Pan American Health Organization

Dominican Republic

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of the Dominican RepublicThe Dominican Republic shares with Haiti the island of Hispaniola, in the archipelago of the Antilles. It borders on the north with the Atlantic Ocean, on the south with the Caribbean Sea, on the east with the Mona Passage, and on the west with Haiti, along a 388-km land border. It has a tropical climate and a land area of 48,311 km2. Its position between the North American and Caribbean tectonic plates leads to seismic risk, and its location also makes it prone to hurricane damage ().

The Dominican Republic is divided into 31 provinces and the National District, in which Santo Domingo (the capital and seat of central government) is located. Elections are held every four years.

Demographics

The estimated population in 2016 was 10,649,000, with 20% living in rural areas. Life expectancy at birth was 71.7 years in 2010 and 73.8 years in 2016. The 2010 census estimated the population density as 196 inhabitants per km2, but with wide variation, ranging from 15 inhabitants per km2 in the province of Pedernales to 10,538 per km2 in the National District (). Figure 1 shows the Dominican Republic’s population structure in 1990 and 2015.

Figure 1. Population structure, by age and sex, Dominican Republc, 1990 and 2015

Between 1990 and 2015, the population grew 46.6%. In 1990 the population pyramid had a rapidly expansive structure. By 2015, a combination of population aging and declining fertility and mortality rates – especially in the last decade – led to a slower-growth pyramidal structure, and a stationary trend in the under-10 age group.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Division of Population, New York, 2015. Updated 2015.

The Economy

The Dominican Republic is a middle-income country, with a per capita gross domestic product (GDP) of US$ 28,700, measured by purchasing power parity (PPP). In 2015, the Dominican economy registered an actual growth rate of 7% (), reflected in the labor market by the creation of 173,402 new jobs, particularly in the construction, services, and local manufacturing sectors, as well as in duty-free zones (). Almost 80% of the income-receiving population earns less than two times the minimum wage from its primary occupation (). The extreme poverty rate declined from 8.4% in 2014 to 7.0% in 2015 (). Also in 2015, the national minimum wage ranged from US$ 174 to US$ 287 ().

Between 2011 and 2014, estimates of inequality showed fluctuations in both rural and urban populations, as determined by the Gini coefficient. The lowest nationwide value was recorded in 2014 (0.463), with a lower coefficient in rural vs. urban areas (0.399 vs. 0.469 respectively) ().

According to Central Bank data, remittances constitute one of the main sources of foreign exchange for the Dominican Republic, with flows accounting for nearly 7% of GDP in recent years (). In 2015, the tourist industry produced US$ 6,153.1 million in income. Haiti has historically been a very active trading partner; immigrants from this and other countries participate in the national labor market in rural and urban areas alike.

Social Determinants of Health

Since 2012, as part of its social policy, the Dominican Government has implemented the “Quisqueya sin Miseria” strategy, with specific plans for literacy (“Quisqueya aprende contigo,” targeting a population of 858,000), comprehensive early-childhood care (“Quisqueya empieza contigo,” covering 656,000 girls and boys under 5), and job creation (“Quisqueya somos todos,” covering a population of 1.5 million across 65 high-priority territories). The Gender Inequality Index shows that, among the population over age 15, 51% of women participate in the workforce, versus 78.6% of men ().

Vulnerable Populations

The Human Development Index (HDI) for the Dominican Republic was 0.715 in 2014, which ranks it 101st in the world, among the high-HDI countries (). As of 2015, the literacy rate among people aged 15 or older was 90.9%.

It is estimated that 20.8% of children under 5 lack a birth certificate. In the poorest quintile of the population and among those living in the poorest border regions, this figure rises to 41%, meaning that hundreds of thousands of boys and girls lack official recognition of their lives and are deprived of essential services (). Another situation that affects the well-being of Dominican children and adolescents is the migration of working-age mothers who leave their children under the care of relatives or friends, which exposes children to risks and infringes on their right to live in a family ().

