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PAHO Basic Health Indicator Data Base This is a multidimensional query tool that offers a collection of 108 indicators from 1995 to 2005. The system presents data and indicators on:
- demography
- socioeconomic
- mortality by cause indicators
- morbidity and risk factors
- access, resources and health services coverage.
Selected indicators are disaggregated into age groups, sex and/or urban/rural region. Generated tables can be exported and printed.
The data presented is updated annually with the latest country information.
GENERAL SITUATION AND TRENDS The Dominican Republic occupies the eastern side
and 74% of the territory of the island the Hispaniola , that it shares with
Haiti , located between the Caribbean Sea the Atlantic Ocean. The country
comprises 48,442 km˛, 30 provinces plus the National District.
Demography:The
population of the Dominican Republic in 2000 was estimated at 8,396,164, with
a population density of 173.3 inhabitants per km˛.
Economy: The economy was based on agriculture
over decades, but mining began to gain importance (ferronickel, gold and silver)
in the 1970s. There was also a fast development of free export industry zones
and tourism. Through free trade agreements, a greater commercial integration
to the Caribbean and Central America was achieved. The growth of GDP in 2000
was 6.8% (GDP per capita was US$ 1,887 in 1999). In 1998, Hurricane Georges
caused losses estimated at US$ 2,024 million. In the period 1996-1999, social
spending as a proportion of public expenditure averaged 39% (6 % of GDP ),
while public investment in social development (health, education and social
welfare) represented 5% of GDP. In 1998, 25.8% of the population was below
the poverty line (US$ 60 per capita monthly). In 1999, 66.5% of the poor lived
in cities. There is a great heterogeneity in poverty between regions of the
country. In 1996, more than 75% of the poor households were located in two
regions: Enriquillo and El Valle.
Education: In 1998, the literacy rate was
84.4% in adults over 15 years of age. Illiteracy is almost three times higher
in rural that urban areas.
Mortality: The estimated crude mortality
rate for 1995-2000 was 6 per 1,000 population ; however, underregistration
is believed to be as high as 42%. In 1998, 83.8% of deaths were physician-certified.
In the same year, registered mortality by age was: 1-4 years, 2.4% ; 5-14
years, 2.1%; 15-49 years, 23.8%; 50-64 years, 16.3%; and 65 and over, 43.9%.
SPECIFIC HEALTH PROBLEMS Analysis by population group Children (0-4 years): The
estimated infant mortality rate was 40 per 1,000 live births (lb), 1995-2000.
Underregistration of deaths in infants was estimated at 60% in 1998. In that
year, conditions arising in the perinatal period accounted for 64.5% of infant
deaths, communicable diseases 13%, and acute diarrheal diseases, 9.4%. Communicable
diseases constituted the leading cause (40%) in the group 1-4 years of age,
followed by external causes (24.6%). In 1999, the leading causes of morbidity
in infants were acute respiratory infections (668.8 per 1,000 lb), acute diarrheal
diseases (329.3 per 1,000 lb), and parasitoses (138.5 per 1,000 lb). The leading
causes of morbidity in children 1-4 years were acute respiratory infections
(221.2 per 1,000 population) and acute diarrheal diseases (69.4). According
to the 1996 ENDESA survey, the prevalence of chronic malnutrition in children
under 5 years was 10.7%. Age groups most affected by dengue in 1999 were infants
(45.2 per 100,000 children) and children 1-4 years (28 per 100,000).
Schoolchildren (5-14 years):External
causes and communicable diseases are the leading cause of death. The rate
of dengue notified for 1999 in children from 5-9 years was 27.3 per 100,000
and in those of 10-14, of 18.4 per 100,000.
Adolescents (10-19 years):The
estimated fertility rate in adolescents 15-19 years was of 87 per 1,000 in
urban areas and 160 per 1,000 in rural areas.
Adults (15-59 years):In
1998, mortality among those 15-59 years of age was 14.4 per 1,000 and the
most frequent causes of death were external causes (36.2%) and communicable
diseases (20.7%), due mainly to an increase in mortality from AIDS and tuberculosis.
In 1998, among those 50-64 years of age, diseases of the circulatory system
were the leading cause of death (37.7%), and neoplasms (18.3%). The highest
fertility rate occurred in the age group 20-24 years, with 199 births per
1,000 women. The total fertility rate was 2.3 births per woman. Contraceptives
were used by 85% of women of childbearing age. In 1996, 98.5% of pregnant
women had a prenatal visit, 98% of them were seen by a physician. The maternal
mortality rate was 80 per 100,000 live births in 1999; the leading causes
were toxemia, hemorrhage, and sepsis.
