Universal Health Coverage in the Dominican Republic: Lessons Learned and Future Directions

Introduction

In this paper, I will analyze in the social, political, and economic constraints of UHC and its progress in terms financing, access, and quality of the Dominican Republic (DR). The article 61 of the Dominican constitution establishes the right to “health”(4): “the State having to ensure the protection of the health of all people, access to drinking water, improvement of food, sanitary services, hygienic conditions, environmental sanitation, as well as procure the means for the prevention and treatment of all diseases, ensuring access to quality medicines and providing free medical and hospital assistance to those who require it”. Based on this, the Dominican Republic has a clear guidance and values of solidarity and equity of the provision of services in health, which is key to the country’s progress to UHC shown in this paper.

The DR is in an island called La Hispaniola shared with Haiti in the center of the Caribbean, with a population of about 11.12 million people. Politically, is a democratic republic with a multi-party political system and three branches of power: executive, legislative, and judicial. The country is classified as upper-middle income by the World Bank, with a GDP per capita of DOP$511859.54, which is about US$8,476.8 in 2021(5). It is considered one of the fastest growing in Latin America and the Caribbean (LAC) for the past 30 years, following a catastrophic economic recession in 1990. From 1993 to 2017, the economy grew at an average annual rate of 5.3 percent (6), helping the nation close the gap with other LMICs in terms of living standards and placing it among the top performers globally and in LAC.

High growth was the result of both a series of key economic reforms implemented in the 1990s and 2000s and favorable geographic and external eco¬nomic conditions. Some of these reforms were the introduction of new trade agreements, investment in tourism, tax incentives on foreign investments, among others. Furthermore, capital accumulation has been the main driver of growth, accounting for half of the country’s expansion since the 1990s, hovering around 50% of total growth, standing out as one of the largest in LAC (7). The DR’s geography, with its beaches and easy ocean access, is also a natural advantage for a strong touristic sector incentivizing economic growth, a shared feature with other Caribbean and some Central American countries. Further, this economic growth has been accompanied by significant progress in terms of poverty reduction, growth of the middle class, and access to services, including healthcare. The Minister of Economy, Planning, and Development indicated the monetary poverty of the country to be at 23.85% in 2021, registering a drop of 16.68 p.p from 2010(8). A key factor that mitigated the impact of COVID-19 affecting the nation’s poverty levels was the significant number of monetary transfers implemented by the government, as the general poverty rate would have been 26.72% had it not been for the transfers, which represents in absolute terms that 302,365 people maintained income above the poverty line thanks for these transfers. The same would have happened with extreme poverty, which would have been at 4.09%; however, it obtained a figure of 3.06% (1.03 p.p. less). These rates for monetary poverty are similar between urban (23.7%) and rural (24.7%) areas, considering that more 30% of the whole population lives in the capital, the grand Santo Domingo.

Despite the growing economy and poverty reduction, this hasn’t translated into more formal jobs and less inequality. Inequality measured by the Gini index is positioned at 0.40 and 0.35, for urban and rural areas, respectively, one of the largest in LAC after Chile and Brazil. In terms of employment, the DR has a large informal employment rate consistent with that of LMICs(8). Only about 40.9% of the population has some sort of employment, and of this percentage, 41% in the formal sector and 59% in the informal sector. The lack of opportunities in the labor market and the poor quality of public services are push factors for Dominicans to migrate. Other social challenges include increasing perceptions of insecurity, with three out of four Dominicans identifying crime and vio¬lence as the most important challenge facing the country, and poor social cohesion with Haitian migrants in the face of large cross-border population movements, which also impacts the provision of services in the healthcare sector(9,10).

Capacity for Government spending

In terms of fiscal space, the capacity for government spending in the DR keeps being constant throughout the years. The government spends on average between 17% and 18% of its GDP yearly and keeps annual fiscal earnings from Central Administration around 14%-15% (11). A study from the World Bank(7) suggest that all the big tax incentives provid¬ed to the private sector and the high informality rates constrain the country’s capacity to generate fiscal revenue which, combined with growing and rigid public expenditure, have put public debt in an in¬creasing trajectory. The public sector non-financial total debt has been rising, currently 45% of the GDP in the country, which limits the country’s spending ability in need¬ed social programs for human capital (health and education). Translating this fiscal capacity to the health system, total public health expenditure as a % of GDP has increased from 1.2% in 2004 to 3.2% in 2017, but still far from 5% which has been suggested as an estimated target to achieved UHC(12). This low spending in health, combined with an out-of-pocket expenditure as a % of current health expenditure of 42.9%, doesn’t protect the population from financial hardship.