As of 2014, the proportion of the urban population living in slums (low-quality dwellings with insufficient living space and limited access to drinking water and sanitation) was 12% ().

The Health System

The Dominican health system can be defined as a social security system guided by the principles of universal coverage, compulsory enrollment, solidarity, comprehensive care, unification, free choice, and gradual implementation, among others. The legal framework that sustains it is set forth in Law 42-01, the General Health Law, and Law 87-01, which established the Dominican Social Security System, laying the foundations for social protection and expanding access to insurance through social security contributions ().

In 2014, the country adopted a model of care based on the primary health care and integrated health service delivery networks strategy, coordinating, managing, and articulating policies, resources, and structures aimed at meeting health commitments and reaching the targets of all institutional stakeholders in the National Health System. This model is being implemented in six provinces in order to generate competencies at the local level, after which the model will be scaled up to other regions of the country.

Furthermore, the health sector is undergoing reorganization within the “separation of roles” framework established by Law 123-15, which includes the administrative and functional decentralization of the Regional Health Services of the Ministry of Public Health (MPH) and the Dominican Social Security Institute, to create the National Health Service (Servicio Nacional de Salud, SNS). Decree 379/14 established that the MPH would have a stewardship role.

The SNS has 1,450 First Level of Care Centers (CPNs), which constitute the institutional base and workplace of one or more Primary Care Units (UNAPs). There are 1,774 UNAPs across the country and 189 Specialized Health Care Centers (CEAS), including 13 regional hospitals, 35 provincial hospitals, 122 municipal hospitals, and 19 national referral hospitals. These hospitals have the necessary capacity to provide the care enshrined in the Basic Health Plan (PBS) in a cost-effective manner, through management agreements signed by the National Health Insurance System (SENASA).

Leading Health Challenges

Critical Health Problems

Emerging Diseases

Acute respiratory infection is most common reason for outpatient visits; therefore, this syndrome and its most serious manifestations are subject to virological surveillance. Two communicable diseases affected the country for the first time in two recent outbreaks: cholera, between 2011 and 2012, and chikungunya in 2014, the latter having great impact and widespread distribution in the general population, with approximately 539,100 cases in 2013. Binational actions with Haiti allowed implementation of a plan to prevent and control cholera and malaria, as well as a joint agenda to tackle HIV and tuberculosis (TB). Analysis has shown major gaps in coverage, as the highest incidence of TB is found in migrants and persons deprived of liberty, with TB rates that are estimated to be 20 times higher than in the general population ().

Neglected Diseases and Other Infections Related to Poverty

Some diseases are in a process of elimination, such as lymphatic filariasis; as of 2015, transmission had been interrupted in Barahona, post-treatment surveillance was ongoing in La Ciénaga, and transmission was low in the eastern bateyes. Schistosomiasis is at the post-treatment surveillance stage and leprosy is also being eliminated nationwide, but the target indicator of < 1 case per 10,000 population has yet to be reached in all municipalities. The country has expanded deworming efforts among preschool children enrolled in public day-care centers and private schools, within the framework of Vaccination Week in the Americas (VWA).

Maternal Mortality

As of 2015, the maternal mortality ratio was estimated at 92 (77–111) per 100,000 live births (). Approximately 70% of deaths were due to direct causes, with hypertensive disorders during pregnancy, childbirth, and the puerperal period accounting for 36%, followed by obstetric hemorrhage (18%), pregnancy-related infections (14%), and miscarriage (13%) (). Maternal mortality was concentrated mainly in four provinces: Santo Domingo, the National District, Santiago, and San Cristóbal (). Adolescents represented 16.2% of all maternal deaths, with the highest proportion (45.9%) among mothers aged 20–29, followed by 34.2%, in those aged 30–39 years and 3.7% among those aged 40–49. In 2011 and 2012, the distribution of deaths by age was different: maternal deaths declined in adolescents and increased in mothers aged 30–39. Regarding place of death, 86% occurred in public health facilities, 9% in private facilities, and 5% in the home. According to the surveillance system, 79% of maternal deaths occurred in Dominican women, and the remaining 21% in immigrant women ().