Elderly (60 years and over): The
leading causes of death in 1998 were diseases of the circulatory system (52%)
and neoplasms (15.7%). There is a network of homes for the elderly but the
majority operate in precarious technical and financial conditions.
Family Health:In
1996, heads of households were women in 27% of homes. Eight percent of households
were comprised of only one person. The majority of children under 15 (56%)
lived with both parents, while 14% lived with neither parent.
Workers' Health:In
2000, there were 6,083 occupational injuries, the majority occurred in the
manufacturing industry, primarily construction. Hospitalization was required
for 77% of the injuries. There were 1,504 cases of occupational disease, heavy
metal poisoning (14.8%), hypertension (14.7%) and low-back pain due to exertion
(12.6%).
Population at the border: The
country's greatest concentration of poverty is located along the entire
area bordering Haiti . Some of the unmet basic needs are related to housing;
overcrowding; wastewater and solid waste disposal, and access to potable water.
Analysis by type of health problem Natural disasters: The
country is exposed to hurricanes by its geographical location and to earthquakes
by the proximity to a geological fault. The most frequent natural disasters
are floods. Hurricane Georges in 1998 had the most negative economic impact
in recent years, when rains affected the entire population, causing 239 deaths
and the destruction of 49,000 dwellings.
Vector-borne diseases: In
2000, there were 1,233 cases of malaria, with a slide positive index of positive
of 0.21 and an annual parasite index of 14.7 per 100,000. There is endemic
transmission of malaria in 36 municipalities of 6 provinces, linked to the
cycles of crop production, and epidemic outbreaks linked to the construction
industry. Dengue is endemic in the country; 3,462 probable cases were reported
in 2000, 798 confirmed (23%), of which 58 corresponded to dengue hemorrhagic
fever, with six deaths. Since July 2000, serotype 3 predominanted. Indices
of infestation by Aedes aegypti were high in urban areas (60%). Frequency
of filariasis was low, but there was a control program including massive treatment
of the population, once a year.
Vaccine-preventable diseases:
In October 2000, an outbreak of poliomyelitis, caused by a poliovirus derived
from the vaccinal virus Sabin type 1, was detected. Between July 2000 and
June 2001, 104 cases of acute flaccid paralysis (3.4 per 100,000 children
under 15) were detected, with 14 confirmed cases. National coverage with three
doses of OPV in children under 1 year was nearly 80% in the last five years,
but in Constanza, the municipalities where most cases were detected, the coverage
had been between 20 and 30%. In 1997, a case of measles was confirmed. In
December 1998, an outbreak in the east of the country lasted two years (14
cases confirmed in 1998, 274 in 1999 and 253 in 2000). Vaccination coverage
against measles in children under 1 year in 1997 and 2000 varied from 80 to
95%. Between 1997 and 2000, 145 cases of diphtheria were detected, with 36
deaths. Eighty-two cases and four deaths of whooping cough were recorded,
1997-2000. In 2000, 4 cases of neonatal tetanus were reported; 102 cases of
non-neonatal tetanus were reported, 1997-2000. Vaccination against rubella
had not been introduced into the Dominican Republic and in 2000, 346 cases
of rubella were confirmed. There has been an annual incidence of Haemophilus
influenzae type b (Hib) of 14 per 100,000 in children under 5 in the National
District, 1998-1999; vaccination was started in 2001. The vaccination coverage
with third dose for hepatitis B in children under 1 year was 68% in 1999.
Intestinal infectious diseases:
A 1999 survey showed that 65.5 % of schoolchildren were infested with Blastomyces
hominis (27%), Entamoeba coli (26.7%) and Giardia Lamblia (17.7%), among others.
Communicable chronic diseases: Tuberculosis
presented an incidence rate in the year 2000 of 62.4 per 100,000 population
, with major variations among the provinces. The case rate with positive microscopic
examination was 34.3 per 100,000 population . It was estimated that in 1999
only 60% of the cases were detected and that only 49.6% of them were cured.
In 1999 the directly observed treatment (DOTS) was initiated. Leprosy has
been reduced considerably and in 2000 the incidence was less than 3 cases
per 100,000 population .
Zoonoses: Rabies
is the most important zoonoses. 12 human cases were reported, 1990-1997, but
none between 1998-2000 . National coverage of canine vaccination has been very
low; 1999 (27%) and 2000 (less than 5%). Cases and small outbreaks of leptospirosis
were confirmed and infections were reported by toxoplasmosis in pregnant women
in some areas of the country.
