RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
The policy that has guided the Secretariat for Public Health and Social Welfare since 1992 is the primary health care strategy. This policy recognizes that health is a fundamental right exercised through free and equal access to the actions that seek to satisfy it. The policy also mandates that the State give priority to the most disadvantaged and vulnerable groups. Central to the policy are democratization, universal health services, equity, humanistic modernity, effectiveness, and efficiency. The main strategies are dispersion and decentralization, societal participation, intra- and intersectoral coordination, and the development and management of knowledge.
However, before these broad policies can be put into practice, many problems need to be solved and many changes must be made in the organization, operation, and allocation of resources in health sector institutions. In mid-1997 the Secretariat set as its highest priority a reversal of a longstanding shortfall in social spending, and declared that the reduction in infant and maternal mortality was its primary objective. In order to attain this goal, the Secretariat has proposed a nationwide mobilization with the participation of all sectors of society, and for a comprehensive plan to strengthen preventive and curative care for children and pregnant women. This goal will be achieved primarily by strengthening health services at the provincial level.
Health Sector Reform
There is an awareness in Dominican society that the State is in need of major reform. So far, responses have included creating the Presidential Commission for State Reform and Modernization in 1996, and in 1997 appointing a new Supreme Court that is empowered to modernize and overhaul the judiciary. Reforms have begun in other areas, including in the financial and tariff sectors, the health sector, and the education sector with a Ten-Year Plan for Educational Reform. The new Presidential commission has laid down general guidelines for these processes as part of the overall effort to achieve humane and sustainable development within the context of the new international realities. Health and education are essential aspects of this social reform.
In 1995 a new interinstitutional National Health Commission was created by Presidential decree and given the express mandate to draft a set of proposals within a year for reform of the sector and to promote the overall modernization of the health sector.
The drinking water, sanitation, and solid waste sectors have recently embarked on a reform and modernization process. It draws its guidelines from the National Drinking Water Plan for Scattered Rural and Marginal Urban Areas and the National Social Development Plan. Both plans give priority to improving living conditions for the most disadvantaged populations.
A National Food and Nutrition Plan that was approved in 1995 is currently being put into place but with much difficulty. In 1997 its implementation was delegated to the Secretariat of Agriculture. One component of this plan is quality control and epidemiological surveillance of foodborne diseases, which is the responsibility of the Secretariat for Public Health and Social Welfare.
Several important trends have been taking shape in the reform process, notable among them the decentralization of the Secretariat, the strengthening of provincial levels, and coordination between government health agencies at the local level.
Organization of the Health Sector
According to the Public Health Code, the Secretariat for Public Health and Social Welfare is the agency in charge of health services and is responsible for applying the Code. The Secretariat provides health care, health promotion, and preventive health services and is structured on three levels: central, regional, and provincial. The role of the central level is essentially standards-setting. Eight regional offices direct the services and oversee the health areas, or units, at the provincial level. The health areas have rural clinics that each cover from 2,000 to 10,000 inhabitants and are staffed with medical interns or assistants, nurse’s aides, a supervisor of health promoters, and the health promoters themselves. Most of the provincial capitals have either a second- or third-level hospital with outpatient, inpatient, and around-the-clock emergency services. Some of the provinces also have health subcenters with inpatient beds, emergency services, and general adult medical care, as well as pediatric and pregnancy care.
The Secretariat’s programs are structured at the central and regional levels. The most fully developed are those for the control of malaria, dengue, and other vector-borne diseases and for the prevention and control of rabies and zoonoses; the national tuberculosis program; immunization; family planning and reproductive health; and basic sanitation. There are epidemiological services at the national level and also units at the regional and local level.
IDSS is an autonomous institution that covers risks from disease, disability, old age, death, and on-the-job accidents incurred by employed workers. In 1994, 6.5% of the general population and 15.4% of the economically active population were affiliated with IDSS, and its expenditures represented 0.7% of the GDP. Since 1990 there has been pressure to completely overhaul social security policy, but to date no reform of IDSS has been accomplished.
Private medical contracts are a form of health insurance developed by private medical centers to expand their client base and guarantee a steady flow of income. Through this system the clinics in the major cities have been able to attract large numbers of workers whose income levels would not otherwise allow them direct access to the services. The range of services varies depending on the specific plan but usually includes medical care and outpatient maternity care, and hospitalization in some cases. Prescription drugs are only covered during hospitalization.
Some nonprofit private services are provided by clinics and hospitals managed by nongovernmental organizations. For example, some institutions or foundations offer low-cost services for such specialized problems as diabetes, cardiovascular diseases, skin diseases, cancer, or rehabilitation. A number of these institutions receive sizable government subsidies through the Secretariat for Public Health, and they also may be paid directly by users.
