First published in ITIJ 99, April 2009
The Dominican Republic continues to be a popular destination for holidaymakers from all over the world. Tatum Anderson reveals how well the country is prepared to deal with those visitors who require emergency medical attention
The first hospital to be built in the Americas appeared on the Caribbean island of Hispaniola, a few years after Christopher Columbus’ arrival in 1492. Indeed along with a university, the hospital became the heart of Santo Domingo, one of the first cities of the New World and today the capital of the Dominican Republic.
The old colonial portion of Santo Domingo still draws tourists from all over the world. Indeed tourism is one of the two most important contributors to the economy, the largest in Central America and the Caribbean. Over three million tourists visited the country in 2002, of which more than half were European, while most of the rest came from North America.
Most tourists visiting the Dominican Republic head for the island’s idyllic Caribbean beaches, especially the large resort developments of Puerto Plata on the north coast and the east coastal resorts of Punta Cana and Bávaro. As a result, there are many medical facilities located in these areas, used to dealing with the needs of international patients. Indeed patient referrals, transport to hospitals, healthcare services and billing processes are all very well established. And many Dominican doctors working in such facilities also have an international education – often training in Mexico, the US and Spain.
But is healthcare provision in these areas all it’s cracked up to be? What of healthcare provision in the rest of the country? And how does the public system compare to the growing private sector?
Quality at a price
Experts on the ground agree that good doctors and facilities are commonplace in such areas. There is also a good range of over-the-counter medicines, including some normally only available on prescription in the countries such as the UK. Private healthcare facilities in these areas are favoured by assistance companies and governments alike, however, and the Foreign & Commonwealth Office in the UK says private medical facilities in Dominican Republic offer reasonable to very good standards of services. Mondial Assistance, which visited 10 facilities across the Dominican Republic in November 2007, concurs. “We prefer to direct our customers to private facilities in the Dominican Republic, which are easily accessible in touristic zones and capable of providing primary medical care,” says Lisette Laso, a provider network specialist at Mondial Assistance.
The two main private healthcare players in resort areas are Grupo Rescue and Grupo Hospiten. Both have established working doctors’ surgeries that operate within hotels, or consultorios. These surgeries are one part of an end-to-end service for guests that also includes everything from ambulance services that transfer patients, to health facilities. “They have placed themselves in a position of becoming very much a one-stop shop of sorts,” says Laso, who adds that both companies are familiar with its billing processes and the way it conducts case management for its clients.
"private medical facilities in the Dominican Republic offer reasonable to very good standards"
Grupo Rescue is a domestic firm with a wide range of full-medical facilities including independent outpatient clinics and a major facility, called Centro Médico Punta Cana, located in the heart of the eastern tourist resort. Another of its facilities is Centro Médico Bournigal in Puerto Plata in the north of the country. Perhaps the better known international brand, though, is Grupo Hospiten, the private Spanish hospital group that has over 1,000 beds in major cities and tourist resorts in Spain, the Dominican Republic and Mexico, and cares for over 400,000 patients a year. Each facility, including those in the Dominican Republic, have achieved similar European quality standards, says the company. Many of its services, such as the hotel doctors’ services, and ambulance services, are run by the company under the brand Clinic Assist in the Dominican Republic. The company also runs a network of doctor’s surgeries in towns such as Bavaro, Juan Dolio and Boca Chica.
Generally, though, Hospiten Group has two main facilities in the Dominican Republic. Hospiten Bávaro, based in Punta Cana, was the first hospital built by the Hospiten Network outside Spain. Opened in 2000, it has 70 inpatient beds and many other services including operating theatres, ICU, X-Ray and a Haemodialysis Club. The other hospital was built three years later in the capital city. This facility, Hospiten Santo Domingo, has 58 inpatient beds and similar facilities.
There is a downside to these groups and other private facilities, however, say assistance experts. Treatment in the Dominican Republic can be incredibly expensive because there are no laws to limit or restrict the fees charged by doctors, ambulances, or hospitals. “Prices are high in comparison to the level of care,” says Mondial’s Laso. Many doctors charge their professional fees separately from hospitals. Like their US counterparts, doctors serve as Treating Medical Officers, which means being responsible for both the admission of a patient and their care whilst in hospital.
Good quality and cheaper healthcare facilities exist in the southern capital, Santo Domingo, which is home to around three and half million inhabitants. Here, it’s possible to find state-of-the-art emergency services, general practice, and clinical laboratories, as well as larger medical facilities offering secondary and tertiary treatment. Steve McQueen, president of the Dominican Assistance Network, which serves many international companies including Mondial Group, Europ Assistance Group, and Spanish Europea de Seguros recommends Santo Domingo hospitals including the private Clinica Abreu and a specialist heart facility, Corazones Unidos. Public hospitals in the capital are also generally good he says.
