The Dominican Republic: economic and social factors that influence access to health
service delivery by the Family Health System of the Dominican Social Security System
Leticia Martinez Martiñon1
This work focuses mainly on one component of the Dominican Social Security System (DSSS), which is
the Family Health Insurance, with the general goal of determining which economic and social factors
may be influencing access to universal coverage of the population living in the Dominican Republic, as
presented by Law 87-01 that created the current Dominican Social Security System.
Access to the benefits of health services can be analyzed from two standpoints: a first, based on the
concept of population coverage by the Family Health Insurance, and from the perspective of the
population that is excluded by this.
A second axis, it to determine whether the population covered by the FHI demands health services,
given the existing co-payment limitation.
In the Dominican Republic, the law poses three financing regimes within the Family Health Insurance:
the Contribute Regime, the Subsidized Regime and the Subsidized Contributive Regime. Each has its own
features and target population to be insured. As the Subsidized Contributive Regime is not
implemented, we can initially visualize a FHI that does not cover the whole of the population living in
the Dominican Republic.
The conceptual delimitation for identifying the target population to be insured by each financing regime
is based on Law 87-01. From this legal and conceptual framework it is possible to determine that not
only the target population to be insured by the Subsidized Contributive Regime is unprotected by the
Family Health Insurance, but also that there is a target population to be insured by the Contributive
Regime and the Subsidized Regime that for some reason is not affiliated.
Throughout the implementation of the Family Health Insurance, it is possible to observe some
limitations in conceptual terms that may be having an influence in the coverage of population by the
currently implemented insurance regimes. The concept of "family nucleus" (outlined by law) is a key
element for having all members of a household included in the FHI.
The target population to be insured by the Subsidized Contributive Regime is a heterogeneous group,
and therefore said regime has to visualize concrete elements for its implementation, rather than
regarding the State as a subsidiary figure, considering a sole contribution rate.
Before implementing the Subsidized Contributive Regime it would be necessary to consider the
structure of the family nucleus, beyond what is defined by the Contributive Regime, as there could be
overlapping of coverage for households, between the Contributive Regime and the Subsidized
Contributive Regime, or exceptions would need to be made so as to avoid duplicating efforts (and their
respective costs) for administrating the granting of said coverage.
1
Actuary by the Faculty of Sciences, UNAM. Post-graduate studies in Demography (ECLAC-University of
Costa Rica and Statistics (INEGI-CIMAT). Second generation graduate of the Master´s course in Actuarial
Management of Social Security. Current Director of the Office of Actuarial Studies and Statistics of the
Superintendency of Health and Labor Risks. Teacher of actuarial matters, INTEC.
For instance, there is currently a target population of the Subsidized Contributive Regime (self-employed
workers) that does not contribute to the Dominican Social Security System. The Family Health Insurance
in the Contributive Regime benefits male or female life partners or direct dependants of an active
contributor of the Contributive Regime. In this sense, they do not contribute to the SDSS, although they
may work and have fixed income.
Within the Contribute Regime, the population with lower income makes little use of services, but when
they do, the amount of an "accident" is larger, not only as a result of the perception of "disease" but
because they do not have the necessary resources to have access to the required service. Expenditures
may sometimes represent over 50% of the monthly income received in the household. The frequency of
use of health services and the high "accident rate" (amount covered per type of service) is differentiated
by salary scales within the family nucleus.
It cannot be said that the National Health System has undergone a strong transformation so far, which
leads us to perceive it as a fragmented public and private system, as opposed to an Integral Healthcare
System, where the whole of the population receives the same quality of healthcare, regardless of who
is paying for the bills: the Ministry of Health, the Dominican Social Security System or individuals.
Universal access to health is a right of the population in a country, stated by each national Constitution.
Healthcare should not depend on affiliation to a financing regime of the Social Security System.
At the beginning of this research work, it is possible to find brief history of how coverage of health
services has been strengthened through an emergent Social Security System, that clearly shows that
before Law 87-01 health coverage was the responsibility of private insurances or One-to-one Medical
Matching Payments in presence of an Dominican Social Security Institute that is completely weakened in
terms of management and operation. This is a key element to understand why some public companies
do not contribute to the DSSS and why some private companies prefer to pay a corporative plan to
expand health coverage of the FHI, or to guarantee access to care through a complementary plan.
The National Health System in the Dominican Republic undergoes an apparent fragmentation where the
institutions in charge of guaranteeing that the whole of the population in the country has access to
health services are not able to coordinate the necessary actions in that direction.
The Family Health Insurance is a sub-system that has to act in line with the guiding axis of health policies
in the Dominican Republic, so as to guarantee that service coverage and procedures meet the
epidemiological profile of the country, while regarding the Basic Health Plan as something more than a
catalogue of products that can be accessed by anyone without a necessary clinical history.