Private for-profit services have been growing rapidly in recent decades. They are provided in facilities ranging from highly sophisticated private hospitals to small centers operating under uncertain conditions, usually located in outlying urban or semirural areas.
Organization of Health Regulatory Activities
Public health regulation is very weak. The existing health care standards are 10 or 20 years old, and health professionals are certified by union-like professional associations.
In 1996 the Secretariat for Public Health and Social Welfare, working with the Private Clinics Association, began to develop an accreditation system for hospitals and private clinics, but the initiative has run into serious difficulties. It has only been possible to reach agreement on a few of the definitions, and nothing concrete has emerged from the process. There is also an effort under way to regulate and accredit public and private laboratories.
The Secretariat’s Drug and Pharmacy Division is responsible for evaluating and registering drugs, as well as for inspecting drug manufacturing laboratories and pharmacies. There are pharmacological standards and procedures in effect to regulate drug registration, and an automated information system has been set up. Nevertheless, the regulatory inspection of pharmaceutical businesses is a weak link in the program. The Dr. Defilló National Public Health Laboratory is responsible for the analytical control of drug quality, but its operations are hampered by the poor state of its infrastructure and equipment. There is no department in the Secretariat responsible for the scientific or technical aspect of drugs. In the area of food regulation, efforts to apply the FAO/WHO code have been relatively ineffective.
Health Services and Resources
Organization of Services for Care of the Population
Drinking Water and Sewerage Systems. The country’s rapid population growth, massive migration to urban areas, and increasing numbers of people living in poverty have resulted in serious deficiencies in the coverage and quality of water and sanitation services. It was estimated that in 1993 the drinking water supply reached 65% of the population-80% of those in urban areas and 46% of the persons in rural areas. Of the country’s 8,463 rural communities, only about 2,100, or 25%, had drinking water services, while sanitary sewerage disposal services covered only 16% of the entire population and 28.0% of the urban population.
Drinking water and sewerage services represent a large share of the Government’s social expenditures.. Institutional weaknesses, staff turnover, and deficiencies in operating and maintaining systems all hamper the sector’s ability to meet the basic sanitation needs of the population.
Disease Control and Prevention Programs. The Expanded Program on Immunization (EPI) coordinates activities with both public and private institutions. Vaccines are procured through the EPI Revolving Fund, with the exception of hepatitis B vaccine, which is purchased directly from the suppliers. Every shipment that arrives is subject to quality control, and samples are taken in the warehouses to monitor the status of the vaccines.
During the 1992-1996 period the government developed combined vaccination strategies based on guidelines aimed at meeting the regional targets to eradicate and control vaccine-preventable diseases. Vaccination programs have been established for all the EPI vaccines, to immunize all newborns in hospitals and health centers against tuberculosis, hepatitis B, and poliomyelitis. In addition, national vaccination days have been held to reach new population groups, such as those under 15 years of age, and protect them against measles.
Vaccination coverage has exceeded 80% since 1993. Between 10% and 20% of the vaccines are administered by private providers. There is no government reporting system.
Epidemiological Surveillance Systems and Public Health Laboratories. The epidemiological surveillance system operates at the national level through the General Directorate of Epidemiology and surveillance units in the specialized programs. In addition, in each of the eight health regions there is a regional epidemiological unit, and in each of the 38 health areas there is at least one professional responsible for epidemiological duties. Also, each of the main hospitals has an epidemiology unit that is responsible for surveillance. The system has evolved and improved considerably since 1996, and it is expected to be strengthened even more after the National Epidemiology Institute starts up its activities, probably in 1998.
The compulsory reporting system relies on weekly passive and compulsory reporting of suspected cases of any of the diseases on the list drawn up for this purpose. For some diseases, such as bacterial meningitis, a special surveillance subsystem has been developed
The epidemiological surveillance system is composed of subsystems that cover the following areas: (a) diseases for which reporting is compulsory; (b) acute febrile conditions; (c) infant births and deaths and deaths of women of reproductive age; (d) harbors and airports, and (e) specialized programs.
Most of the surveillance support is provided by the Dr. Defilló National Laboratory, although the Central Veterinary Laboratory, the National Anti-Rabies Center, the National Malaria Eradication Service, and the main hospitals also contribute to this effort.
