Primary care in the Dominican Republic: a Policy Proposal
Over the last three decades, the DR has seen significant strides in its economic development as a country, albeit less so in its health care development. Costa Rica’s health and social policies can serve to inform and frame the recommendations for improving primary care in the DR. In its pursuit of a more efficient and effective primary healthcare system, the DR must improve upon its accountability to government agencies and resource allocation, and health system infrastructure. Given the DR’s current political and socioeconomic status, policymakers must pay attention to the main areas of health care infrastructure, healthcare financing, public health initiatives, and medication.
One of the best ways the DR can improve its primary care delivery model is by improving its health care infrastructure. Current resource allocation systems in the DR dictate that resources are provided in a trickle-down manner in which big cities and other urban areas receive resources first. In contrast, city outskirts and other rural areas have become accustomed to sparse and, many times, delayed resource delivery (Accessing Healthcare, 2015). Like with many of the DR’s most pressing health care problems, it is vital to ensure government agency accountability to allocate resources equitably. Without this accountability, disparities have become magnified across health coverage tiers and across country regions. Lack of care coordination has also contributed to these disparities (Rathe 2018). TO ADDRESS THIS ACCOUNTABILITY AND COORDINATION PROBLEM, the DR can learn from Costa Rica’s integrated health care team system Equipos Básicos de Atención Integral de Salud (EBAIS). The EBAIS system has provided Costa Rica with a robust evaluation system for maintaining quality and ensuring accountability of all government agencies.
Additionally, it has provided a comprehensive and interconnected network for care coordination. The DR’s current infrastructure is not detailed to the level which would allow the development and implementation of a system like that of Costa Rica’s EBAIS system, as the DR’s focus continues to exist on the high-level three-tier regime differences. Therefore, it stands to reason that the DR can benefit significantly by implementing a similar system and should work to develop infrastructure that is intricate enough to support the existence of such a system.
The DR’s primary care health system can also greatly benefit from increasing its government funding. There are two crucial points to consider here. The first is dedicating more funding towards healthcare as the DR experiences consistent annual GDP growth, providing more funding for healthcare across the country. However, the second consideration is perhaps more impactful, as the DR’s current framework for healthcare expends most resources on specialized services and third-level hospitals (Rathe 2018). In fact, with primary care accounting for a mere 3 percent of the budget, we recommend a significant increase in resource allocation as that alone can substantially benefit primary care delivery. This could help with the issues of enforcing the use of first-level facilities as the direct contact for patients and the problem of being unable to offer higher payments for public providers of primary care. Another timely issue that should be addressed is closing the gap in health insurance coverage. Although the DR has made significant progress with providing health coverage for those who cannot afford it, there still is a substantial population that lives without coverage (Rathe 2018). This disparity is exacerbated in rural areas and can be explained by the separation of tier coverage, resulting in a subset of the population without insurance. To address this is recommended that the DR pools all its funding into one central coordinating unit to ensure equitable distribution. Priorities should include guaranteeing coverage of certain health conditions and reducing funding differences between the Contributory and Subsidized regimes.
As a result of its lackluster infrastructure and coordination and its misuse of resource distribution, the DR still lags in many public health metrics despite its economic growth. Health indicators related to the neonatal, infant, and maternal mortality and high adolescent pregnancy rates have strained the primary care system in the DR (Rathe 2018). Although the government has expressed interest in increasing health services to these vulnerable groups, it has not shown meaningful progress (PAHO 2015). Other public health initiatives have seen a similar pattern of inconsistent commitment from the government. For example, although the DR has succeeded in improving health coverage and access by focusing on immunization initiatives and increasing physicians and institutions available per capita, it has neglected other initiatives like providing potable water to the general public. Because of this, the DR is ranked last of the 19 Latin American countries in providing access to clean water sources (Rathe 2018).
It is important to hold the government accountable for the public health initiatives it has set forth to improve. It is clear based on published literature that the DR is aware of its most pressing public health initiatives and has already drawn up plans for many. However, the execution of these plans remains the primary concern. With improved infrastructure, the DR can model their public health progress using a similar evaluation method to that of Costa Rica’s Evaluación de la Prestación de Servicios de Salud (EPSS). This would facilitate a focused approach to improving public health while providing an evaluation system that would iteratively identify areas of improvement. With increased financing, the DR can prioritize primary care access, coverage, and delivery, thereby making possible the execution phase of these public health initiatives.
The achievements made by the Dominican Republic in the area of health insurance have allowed an increasing number of people from different socioeconomic levels to make use of health services, producing different patterns of utilization today in essential areas such as medication. Rodríguez et al. (2019) showed differences in the ways of use and consumption of services among income deciles, where the higher deciles showed the highest percentage of people who used health services (46%) and the highest consumption (47%) of those services, especially on medication. These differences call attention to potential inequalities and barriers in access to care and health coverage. Therefore, we propose a cap maximum pricing or price reference for medication access in DR and measurement of the volume control. External reference pricing (ERP; also known as international reference pricing) refers to using the price of a pharmaceutical product in one or several countries to derive a benchmark or reference price from setting or negotiating the cost of the product in a given country. Reference may be made to single-source or multisource supply products (WHO, 2013). In regards to volume, setting volume control to providers and patients, and eliminating the option to prescribe the established brand of medicine to incentivize generics prescription, could help to regulate the differences in utilization of services among different people in lower and higher income deciles. These policies would eventually help lower these accessibility barriers in the population and decrease private expenditure and overuse of low-value care in pharmaceuticals.
DR is a country that has a unique three-tiered system that finances its healthcare. Coordinated communication between these tiers and their private and public sectors is essential to developing an effective health system and eliminating impediments to the political structure. Wholesome healthcare budgets being fundamental roots to care coverage and the provision of primary care across populations, allocation of resources is much more critical for DR. Rates of improvement in care delivery and coverage can remain stagnant with the allocation of resources in inappropriate avenues. DR’s current health expenditure and resource allocation trend focus on specialized care provided in third-level hospitals, making the budget available for primary care less than substantial.
To have an integrated and structured health system, the best cost-effective approach is primary health care. Its two guiding principles are prevention by early detection of diseases and promoting health care. Primary health care is thinking about health in a way where all the levels interact and counter interact, dealing with fragmentation and segmentation problems. This approach is not an end in itself, instead it is a strategy that is transversal both to the levels of attention and to society, going beyond first level services, which helps organize equitable and quality health systems to reach the goal of universal health. With primary care best practices of Costa Rica in mind, the accountability of government resource allocation and coordination of government regimes are major avenues to improve upon (Rathe, 2018). It is vital to ensure resources reach the most rural parts of the country (Accessing Healthcare in the Dominican Republic as An Expat, n.d). The quality of care can be improved using the Effective Evaluation System (EES), and care access can be bolstered using Costa Rica’s EBAIS model. It has proved to be a robust evaluation system for maintaining quality and ensuring accountability for Costa Rica.
The DR can significantly benefit from a systematic approach like this. Furthermore, complete health care coverage must be aimed for through a well-built insurance framework to fill in all current gaps and make additional expenditures in risk reduction, early deduction, and care continuity in maternal health (Health in Americas, n.d). Carrying out health care infrastructure, financing, public health initiatives, and medication expenditure policies in the Dominican Republic would move many political and economic interests of both private and public participation. This can cause distortions; however, it will be better in the long run for society since it ensures the closest care to people and the community to enjoy the right to health.
References
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