HIV/AIDS:The
annual incidence of reported cases of HIV/AIDS declined from 6.4 to 3.9 per
100,000 (high underreporting is assumed), 1995-1998. In 1998, AIDS represented
3.7% of diagnosed mortality at the national level. The transmission was heterosexual
in 80% of cases.
Sexually transmitted infections:According
to surveys, estimated incidence of syphilis in women was 300 per 100,000;
genital ulcers, (2,300); genital herpes, (900); and chlamydiosis, (620).
Nutritional and metabolic diseases: Low birth
weight was recorded as 7.3%; a survey in 1996 found that 90% of children received
breast-feeding at birth; acute malnutrition in children under 1 year attending
health facilities was 0,75% in 1999, but deficit of height-for-age in schoolchildren
was close to 20%. Micronutrient Surveys within children under 15 showed deficiencies:
iron, 30%; iodine,74%; vitamin A, 19%. Diabetes is a growing problem, representing
4.2% of deaths in 1998.
Diseases of the circulatory system: Prevalence
of hypertension in adults was estimated at 24% nationwide. In 1998, the leading
causes of mortality in the general population were: ischemic heart disease,
11.3 % (19.8 deaths per 100,000 population) and cerebrovascular diseases,
8.8%, (15.5 deaths per 100,000).
Malignant neoplasms: In
1998, malignant neoplasms represented 13.1% of registered deaths. Most frequent
sites were prostate (1.9% of the total of deaths), other digestive organs,
and peritoneum (1.8%), trachea, bronchia, and lungs (1.4%), stomach (0.9%),
breast (0.8%), colon (0.6%), and cervix (0.5%).
Accidents and violence: Accidents
and violence represented 19.5% of deaths in 1998. The mortality rate from
accidents was 24.8 per 100,000; homicide, 8.2. Between 1986 and 1998, the
suicide rate tripled, reaching 7.5 per 100,000 in 1998.
Emerging and reemerging diseases:
In 1999, the mortality rate for meningococcal disease was of 2.3 per 100,000,
with highest risk in those aged 9 years. Nearly 600 probable cases of bacterial
meningitis were detected per year in the National district (50% confirmed).
RESPONSE OF THE HEALTH SYSTEM
National health policies and plans: As part
of State modernization, 1996-2000, decentralization was a main orientation,
as well as availability of services and drugs; actions were taken to face
problems of coverage, organization, management and quality of services. A
set of strategies based on primary care and democratization was addressed
to improve equity with respect to access to services.
Health sector reform: In 1997, a framework
was established for the management of health sector reform under six principles:
universality, equity, comprehensiveness, solidarity, participation, and sustainability.
In 1996-2000, a process of decentralization of the Ministry of Health and
hospital management began; a new model of care was established, with emphasis
on the first level care; standards of care were formulated; and health promotion
strengthened. The Social Security Reform Law established the separation of
financing, care delivery, and insurance, creating a compulsory basic universal
health insurance plan. The General Health Law regulates the leadership role
of the Ministry of Health. Modernization of procurement, inventory, and distribution
of drugs and medical supplies has been proposed to better meet the needs of
providers.
The health system: The
health system comprises two subsectors, the public subsector (insurance and
provider institutions of nonprofit and for-profit services, governed by the
General Health Law) and the private subsector (nonprofit and for-profit).
The Ministry of Health provides leadership for the system and provides services
to 75% of the population, most of whom are uninsured (care is free but with
no guarantee of access or quality). The private sector provides services mostly
to the upper-economic strata. Types of insurance include worker-employer prepayment
schemes (such as the Social Security Dominican Institute), prepaid private
health insurance, self -managed insurance and private providers.
Organization of regulatory actions: Standards
of accreditation, regulations and good practices have been established for
health facilities, laboratories and pharmaceutical companies, although regulatory
processes are still needed to improve the quality of care, quality control
and biosafety. The Bureau of Drugs and Pharmacies in the Ministry of Health
is responsible for the evaluation, registry, and control of drugs. Between
1996-2000, the physical infrastructure of the health services network was
improved and expanded, both in the public and private sectors with the introduction
of new technologies. Strengthening of environmental action is carried out
through primary environmental care. In the year 2000, the General Law on Environment
and Natural Resources was promulgated.