Solid Waste Collection and Urban Cleanup Services. These services are the responsibility of local communities. In almost all the cities, coverage is minimal, collection is sporadic, and solid waste is disposed of in open-air pits. The administrative units in these services are weak and suffer from shortages of equipment, funding, and specialized personnel. Trash collection in the National District was privatized in 1992, and since then services have improved in the residential areas. There are no special procedures or standards that apply to hospital solid wastes.
Control of Environmental Risks. The lower-income areas surrounding the main cities lack water supply, sewerage, or trash collection services. Many of the dwellings there are overcrowded, constructed of cast-off materials, and located near pollution sources.
Sewage runoff and liquid and gas pollutants from industry and agriculture come under the responsibility of several different institutions, including the Secretariat for Public Health and Social Welfare, the National Water Supply and Sewerage Institute (INAPA), the municipal councils, the Secretariat of State of Agriculture, the National Bureau of Forestry, and other entities, none of which has specific policies or programs. There is also no specific legislation or adequate coordination, and resources to oversee these activities are very limited.
There is considerable pollution of groundwater and of beaches near the coastal cities.
Workers’ Health. The Secretariat for Public Health, the IDSS, the Secretariats for Labor, Education, Agriculture, and Public Works, and the municipal governments share responsibility in this area. According to the limited information available, the high number of disabilities, workplace injuries, and occupational diseases is cause for concern. Programs geared toward preventing these problems have not been extensively developed; the reality is that workers are unprotected and ill-prepared to deal with these risks.
Disaster Preparedness. The Dominican Republic is located in an area exposed to cyclones, earthquakes, and floods-phenomena that have taken a significant toll in terms of economic damage and loss of life. A coordination office has been created in the Secretariat for Public Health to oversee implementation of the national plan for disaster preparedness.
Health Promotion. The Secretariat for Public Health has encouraged the establishment of local development programs, the most advanced of which is in the province of Salcedo. There, excellent results have been achieved in the improvement of environmental sanitation and the reduction of deaths from such causes as gastroenteritis, from which there have been no registered deaths since 1994.
The Department of Healthy Communities was established within the Secretariat in 1997 to coordinate local development initiatives, strengthen provincial development councils, and create healthy communities.
Food and Nutrition. The National Food and Nutrition Plan is currently being redrafted, with the goal of building food security and encouraging the formulation of projects to mobilize resources to carry out the Plan.
Oral Health. During 1995, 445 dentists and 197 dental assistants working for the Secretariat for Public Health performed a total of 324,977 clinical dental interventions in 174,699 consultations. Prevention measures, basically consisting of fluoride rinses, currently reach only 10% of the schoolchildren between 6 and 14 years of age.
Organization and Operation of Personal Health Care Services
According to data from the Secretariat for Public Health, in 1996 there were a total of 1,334 health facilities in the country, of which 730 (55%) came directly under the Secretariat, 184 (14%) under IDSS, 417 (31%) under the private sector, and 3 (0.2%) under the armed forces. There were 15,236 hospital beds, of which 7,234 (47%) belonged to the Secretariat, 1,706 (11%) to IDSS, 5,796 (38%) to the private sector, and 500 (3%) to the armed forces. These numbers represent a bed/population ratio of 1:500. However, there is a discrepancy among different sources on the number of beds available.
In 1996 the total number of outpatient consultations provided by facilities under the Secretariat came to 5.8 million, or 0.8 consultations per inhabitant, of which 2.2 million were emergency consultations, or 0.3 per inhabitant. There were 372,000 hospital discharges, or 50 per 1,000 population. No comparable current data are available for IDSS or other public institutions.
Inputs for Health
In 1996 the value of the private sector drug market was US$ 186.4 million, while in the public sector purchases by the Government’s Essential Drugs Program were estimated at US$ 15 million. Adding to these amounts the expenditures by IDSS and the armed forces, the annual average per capita expenditure on drugs is estimated at US$ 30.
The Essential Drugs Program is responsible for buying and distributing drugs for public sector institutions based on the product list prepared by the Secretariat for Public Health.
The country has 84 drug laboratories that produce drugs and related products financed with domestic capital and one laboratory financed with multinational funds.
There is no reliable record in the Dominican Republic of equipment available in the public and private health facilities. However, the country has made sizable investments not only to equip the large network of existing services but also to periodically update the equipment on hand. There are recognized problems in the area of maintenance, and the average life of the equipment is far shorter than it should be.
At the beginning of 1997 the “Health Plaza,” a Government-owned complex located in Santo Domingo, began operating. It contains hospitals for maternal and child care, geriatrics, and traumatology, plus an advanced diagnostic center. A sizable investment has been made in this complex, which has 430 new beds and highly advanced technology.