The National Health System still has to manage the implementation of primary care centers able to
respond to the demand of the population in the country.
The integration of the National Health System in practice may bring about an efficient use of resources.
It is estimated that by December 2013, the Expenditure in Health was of 2.47% of the GDP, where 1.28%
2
3
of the GDP corresponds to the Central Government Expenditure and 1.19% to the DSSS . That is, we
know that 1.19% provides healthcare to 51.4% of the population in the country within the Dominican
Social Security System, but we do not know which population supports 1.28% of the Central
Government Expenditure in relation to healthcare; maybe the State is duplicating its financing for
2
Expenditures in Health. Current Expenditure: includes payment to personnel that provides direct healthcare to people,
contributions to social security (does not include transfers for the SR), non.personal Services, supplies and materials. Expenditure
made by all public institutions linked to healthcare of people. MISPAS, F.F.A.A., PN, DSSI and other public institutions.
3
It only includes expenditures in health. (Health Services benefits for People Affiliated to the Contributive Regime, the Subsidized
Regime, the Special Plan for Pensionists and Retiree and Traffic Accidents).
healthcare, as the population of the Contributive Regime may be using public services at no cost, when
the Contributive Regime should actually be paying for the bills. Through ENHOGAR 2012 it was possible
to see that the population from birth to 4 years of age has less access to health services of the FHI,
confirmed by the estimation of population coverage that includes age and gender groups; statistics
result from the Family Health Insurance itself.
In demographic terms, the mortality rate of the population from birth to 4 years of age is among the
highest in the country, making it important to set actions so that health coverage for this population is
indeed universal, so as to guarantee healthier generations while also decreasing mortality rates.
Coverage of health services in the poorest regions in the country is still limited, as it is necessary to focus
on affiliation, in spite of advances made by the Subsidized Regime.
Co-payment to be covered by the population of the Contributive Regime is a limitation, especially for
those families where the monthly salary is not enough to cover for co-payments that may represent
more than their monthly payment. The concept of "Subsidy" within the Contributive Regime should be
reviewed, as the lesser-income population is not able to make the same co-payment as the population
with higher income within the same financing regime.
A differentiated co-payment should be established according to the contribution made by each
contributor to the FHI; when co-payment in absolute terms is larger than the contribution made by a
contributor through collection, the former should not be paid or a maximum monthly payment should
equal the monthly contribution. For instance, if 9.3% of the contributor’s salary represents RD$500,
that person cannot make a co-payment that is larger than said amount per month.
Co-payment in the Dominican Republic is generating limitations in timely access to healthcare. The
population of the Contributive Regime is delaying healthcare as it depends on having money to pay for
it. Not caring for a health problem since its beginning becomes a control problem at a later stage,
where the final outcome is the deterioration of health.
Another key element is that the Family Health Insurance does not have a fund fed by a percent of the
collection of contributions, which undermines the financial sufficiency of collection at a given moment.
This applies for the Contributive Regime, but should also be considered for the population subsidized by
the State.
In light of the results of ENHOGAR, it was possible to note that there are self-employed workers whose
healthcare is subsidized by the Contribute Regime, for being the life partners of the title contributor that
maintains the family nucleus. This has to be taken into account, as this is the case of working
populations that, as the Subsidized Contribute Regime is not in force, they are benefited by the
Contributive Regime without the corresponding contributions.
The efficient use of resources of the Family Health Insurance would be larger if the risk-management for
healthcare of the insured population is applied. Work has been done more in terms of establishing
indicators that allow measuring financial management than in terms of health management.
The Health Information System that supports the analysis of the individual contribution is more aimed at
studying the cost and frequency of use of services provided to the affiliate population than to outlining
the epidemiological profile of the insured population. It is not possible to know the impact in health of
the FHI, or even which pathologies are being cared for by the FHI in absence of a diagnosis.
ENHOGAR 2012 clearly states that there are homes that may have more than one family nucleus, under
the concept outlined by Law 87-01, as the family nucleus is defined by the age of children, and the direct
family ties.
This may generate exclusion as people from the same household may be affiliated to a same financing
regime that excludes a family member as he or she does not comply with the requirements to be
included in any existing financing regime, or cannot be included even through payment made by the
active contributor as the family relation does not allow it.
The Family Health Insurance is not regarded as an insurance that covers healthcare during the passive
stage of contributors in a regular manner. A fund created by contributions made during an individual’s
active stage in life, may guarantee healthcare during the passive stage of life.
There is sufficient information within the Dominican Social Security System so as to expand some of the
line of actions outlined in this work. But it is important to continue strengthening the sharing of
information that allows a closer look at the profile of the population that has access to healthcare
services provided by the Dominican Social Security System.