Country Report: Dominican Republic
The Dominican Republic is situated in the Antilles archipelago between the Caribbean Sea and the Atlantic Ocean, occupying approximately two-thirds of the island of Hispaniola, which it shares with Haiti. It is divided into 31 provinces and the National District, where Santo Domingo, the country’s capital, is located.
Between 1990 and 2015, the population grew by 47.2%; the country’s population pyramid continues to expand, albeit at a slower rate, and is stationary in the under-10 population.
In 2015, the country had a population of 10.6 million, with 80% living in urban areas. In 2016, life expectancy at birth was 73.8 years (70.8 for men and 77.0 for women).
Basic health and development indicators steadily improved between 1990 and 2015, with a human development index score of 0.715 in 2014.
Remittances are a main source of foreign exchange for the Dominican Republic, accounting for nearly 7% of GDP in recent years. In 2015, the tourism industry produced revenues of US$ 6.15 billion.
- Adolescent pregnancy (especially among the least educated, poorest young women, as well as those living in rural areas) has been given special consideration by the health authority. The government has expressed a willingness to increase the availability of comprehensive health services for this population group.
- Since 2012, as part of its social policy, the Dominican government has implemented the Quisqueya sin Miseria strategy, with plans for literacy activities, comprehensive early-childhood care, and job creation in high-priority areas. These measures are intended to support the development of productive capacities in impoverished communities in the Dominican Republic. In practice, this means promoting better coordination among the activities of the different national ministries, local governments, and social and community organizations.
- The country has made progress 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 the gradual incorporation of DRR into the National Planning and Public Investment System in 2013-2014.
- Through the "Disaster-Safe Hospitals" initiative, the Hospital Safety Index has been implemented in over 60 priority health facilities; academic institutions have been integrated into the training and certification of safety evaluators; and technical guidelines have been prepared for hospital design and construction.
Figure 1. Distribution of the population by age and sex, Dominican Republic, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan American Health Organization. PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- In 2014, there was significant income inequality, reflected in a Gini coefficient of 0.463.
- Almost 80% of the income-receiving population earns less than twice the minimum wage from its primary occupation. It is estimated that the extreme poverty rate declined from 8.4% in 2014 to 7.0% in 2015.
- In 2014, mean schooling was 7.7 years.
- Between 85% and 87% of households (90.6% in urban areas and 75.7% in rural areas) use an improved water source for drinking.
- An estimated 1 to 1.5 million Dominicans reside abroad. According to the National Immigrant Survey of 2012, the foreign immigrant population is equivalent to 5.55% of the total national population. The survey did not determine the number of people living in the country without the proper documentation.
- The majority of disasters are caused by hurricanes and earthquakes, which have major economic and health consequences. Drought is also a critical concern.
HEALTH SITUATION AND THE HEALTH SYSTEM
- In 2015, the maternal mortality ratio was estimated at 92 deaths per 100,000 live births. Maternal mortality was concentrated mainly in four provinces: Santo Domingo, the National District, Santiago, and San Cristóbal. That same year, 68.6% of births were attended by trained personnel.
- Adolescent girls who are less educated, poor, and live in rural areas are at greater risk of pregnancy and have higher pregnancy rates.
- The adolescent pregnancy rate is twice as high in regions with higher female unemployment as in other regions of the country. Adolescent pregnancy is also associated with lack of access to reproductive health services among women aged 15-19.
- In 2015, mortality in children under 1 year was 22.9 deaths per 1,000 live births (31 in urban areas and 28 in rural areas). In 2012, disorders originating in the perinatal period accounted for 65% of deaths in children under 1. Sepsis was one of the five leading causes of death in children under 5, with an even higher risk in children under 1.
- In 2012, traffic injuries were among the five leading causes of death in the population aged 5-44. The two leading causes of overall mortality for the over-45 age group were the same as for the general population: ischemic heart disease and cerebrovascular disease.