In 2013, the age-specific fertility rate in women aged 15–19 was 89.0 per 1,000 (). In the same year, the proportion of births in adolescents aged 15–19 increased to 43.9% (). More than 22.1% of Dominican adolescents have been pregnant, while 27.5% of those aged 15-19 are married or cohabiting. Patterns of teenage pregnancy reveal a scenario in which poorer, less-educated girls and those living in rural areas are at a disadvantage and are most vulnerable and at risk. Box 1 summarizes the inequities in teenage pregnancy in the Dominican Republic.

Box 1. Inequities in Adolescent Pregnancy

The least-educated, poorest young women, as well as those residing in rural areas, are at a disadvantage when it comes to teenage pregnancy, and are those most affected by this situation. The rate of teenage pregnancy is twice as high in regions with higher female unemployment than in other regions of the country. Moreover, pregnancy and fertility in adolescents are associated with lack of access to reproductive health services among women aged 15-19. In response to this issue, the State has expressed a willingness to make comprehensive health services more available to this population group.

Human Resources

The Health Careers Law was enacted in 2014. The density of human resources in health in 2015 was 25 per 10,000 population, a major increase from the 2011 baseline rate of 19 per 10,000 population. There are an estimated 21.2 physicians and 3.8 nurses per 10,000 population. However, the geographical distribution of health workers is unequal, ranging from 8.2 physicians per 10,000 population in the province of La Altagracia to 50.5 physicians per 10,000 population in the National District ().

Health Knowledge, Technology, and Information

Overall, 95% of people living in urban areas and 91.3% of those in rural areas have a mobile phone (). Cellphones have been used to convey prevention messages to the population during outbreaks and epidemics, and the MPH has developed a mobile app that makes it easy for health workers to access treatment protocols through their phones.

Furthermore, an ever-growing number of Dominican universities are implementing initiatives to promote the use of mobile phones by students and instructors as a teaching and learning resource, making it easier for them to access online information resources through specific applications.

In 2014, the National Health Research Policy was approved, establishing guidelines for the National Health Research System.

The National Fund for Innovation and Scientific and Technological Development (FONDOCYT) prioritizes health topics among its lines of research. The MPH’s National Directorate for Health Research (DINISA) has a program for researcher training, prioritizing different lines of research, based on a consensus of several actors, to promote studies consistent with the country’s needs. The promotion and monitoring of compliance with ethics standards is the joint responsibility of the Directorate and the National Council for Bioethics in Health (CONABIOS).

In addition to public institutions in the health sector, academic institutions that train human resources for health ensure access to high-quality information, with specialized health-related collections and institutional repositories. The Pan American Health Organization (PAHO) Knowledge Center houses the most complete collection of publications on public health.

The scientific output of the health sector is limited by the scarcity of research, which means that scientific journals are published only irregularly.

The Environment and Human Security

Forests cover 39% of the country’s land area. The percentage of land and marine protected areas has remained around 19%, while 26% of land is currently designated as protected area. Production and consumption in the country produces around 21 million metric tons of carbon dioxide (CO2) emissions annually, with long-term emissions tending to increase every year ().

Ozone Depletion

Manufacturing of chlorofluorocarbon (CFC)-containing goods was discontinued in 2010. Accordingly, hydrochlorofluorocarbon (HCFC) use has increased, although HCFCs are scheduled for elimination by 2030, within the framework of the Montreal Protocol.

Drinking Water, Sewerage, and Basic Sanitation

Overall, 86.8% of homes (90.6% in urban areas and 75.7% in rural areas) use an improved water source for drinking. In the richest quintile of the country, access to improved drinking water reaches 97%, versus 83.7% in the poorest quintile. Specific facilities for hand-washing with soap (or another cleansing agent) and water are available in 56.1% of homes (60.2% in urban areas and 44.9% in rural ones) ().