Organization of public health services:Health promotion: In 2000, the General Law on Youth
and the Law on Tobacco Use were enacted, and the Law of Traffic was amended
to require seat belts. Between 1995-2001, the Bureau of Health Promotion and
Education and the Department of Healthy Municipalities were created to initiate
strategies on health promotion. The Secretariat for Health created the Comprehensive
Adolescent Care Program, that in 2000 offered 37 specialized services and 5,000
organized adolescent "multipliers" who promote health in the community.
Disease Prevention and Control: Maternal and child care are the most advanced
Integrated Management of Childhood Illness and the Expanded Program of Immunization;
vector-borne diseases; zoonoses, tuberculosis, leprosy, and AIDS/STI. More than
100 community organizations participated to reduce maternal and child mortality.
Health analysis and epidemiological surveillance: The General Bureau of Epidemiology
has the normative responsibility for a decentralized surveillance system (a
component for early warning and one prevention and control). At the central
level, it includes units of surveillance, health situation analysis, and computer
support. Potable water , sewerage, and management of solid waste: Potable water
and sanitation are the responsibility of the National Potable Water and Sewerage
Institute. Services in the communities are the responsibility of more than 20
associations of rural water supply systems. In 2000, 71.4% of the population
had drinking water services. The coverage of excreta disposal systems was 89.5%,
while coverage of sewerage services was only 20.1%. Air pollution prevention
and control: Air pollution prevention and control is under the responsibility
of the General Health Directorate and Environment of the Ministry of Health,
with programs on education, prevention, and training in air quality.
Organization of individual health care services:The public subsector (administered by the Secretary
of Health) is organized at four levels of management, central, regional, provincial
and local. Health services are organized in three levels of care: primary
care (1,099 ambulatory establishments; 474 are rural), secondary care (126
establishments with five basic specialties), and tertiary care (42 specialized
hospitals). Furthermore, the Dominican Institute of Social Security and the
Armed Forces have health care facilities of diverse complexity. During the
period 1996-2000, mental health services were expanded. At least 10 hospitals
incorporated beds for mental health patients, and 5 crisis intervention units,
community centers and 1 daytime care hospital. Care of persons with disabilities
is provided in more than 310 establishments, in public and private centers
of health care. There are many clinical laboratories, some of them of great
complexity, where quality has increased progressively. The state offers free
oral health services, especially those of preventive character and those of
low complexity and cost, with emphasis on maternal and child population.
Health inputs: The
country has 51 hospital pharmacies, 1,937 community pharmacies, 740 popular
drugstores, 100 national laboratories that produce drugs, and 682 warehouses
for storage and distribution. In 2000, 70% of the products were imported.
Human resources: In 2000, the country had 15,679
physicians (19 per 10,000 population), 2,603 professional nurses (3 per 10,000),
12,749 auxiliaries or technical personnel of nursing (15 per 10,000), 7,000
dentists (8 per 10,000), and 3,346 trained pharmacists. There were several universities
for health professionals, recognized by the National Board of Higher Education:
9 schools of medicine, 6 schools for training nurses and technicians, 7 for
dentists, 4 for pharmacists. The number of nurses that graduates from the university
(70 per year) is very low relative to country's needs. Fifty- three medical
residency programs are carried out in 15 teaching hospitals with 20 specialties
and six subspecialties. Four universities offered five public health-related
programs and five had master's degree public health programs.
Health research and technology: Most research
has been carried out in the Maternal and Child Health Research Center . There
are a growing number of institutions that offer access to technical literature
through the Internet. There is a Virtual Health Library, but less than half
of the eight libraries in the Hospital Library Network have access to Internet.
Expenditure and sectoral financing:
In 1996, the total expenditure per capita in health was US$ 111 (6.5 % of
GDP) and as there were no significant structural changes between 1996 and
2000, it was assumed that the level remained stable over the period. The private
sector finances the majority of health costs - 55% come directly from households,
75% of which have no insurance nor pre-payment mechanisms. The public sector
allocates 64.5% of its budget to wages. The budgetary execution for the Secretary
of Health in 1999 was 80%.
External technical and financial cooperation
in health: International cooperation continues
to be very active, where PAHO, UNICEF, UNDP, UNPF, FAO, and UNAIDS stand out.
In regard to bilateral aid, USAID has committed US$ 25 million for 2000-2004
and the European Union initiated a four-year project of EU$ 13.5 million,
in 2000. Also, many nongovernmental organizations collaborate in local projects.
The World Bank and the IDB finance two projects related to decentralized health
management.