- Between 2012 and 2015, BCG vaccine coverage was over 95%, and DPT3 coverage ranged from 82% to 90% in the under-1 population.
- In 2015, one case of diphtheria was reported (none were reported in 2012-2014). Whooping cough prevalence increased, with 69 cases in 2015.
- A cholera epidemic occurred in 2011–2012. In 2013, 539,000 cases of chikungunya virus infection were estimated.
- In 2015, the incidence of malaria was 1.9 per 100,000 population. The populations at greatest risk of malaria are temporary migrant workers in the agriculture and construction sectors.
- Canine-transmitted human rabies has not been eliminated; in 2015, two deaths from this disease were confirmed.
- Lymphatic filariasis is in the process of elimination, as is leprosy, which has yet to reach a target indicator of less than 1 case per 10,000 population in all municipalities.
- In 2010, the prevalence of hypertension was 34.7% and the prevalence of type 2 diabetes mellitus was 9.9%.
- In 2013, chronic malnutrition in children under 5 was 7.1% and childhood obesity was 7.6%. In 2014, 56.3% of adults were overweight.
- The health system is defined as a social security model guided by the principles of universal coverage, compulsory enrollment, solidarity, comprehensive care, a unified system, free choice, and gradual implementation, among other legally recognized principles.
- In 2014, the country adopted a model of care based on the primary health care strategy and the Integrated Health Services Network.
- The Ministry of Public Health has a governance role and includes the National Health Service.
- In 2015, 65% of the population was enrolled in the Family Health Insurance system. Of this group, 47.5% were covered by the subsidized regimen and 52.5% by the contributory regimen.
- Health expenditure currently represents 4.1% of gross domestic product (GDP), public funding schemes 2.7%, and private funding 1.4%.
- In 2011, there were an estimated 21.2 physicians and 3.8 nurses per 10,000 population.
- The National Health Service has 1,450 primary care centers, 1,774 primary care units (UNAPs), and 189 specialized health care centers (CEAS), including 13 regional hospitals, 35 provincial hospitals, 122 municipal hospitals, and 19 referral hospitals.
- These facilities have the necessary capacity to provide the care stipulated in the Basic Health Plan (PBS), which includes a package of services covered by the Family Health Insurance system for members of the Dominican Social Security System’s contributory regimen.
- In 2015, the basic list of essential medicines was updated, based on the World Health Organization’s Model List of Essential Medicines.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- Between 1990 and 2015, the country made great progress in health and overall development. It is worth noting that infant mortality plummeted 50.3% in this period. Pending challenges include continuing with maternal and child strategies and programs to reduce under-5 and maternal mortality.
- Health insurance coverage in the country has increased substantially in the past five years, from 43% in 2011 to 65% in 2015. However, there is still a major gap for a significant portion of the population.
- A significant challenge is updating the list of benefits that should be covered by the Dominican health system. This list should be based on disease prioritization and must be financially sustainable.
- The country’s health profile suggests that the main health determinants, such as poverty, inequity, education, gender-based inequality, and migration, should be taken into account in the design of prevention programs.
- The country also seeks to provide effective vaccination coverage in all territories and communities. Another priority is increasing access to antiretroviral therapy for the population living with HIV.
- Preventing and reducing non-communicable diseases require an intersectoral approach for the adoption of standards and action in areas such as smoking and food labeling to address the major risk factors in the population.
- Some of the social and health determinants that affect adolescents indicate the need for State policies to address underage marriage, therapeutic abortion, and the lack of sex education.
- Outbreaks of cholera and drug-resistant tuberculosis are among the challenges that require joint efforts with other countries in the Region.
- The treatment of injuries from external causes, substance use disorders, social violence, and the prevention of femicide have become major public health concerns.
- It is critical to improve the birth certification structure and registration systems, specifically in areas with higher levels of poverty and in border regions. An estimated 20.8% of the population aged 0-5 lack a birth certificate, which impedes the delivery of basic services and health planning.
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