Epidemiological context

The DR is currently in an epidemiological transition as those to higher income countries in LAC, with a growing prevalence of NCDs, mainly cardiovascular diseases. They stand out mainly ischemic heart (140 deaths per 100,000) and cerebrovascular diseases (74 deaths per 100,000), representing the first and second cause of death in the region. Furthermore, the DR is recognized for being one of the countries with the highest deaths by road injuries, representing 67 deaths per 100,000. The combination of disregard for the rules, the congestion of the country, drunk driving, and congestion of motorcycles, drives these results. There is also an increasingly reduced weight of communicable diseases, which as a group explain 9% of deaths. Table 2 shows the main indicators of health system, coverage, and outcomes results in the DR. In the DR there is an evident “paradox”, which is reflected in the coexistence of adequate indicators in terms of service coverage –such as institutional delivery attended by professionals and the high coverage of prenatal check-ups for pregnant women– and relatively poor health outcomes, which point to suggest low quality of care, such as high maternal mortality at birth their children as well as newborns, events that occur especially in the poorest population(13). Furthermore, there are no official indicators for the maternal mortality of Haitians, but there is an evident social discontent in the country with Haitians mothers crossing the border to give birth in the DR’s public facilities, and speculation that these mothers increase the MMR in the country. This epidemiological context and challenges suggest that, even though there is coverage of healthcare services in terms of enrollment (as we will see below), a new way of providing care is needed to increase quality, especially for the poor.

Health System context

Financing

Prior to the commissioning operation of the health reform approved in the year 2001, the Dominican Republic's health system was disjointed. On the one hand, there were public providers who treated anyone who requested care in an open manner, but because of their poor quality, their target demographic was lower-income, unemployed, and uninsured individuals. A traditional social security organization called the Dominican Social Security Institute (IDSS) existed. It had its own providers, affiliated formal workers (but not their families), and had a wage cap above which payments were not collected. Only 6% of Dominicans were covered by this insurance, but its services were of higher quality than those provided by the free public system. The private sector, which catered to upper-class residents, was present alongside this. After 2001 and following the implementation of the health reform in 2007, the Dominican health system has experienced a profound structural transformation. Figure 3 shows the current financing and organization of the system, with a public and private system at the pooling, buying, and provision/delivery level. The reform created a new institutional framework with Family Health Insurance (SFS in Spanish), with the goal of achieving UHC.

The SFS offers the same explicit Basic Health Plan (PBS in Spanish) of preventive and curative services, eliminating all exclusions. The SFS is financed by a mixed Social Health Insurance (SHI) system, where formal employees within the RC would be financed by salary-based contributions by employee and employer, while the RS (subsidized) is finance by general taxed revenues for the unemployed and population with incomes below the poverty line. The informal sector with low salaries above the minimum, would voluntarily contribute under the Contributory-Subsidized Regime, with partial government subsidies. In 2020, this last regime was absorbed by the RS and all the informal workers were added there. All resources would go into a single fund, the Social Security Treasury (TSS in spanish), which would transfer per capita payments to the Health Risk Administrators (ARS in spanish), entities that would oversee insurance and risk management, as well as contracting of the health providers(14).

In terms of enrollment, the country has seen great results throughout the years: going from a population coverage of 65,000 in 2004 to almost 10 million (about 90% of the population) in 2021. In the subsidized regime, which is financed by the government, 3.3 million people have affiliated, which is equivalent to more than 95% of the poor population, according to the system of identification of people entitled to benefits social. Figure 5 shows the distribution of the population in each regime (subsidized, contributive, and pensions), by type of ARS (public or private). As we can see, more than 50% of the whole population is affiliated to the subsidized regime, covering practically all the people considered poor according to official statistics, and those with informal jobs paying a small premium, leaving out only those who do not have identification documents. Further, most people are enrolled within the public ARS which is National Health Insurance (SENASA in spanish), both in RS and RC, because even though is a public insurance, it also contracts with the private network. There are more than ten private ARS in the country, but only 3 of them take over 90% of the whole population affiliated to a private insurance.

Despite enrollment successes in the SFS (one side of the cube), the country has not shown advancements on increasing the costs that are covered by the basic plan and the services provided (other two sides of the cube). Further, the reform has not be implemented effectively within the subsidized system, which implied a restructuring of public services. These continue to operate with poor levels of quality, inefficiency, lack of governance, poor infrastructure, and lack of equipment(1).

Payment

One of the main areas in need for reform in the country is the payment control knob. In the DR, provider payment varies by type of provider (public or provider). Public providers have salaried employees and have greater possibilities of cost containment than the private sector, which relies on fee-for-service. However, these salaries in the public network exist without any bonuses, it incentivizes the provider to underprovide care/don’t go to work, because the provider's salary is typically fixed and not tied to the volume or type of services delivered. A study made by the Minister of Health with USAID found that any of the doctors in the public network assist to work every day, 53% of them only did it once per week. The work days or the contracts are for four hours, but the providers they work –on average– 45% of that time (15). Regarding the private network, fee for service provision without a global budget incentivizes the provider to provide more services with higher reimbursement rates, which can lead to patients getting more services than they need and so there is some risk of a negative impact on health because of the receipt of (potentially harmful) unneeded health services.