Furthermore, the country has developed an information system for control and monitoring of water quality, pursuant to the provisions of the 2030 National Development Strategy. As of 2015, the National Institute for Drinking Water and Sewerage Systems (INAPA) had set up the Drinking Water Monitoring System (SISMOPA) in five provinces. The MPH, in turn, moved forward with the first stage of the design of a similar system, the Water Quality Surveillance System (SISVICA).

Overall, 95.5% of household members have access to unshared improved toilet facilities (97.5% in urban areas, 89.7% in rural ones) (). In 2014, 2.2% of the population did not have human waste disposal services (1.2% in urban areas and 5.4% in rural ones). Wastewater coverage is 22.2% (27.8% in urban areas versus only 5.4% in rural ones) ().

Natural and Manmade Disasters

The Global Climate Risk Index 2015 () ranks the Dominican Republic among the top 10 nations most affected by extreme weather phenomena, such as tropical storms Isaac and Sandy in 2012 and a major drought that affected the livestock sector and limited the availability of water for human consumption in 2014. The periodically rising water levels of Lake Enriquillo and a buildup of major disasters in this area of the country continue to constitute a silent crisis posing severe threats to human security.

The country has made strides in disaster risk reduction (DRR), driven by the reform of Law 147-02 on risk management, implementation of the National Plan for Comprehensive Disaster Risk Management (PN-GIRD), and gradual incorporation of DRR into the National Planning and Public Investment System during 2013–2014.

Through the “Hospitals Safe from Disasters” initiative, the Hospital Safety Index has been implemented in over 60 high-priority health facilities, academic institutions have been integrated into the training and certification of safety evaluators, and technical guidelines have been developed for hospital design and construction.

Surveillance, warning, and response activities are carried out both as a routine activity and in communicable disease emergencies, such as Ebola and Zika virus. Yearly self-assessments for International Health Regulations (IHR) monitoring show that less progress has been made regarding preparedness and response to chemical or physical (nuclear or radiation-related) emergencies.

Aging

The National Statistics Office (ONE) forecasts that by 2020 people aged 65 and older will constitute 7.35% of the overall population, versus 6.22% in 2010 (according to Census data) (). According to the 2012 National Workforce Survey (ENFT), more than one-third of older adults continue to work (). The legal framework for the care of older adults is provided by Law 352-98 (on protection of the elderly), General Health Law 42-01, Law 87-01 (creating the Dominican Social Security System), and the regulations implementing Law 352-98 (2004).

The official agency tasked with defining and implementing nationwide policies for the benefit of older persons is the National Board of Older Adults (CONAPE). It was established in 1998 pursuant to Law 352-98, which governs public and private institutions for the care of the elderly.

Relevant initiatives geared to older persons include the Program for Protection of the Elderly in Extreme Poverty (PROVIDES), the Calle por Calle program for older adult literacy, the Center for Correction and Rehabilitation of Older Adults Deprived of Liberty (CCR-AM), the Older Adult Diagnosis and Follow-Up program, and units specializing in violence against older adults ().

Migration

Emigration rates are rising, with a trend toward illegal and undocumented emigration, followed by feminization of migration and deportations. An estimated 1–1.5 million Dominicans live abroad.

According to the 2012 National Survey of Immigrants (ENI) (), the total migrant population living in the Dominican Republic was 524,632, of whom 458,233 (87.34%) were of Haitian origin and 66,399 (12.66%) of other nationalities; 336,494 (64.14%) were men and 188,138 (35.86%) were women (). The foreign immigrant population accounts for 5.55% of the national total population. The survey did not determine how many people are living irregularly in the country. Subsequently, in 2015, 288,466 people registered for a national plan to legalize foreigners living irregularly in the country. This process continued through 2016, when 249,741 such requests were approved ().