"treatment in the Dominican Republic can be incredibly expensive"
Despite this, fewer tourists are treated in Santo Domingo because it is a fair way from the beaches – a drive of between three and four hours, says McQueen. In addition, many assistance companies prefer to keep their non-Spanish-speaking patients and friends in tourist areas where they are better able to communicate with staff. This is because many medical facilities in the Dominican Republic outside of such areas do not generally have English or German speaking staff.
On the mend
Regarding access to emergency care, there is an emergency 911 service within Santo Domingo, but its reliability is questionable says the US state department. Getting to a good hospital, however, is not always easy because roads can be poorly maintained and the country also has one of the worst road accident records in the world; there's a fair amount of drink driving, say residents.
That is not to say there are not ambulance services. A whole host of private companies operate throughout Dominican Republic. However, many expect payment for their services in full before they transport patients. That can be a challenge for those experiencing a medical emergency. One example is ProMed, a private, nationwide ambulance service that operates in Santo Domingo, Santiago, Puerto Plata and La Romana, according to the US Department of Commerce. Of course, not all ambulance firms operate like this, including Movimed, which is used by Dominican Assistance Network.
But, crucially, there are currently no commercially available air ambulances based in the Dominican Republic, says McQueen. This is because many domestic air ambulance companies have now gone out of business. McQueen uses a US air ambulance provider called National Air Ambulance, which has aircraft based in Miami, a flight of one and half hours away from the Dominican Republic, and Puerto Rico, which is only half an hour away. Air ambulances can be made available within three hours’ notice, he says.
Overall, assessing the level of care in the Dominican Republic is difficult because no hospitals in the country have been accredited by the internationally recognised Joint Commission International. Outside major conurbations, however, public health services in the country have been regarded as very poor by health professionals worldwide, so there is a vast inequity with regards to access to quality public health services. Such hospitals have often suffered from poor hygiene, overcrowding, and have lacked supplies. There have also been high levels of corruption, and absenteeism amongst staff is rife. In addition, many rural hospitals are staffed by inexperienced doctors, forced to work in the social system for a year as part of their training, before fleeing, typically, to the private sector.
The system, which has been woefully underfunded in the past, is put under extra strain by the sustained influx of Haitians crossing over the border. The Dominican Republic, with its nine-million-strong population, occupies the eastern two-thirds of Hispaniola. The rest of the island is occupied by the neighbouring state of Haiti.
International travellers falling ill off the beaten track, therefore, might encounter the public health services experienced by many ordinary Dominicans – in fact, half the population lives in rural areas. “In a big city, facilities are very good, but if you leave the main cities some of the facilities are very basic,” says McQueen. Furthermore, the US State Department is not impressed by the country’s blood supplies, which it says are often limited at both public and private hospitals even in emergencies.
The most basic problems, from the point of view of assistance companies and travellers, is that many of the more out-of-the-way clinics are less likely to be familiar with treating international patients, or with insurance and direct billing processes. In fact, many rural clinics refuse to deal with assistance companies at all – international or domestic – and demand upfront payment from patients for treatment.
Inequities in the Dominican hospital system have been entrenched by the different healthcare services systems present throughout the country. The private system, of course, has serviced the upper echelons of Dominican society. According to the US Department of Commerce, there are more than 36 insurance companies offering medical coverage to approximately ten per cent of the Dominican population. And there is a growing trend for well-to-do Dominicans to travel to the United States for medical treatment. Richer citizens travel to nearby Florida, New York, Texas, and Puerto Rico. Some of the major private hospitals in Dominican Republic even have patient referral contracts with US hospitals. The public health care system, on the other hand is free. It is administered and paid-for by the government and provides services to around 75 per cent of the population, most of whom are uninsured. The government owns approximately 150 public hospitals and health centres up and down the country. However, as shown, there is little or no guarantee of access or quality, say experts.
As well as public and private services, the Dominican government has operated a third service specifically for workers. This Social Insurance Service (SIS), which has been managed by the government trough its Instituto Dominicano de Seguro Social (Dominican Institute for Social Insurance) has been funded through contributions from employers. The system directly funded specialist SIS hospitals but is seen to provide poor services by many Dominicans in work. They often choose not to use it.
"A whole host of private ambulance companies operate throughout the Dominican Republic"
A huge and ambitious reform of the health sector is changing the picture dramatically, however. Aid money from the US, Europe and Japan, is been used to transform the healthcare that poor Dominicans receive. In recent years, law reforms have effected a change in the structure of services, and have resulted in a compulsory basic universal health insurance plan. The reforms are also improving access to healthcare that workers in the Dominican Republic can expect. They are now able to contribute to a social insurance plan that can be used to buy private healthcare services for themselves and their families, rather than relying on government-run SIS facilities. That means more and more ordinary Dominicans are using private healthcare services, including the big groups more often seen at the resorts. “People who are in work and their dependents, can go to big clinics like Hospiten,” says McQueen.