Doctor’s Here

With a universal coverage mandate on the books, the government’s share of healthcare coverage extended to around 75% of the population in 2013. With many public sector patients uninsured, the private sector generally provides services to the more affluent segments of the population. While the state has assumed responsibility for the majority of healthcare recipients in the country, their share of health care expenditures has risen over the past decade. According to World Bank Indicators, this percentage rose from 43.4% in 2010 to 50.9% in 2012. While healthcare spending as a percentage of overall government spending fell from 15.9% in 2000 to 14% in 2010, this is more reflective of the country’s rising GDP and tax base than a lack of political will. This said, the WHO has called for increased attention to the sector, and stressed that further healthcare reform and progress must be framed within the country’s macroeconomic context. In doing so, comprehensive coverage and services will underscore improved equity, quality, and financial protection for the Dominican population.

The public sector consists of the Ministry of Public Health and Social Welfare, the National Health Council, the National Health Insurance program (the DR’s principal public insurer), and the National Health Council. The Ministry of Health operates on a three-tiered organizational structure—central, regional, and provincial. At the central level, the office of the minister is supported by six vice-ministries: Administration and Finance, Planning and Development, Public Health, Quality Assurance, the Directorate for Strengthening Regional Health Services, and Social Welfare. In 2012, the Ministry was composed of a network of 1,853 facilities made up of 1,703 primary care units and another 150 specialized treatment centers. These specialized centers entail 15 specialized hospitals—such as advanced cardiac and oncology institutes—20 provincial hospitals, 11 regional centers, and 104 municipal hospitals. Standards of accreditation, regulations, and good practice have been established for health facilities, laboratories, and pharmaceutical companies, although regulatory processes are still needed to improve the quality of care, quality control and biosafety. In the past few years, the physical infrastructure of the health services network has improved and expanded, both in the public and private sectors, with the introduction of new technologies.

FOOTING THE BILL

The Pan American Health Organization estimates that in 2008, health expenditures in the DR stood at $560 million, or 5.5% of the GDP. In 2012, this figure was slightly down at 50.9%, however with a GDP increase from $45.8 billion to $58.92 billion over the same time period, this translates into a significant overall increase in healthcare spending, reaching $552 per person. Between 2002 and 2010, per capita health expenditure rose by 190%. This is in line with increasing public healthcare expenditures as a percentage of total spending, where government operations see lower margins. For example, in 2004, the government’s percentage was 28.7%, but eight years later in 2012, the percentage was 50.9%, reflecting a growing state role in healthcare provisions. Moreover, increased government spending is translating into important healthcare gains for the country. Life expectancy has risen to 73.2 years for 2012, with the latest WHO estimates at birth being 76 years for males and 78 years for females. Another indicator that public health services are gaining on the private sector is that 95% of births among the poorest 20% are attended by a skilled professional, whereas this rate stands at 99.1% for the richest 20% of the population—a discrepancy of just over 4%. This suggests that even the poorest members of Dominican society have improved access to quality natal care, compared to other countries in the region where such rates are much lower.

From the private sector side of the equation, the Dominican Republic is also importantly the regional base for various top medical technology companies, which have chosen the country as a hub for developing, manufacturing, and marketing a wide range of medical products. The country forms one of the largest clusters for healthcare manufacturing in the Caribbean and the Central American region. The medical device industry represents 6% of free zone exports, valued at $286 million, whose main export market is the US. Importantly, this industry as a whole employs approximately 9,000 skilled workers, providing a level of human resource skill that competes solidly at a global level.

THE ROAD AHEAD

Dominican health policy is guided primarily by the government’s Ten Year National Health Plan for 2006-15 (NHP), which serves as both a road map for the future and a diagnosis of the present. The NHP outlines nine strategic objectives for strengthening the health sector: (1) provide effective government stewardship; (2) strengthen patient care; (3) enhance public health; (4) develop the social health insurance system; (5) ensure necessary financing; (6) develop the health civil service system; (7) develop information and surveillance systems to tackle problems; (8) strengthen the role of local communities in health; and (9) develop integrated approaches specific to women’s health. These strategic objectives map out and address the major gaps that prevent the Dominican Republic—especially its poor and vulnerable populations—from achieving better health outcomes by improving equitable access to health services, reducing out-of-pocket costs, and strengthening the health system. The long-standing challenges are linked to poverty and include issues closely aligned with larger international priorities, such as HIV prevention, maternal and child health, tuberculosis, malaria, and improved nutrition.

In terms of developing local solutions to global problems, the Dominican Republic is actually punching well about its weight. The incidence of HIV prevalence in the country appears to have stabilized to between 0.8 and 1.1% in the general population. Poor Dominicans comprise 36% of the general population, but almost 48.4% of the HIV positive population. TB also remains endemic to the Dominican Republic, with an incidence of 70 per 100,000 persons. Case detection rates and cure rates remain below government targets at 60% and 75% respectively, and government effort is focused on bring these numbers to targeted levels.

Public health preparedness is also an important issue for the Dominican government. Natural events such as hurricanes and earthquakes have the potential to divert the focus of the health sector from existing efforts at disease prevention to dealing with emergency response issues. Yet with a clear health plan in place, the combined efforts of different sectors of society, and support from international partners, the country is not only keeping abreast of challenges, but also keeping ahead of events.