Monitoring the Health System’s Organization and Performance

As of 2015, 6,545,259 people (65.3% of the population) had joined the Family Health Insurance system (); 47.5% were covered by the subsidized regimen and 52.5% by the contributory regimen. The dual contributory-subsidized regimen, which serves SDSS members without a contractual relationship, has yet to begin operation. There is still a 30% gap with regard to the target of 9 million members by 2015, proposed in the 10-year Health Plan (PLANDES 2006–2015).

The General Directorate of Medicines, Food, and Health Products (DIGEMAPS-MPH) is the country’s regulatory agency for these products. In 2015, the basic list of essential medicines was updated, based on the World Health Organization (WHO) Model List of Essential Medicines and pursuant to the restructuring of the Basic Health Plan.

The MPH has set up a Unified Medicines and Supplies Management System (SUGEMI) for the public health services network. Essential drugs and supplies are procured jointly through the Essential Medicines Program/Logistic Support Center (PROMESE/LIME).

Health expenditure currently represents 4.1% of GDP. Public funding schemes (the traditional MPH scheme and the subsidized and contributory regimens of the Family Health Insurance scheme) represent the majority (2.7%), while private funding accounts for 1.4% altogether ().

In the MPH budget, funds allocated to public health (disease prevention and health promotion in communities) constitute 1.5% of the current national health expenditure and 4.5% of all resources managed by the MPH. These resources are used to fund all public health programs for disease prevention and control, as well as all epidemiological surveillance activities. Most resources are destined to specialized (mainly inpatient) care; the amount allocated to primary care is one-tenth of one percent of the resources allocated to MPH suppliers ().

Finally, patients’ out-of-pocket expenditures for medical visits, laboratory tests, diagnostic studies, medicines, and hospital admissions accounted for 74.8% of private health expenditures in 2001–2005 and 63.9% for the period 2011–2015 ().

Prospects

In 2015, priority gaps were identified in the country, including the mortality rate in children under 5 (32.8 versus the target of 19.8 per 1,000 live births [MDG 4]), the maternal mortality rate (107.7 versus 46.9 per 100,000 live births [MDG 5]), and the percentage of PLWHA with advanced infection having access to antiretroviral drugs (66.5% versus 80% [MDG 6]).

Furthermore, intersectoral action to reduce NCDs is needed in order to progress toward the SDGs. This includes health promotion and prevention through partnerships between the public and private sectors and civil society aimed at the adoption of cost-effective strategies such as the WHO Framework Convention on Tobacco Control (FCTC), taxes on sugar-sweetened beverages, and food marketing and labeling for a healthy diet.

Insurance coverage in the country has increased substantially in the last five years, from 43% in 2011 to 65% in 2015. On the path toward universal health coverage, several challenges have been identified, such as including a greater number of people, expanding priority services, and reducing out-of-pocket expenditures. The new range of benefits provided––based on prioritization of the diseases that should be addressed by the Dominican health system––is also a challenge. The gradual incorporation of these benefits into the system for guaranteed comprehensive coverage of priority diseases and health problems (CIGES, for its Spanish acronym) could facilitate financial sustainability.

Progress with this model entails the development of an integrated health services network with a focus on primary care. Improving the quality of health expenditures and allocating greater funding to primary care units are alternatives in line with the national consensus on the health agenda.

The national health profile should be taken into account in the design of programs for the prevention of the main determinants of health in the country, such as poverty and inequity, education, gender-based inequality, and migration.

Regarding vaccines, the next step is to achieve efficient coverage across all territories and communities in the country, laying the groundwork for introduction of new biologic agents (such as the HPV vaccine), and strengthening the vaccine-preventable disease surveillance system.

Regarding adolescent health, some of the social determinants of health involve State policies that pertain to underage marriage, therapeutic abortion, and the lack of sex education.

Likewise, there is an opportunity for greater alignment between the State, public and private institutions, and other actors in order to promote sexual and reproductive health; to plan for and develop human resources for appropriate antenatal care, clean delivery attended by skilled personnel, and immediate, appropriate newborn care; and to ensure the availability of appropriate contraceptive supplies and methods at each level of care.

