent health issues.  The Regional Boards are fully involved the development of the PR Title V State Action Plan and its implementation throughout the Island. 

Having a broad and strong network of partners within and outside the health field is also an asset of the MCAH program that is crucial for the on-going needs assessment and health promotion efforts in communities.  The MCAHP supports the efforts of partners through staff participation in task forces, committees and alliances. For example, the Pediatric Consultant was appointed to the PR Children’s Justice Act (CJA) Committee that aims at improving the investigative, administrative, and judicial handling of child maltreatment.

The MCAH program has a well-established health promotion component on maternal, infant, child and adolescent health. The health promotion component includes the following strategies: a) a prenatal course that provides pregnant women with tools to maintain a healthy pregnancy and prevent risk factors; b) parenting courses targeted at parents of children 0-5 years old and parents of children aged 6-11 years on healthy eating, physical activity, preventive/routine medical visits, personal safety, home safety and positive childrearing; c) massive media campaigns promoting healthy pregnancy, breastfeeding and adolescent well-visits; d) dissemination of information through presentations and written educational materials to the general public and interest groups and; e) training and information to health professionals on a variety of health topics including laws and administrative orders.

Another MCAHP asset is a highly committed multidisciplinary staff from the health and social sciences fields. Included in the staff are former participants of the Home Visiting Program that were hired as nurse home visitors and community health promoters.  Almost two years after being struck by Hurricane María, the MCAH Program staff at the Central Level are still housed in a temporary facility having to work under duress in cramped spaces with limited lightning.  In spite of this, the staff with resolve and high compromise have continued their health efforts to benefit MCA populations across the island.

One of the CSMND strengths is the staff commitment to serve the CSHCN population and their families. Although staff recruitment is challenging, the CSMND has minimal staff turnover. The majority of the recruited staff is retained as a result of the competitive compensation, a healthy teamwork environment, and ongoing effective skills development and educational activities.

Since 2016 the CSHCNP has been actively working to enhance its coordinated and family centered care services. This initiative began with the creation of a Quality Improvement Committee (QIC) composed of key staff at the State Level and key personnel from each RPC including families. Participation of families at all levels has enhanced family-centered care and family-professional partnerships. 

A strong network of collaborating partners within and outside the DOH is also an asset that has strengthened the family-centered care services and support to children and youth with special care needs and their families.

PR Title V will definitively tap its internal strengths as well as those of Puerto Rican society to face the challenge of improving health and wellbeing in the context of a very slow recovery process after a catastrophic event and a myriad of social and economic adverse conditions at the individual, familial, community and institutional levels.