Another aspect that affects payment is the difference of per capita between the subsidize and contributive regime. The per capita spending in 2023 of the RS was is US$55 per affiliate per year, much lower than the RC per capita spending of US$332 per person per year(16,17). This difference is partly because the RS operates with public providers, which receive supply-side financing. This difference would be okay if the public system only served the people currently affiliated with the RS, however, this network is open and anyone who needs services must be taken care of including those who are not affiliated with any insurance regime, and those who have insurance and want to avoid copayments. Only the type of provider affects provider payment, hence SENASA outsources a sizable portion of its services to the private sector utilizing a fee-for-service payment model. In the end, this results in the RS's per capita being too low to adequately protect its population, a disparity that is partly caused by the way providers are compensated.

Organization

In the Dominican Republic, the entity that regulates the public network of the public hospitals is the Health National Service (SNS, in Spanish), which is a public entity with administrative, financial, and technical autonomy, attached to the Ministry of Health(18). These are called Regional Health Services, because the organization of the public health system is done at the municipal, province, and regional level of the country. There exists a total of 1,415 public hospitals, where 13.36% are for secondary and tertiary care and the rest (86.64%) are for primary care(19). Further, both the specialized hospitals and primary care centers are divided by categories. The latter has 17 centers of national reference, 13 municipal/self-managed hospitals, 27 province hospitals, and 15 regional hospitals. The former has 1098 first level centers, 87 diagnostic centers, and 41 consulting rooms/zone centers. Regarding the private sector, outpatient healthcare providers offer services where patients can choose GPs or specialists. There are none published studies with the prevalence of service delivery of the private sector in the DR, but various sources estimate that there are more than 7,000 establishments, among which it is estimated that more than 400 are private hospitals, 500 diagnostic centers and nearly 4,000 medical offices/outpatient centers. The rest are pharmacies, ophthalmological centers, opticians, etc. (13,14). In 2013, the Demographic and Health Survey estimated that most of the population's health services—59 percent of outpatient consultations and 51 percent of inpatient services—were delivered through the public system. We don’t have recent estimates of the usage of services between public and private, but by quintiles, there is evidence that upper quintiles utilize more specialized services in the private sector without having a primary care consultation. Additionally, the usage of services in the private sector is correlated with income, despite the fact that a disproportionately large percentage of individuals in the upper quintile also utilize public services(20).

Lessons Learned and Recommendations

There are many positive outcomes that have result for the Dominican health system after their implemented reform in 2007. Some of those are: 1) affiliation of about 90% of the population in less 15 years, 2) an explicit and uniform benefit package offered to the whole population affiliated (PBS), institutional development of the main organizations of the system, and 4) a right-enforced system where every citizen knows where to go to enforce their right to coverage and healthcare. However, there are many recommendations that the DR could take to have a better health system and achieve UHC without financial hardship, so all people have access to the full range of quality health services they need, when and where they need them. The proposed policies would be:

1. The identification of the 10% that is left from coverage (non-poor, informal workers), to capture them to the subsidize system. This could include doing searches for those that are non-registered in official documents with the health of the Electoral Central Joint (JCE, in Spanish), or providing momentaneous tax grants for those to enroll in the system.

2. Primary Healthcare as a first door entry of care for the SFS: PHC has been advocated for decades and is enshrined in current legislation. However, in the DR there is no enforcement of using first-level facilities as the first contact before being referred to more specialized care. Most people go directly to specialized care, which ultimately is a waste of resources for the system. If there is main emphasis on the existence of a network of primary services with significant problem-solving capacity, this could be translated into an improvement in efficiency and a reduction in the waste of resources. This would lead to the reduction of OOPE, which is currently estimated to be at 45%; extremely high considering that most of the financing is public. Most of this expenditure is on medicines, estimated to be around 30% (21). Proposed policies include rationalization of medicine without prescription, decrease in copays, and further monitoring to prevent illegal payments.

3. Provider payment reform: as exposed, it is imperative to transition from a system of purely fee for service in the private sector, to a mix system with Diagnostic Related Groups (DRG) and global budget. For the public system, the salaries could be improved with bonuses or pay-for-performance (P4P) in certain areas such as maternal/infant care, and communicable diseases and Capitation for primary care and a mix system of secondary and tertiary care. In 2018, there were some initiatives of a P4P system being implemented for primary care in certain regions of the country, however, the government needs to reallocate resources to continue these initiatives without external funding.

4. A key issue to guide the country towards universal coverage with equity and without excessive financial burden, is the allocation of more public resources to cover a large part of the health needs of the population. This includes an increase in the per capita of the RS, which would lead to the funds allocated for the protection to the lower income to increase.

5. In-depth revision of the PBS: The current insurance catalog is aimed entirely at health procedures, rather than focusing on actual health diseases. This translates into administrative and political disorders of wrongly reporting repeated information in the system and causing service delays between the insurance companies and patients. There should be done a restructure of the covered costs by the basic health plan, and an increase of covered services (mental health, palliative care, etc.), so it is built on guaranteed coverages of certain health conditions considered to be priorities.

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