The National Sanitation Strategy, which is undergoing approval, is an alternative to improve the distribution, coverage, and quality of drinking water and waste disposal services in urban and rural areas.

The intersectoral response to public health threats entails keeping the basic IHR skillset up to date. The country’s experience in preparedness for infectious events, such as the international Ebola and Zika virus emergencies, demonstrated the feasibility of bringing together different actors for routine activities, and for situations and contingencies such as chemical or nuclear threats.

Outbreaks of cholera and drug-resistant tuberculosis are among the challenges that require joint efforts between countries, as well as United Nations (UN) support for the binational health agenda of the Island of Hispaniola. The same is true of maternal mortality, natural disasters, and the consolidation of advances in health, such as the elimination of lymphatic filariasis and malaria within the framework of the Elimination of Malaria in Mesoamerica and the Island of Hispaniola (EMMIE) program.

People under 35 years of age represent at least 60% of the total population. A demographic transition is underway in the country, triggered by a decline in fertility and an increase in life expectancy; thus, key challenges include preventing a rise in infectious diseases, maternal and child health problems, and the burden of disease and mortality attributed to NCDs. Furthermore, from 2010 to 2015, the treatment of injuries due to external causes, disorders linked to substance use, social violence, and the prevention of femicide became firmly consolidated as major public health problems.

The monitoring of health strategies through subregional integration, South–South cooperation, the harmonization of triangular cooperation, and the new 2018–2022 United Nations Development Assistance Framework (UNDAF), together with the 2030 National Development Strategy, constitute a consensus on the path toward progress in health and achievement of the SDGs.

References

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31. Ministerio de Trabajo, Observatorio del Mercado Laboral Dominicano (Dominican Republic). Panorama laboral Dominicano 2005-2012. Santo Domingo: MT; 2012. Available from: http://www.ministeriodetrabajo.gob.do/transparencia/images/docs/publicaciones/panorama-laboral-2012-omlad.pdf.

32. Procuraduría General de la República Dominicana. Violencias de género, intrafamiliar y delitos sexuales preliminar: enero–diciembre 2015, enero–diciembre 2014. Santo Domingo: PGR; 2016. Available from: http://estadisticas.pgr.gob.do/%23/violencia-de-genero/.

33. Ministerio de Salud Pública y Asistencia Social (Dominican Republic). Plan de acciones prevención y control enfermedades transmitidas por Aedes aegypti (dengue, chikingunya, zikavirus. Santo Domingo: MSPAS; 2015. Available from: http://msp.gob.do/oai/documentos/PLAN-DENGUE-CHIK-ZIKA-2015.pdf.

34. Pichardo R, González M AR, Ramírez W, Escaño F, Rodríguez C, Jiménez RO. Estudio de los factores de riesgo cardiovascular y síndrome metabólico en la República Dominicana: EFRICARD II. Santo Domingo: Instituto Dominicano de Cardiología; 2012. Available from: http://www.arssenasa.gov.do/index/documentos/estudio_efricard%20ii.pdf.

35. Instituto Nacional de Bienestar Estudiantil (Dominican Republic); United Nations Children’s Fund; World Food Programme; United Nations Development Programme. Encuesta nacional de micronutrientes en la población escolar de la República Dominicana ENM-2012. Santo Domingo: INABIE; 2013. Available from: http://media.onu.org.do/ONU_DO_web/596/sala_prensa_publicaciones/docs/0773861001389194239.pdf.

36. Ministerio de Salud Pública y Asistencia Social (Dominican Republic). Indicadores básicos 2015. Santo Domingo: MSPAS; 2016. Available from: https://www.paho.org/dor/index.php?option=com_content&view=article&id=25:indicadores-basicos-salud&Itemid=135.

37. Ministerio de la Presidencia (Dominican Republic). Estadísticas institucionales: sistema 911. Santo Domingo; MINPRE; 2016. Available from: http://minpre.gob.do/transparencia/estadisticas-institucionales/.

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Reference/Note:

1. Basic health indicators, World Bank, 2013.

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