As the global health community has focused its attention on infectious disease, maternal mortality, and malnutrition, the insidious effects of chronic illness have grown to tragic proportions among the world’s most impoverished people. In 2005, non-communicable diseases (NCDs) – especially cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes – caused 35 million deaths, or 60% of all deaths worldwide. Of these, 80% were in low- and middle-income countries like the Dominican Republic. Despite this burden on the poor and a projected 17% increase in deaths from NCDs over the next 10 years, NCD prevention and treatment has lagged as a priority on the global health agenda.
On a global scale, the number of deaths caused by chronic illness is more than twice the number caused by HIV/AIDS, tuberculosis, malaria, maternal conditions, and malnutrition combined. However, the relative differences in death rates are significantly more narrow in low-income countries like the Dominican Republic than in high income countries. The burden of illness in the DR may be illustrated through disability-adjusted life years (DALYs) per 100,000 population:
- Communicable, maternal, perinatal, and nutritional deficiencies: 5,798 DALYs
- Infectious and parasitic diseases: 2,897
- Perinatal conditions: 1,243
- Maternal conditions: 611
- Non-communicable diseases: 13,390 DALYs
- Neuropsychiatric disorders: 3,585
- Cardiovascular disease, including hypertension: 3,317
- Cancers: 1,384
- Diabetes: 667
In comparison, in the US, DALYs due to communicable diseases total 896 per 100,000 population, and 10,481 for non-communicable diseases. Mortality rates and risk factor prevalence rates further demonstrate the gravity of the NCD burden in the DR. In fact, NCDs are now the leading cause of death in the Dominican Republic, accounting for 68% of total mortality:
(Graphic taken from the World Health Organization, Dominican Republic NCD Country Profile, 2011)
At the same time, however, the Dominican Republic lags behind the United States and the Latin America & Caribbean Region as a whole on many basic health indicators. Maternal and under-five mortality ratios are nearly four times as high as those of the United States. Preventable infectious diseases such as cholera and dysentery continue to affect the Dominican Republic’s more than 9.4 million people, especially the 27% of the rural population that lacks access to any potable water services, and the 7.5% that lacks any latrines or other sanitation facilities. Such disparities underscore the need for initiatives that improve access to and the quality of basic healthcare and public health services:
(Statistics taken from the United Nations Development Programme 2011 Human Development Report)
The Dominican Republic spends only 5.9% of GDP on health, in comparison to 7.6% for the region and 16.2% for the United States. More than 50% of the entire population lives below the national poverty line. Measures of income inequality demonstrate a significant gap between the poor and wealthy — while gross national income per capita (in US dollars) is $8,087, the Gini coefficient is 48.4 (a value of zero would represent absolute equality, a value of 100 absolute inequality). In comparison, income per capita in the United States is calculated as $43,017, and the Gini coefficient is 40.8.
The dual burden of infectious and chronic illness among the poor demands a comprehensive response at the individual, community, and national levels. Diagonal programs – combining vertical responses to address specific illnesses, and horizontal responses designed to reach broad populations – can play an important role in treatment, prevention, and quality of life improvement. In order to most effectively address this epidemiological transition, health systems must be strengthened and reoriented to ensure equitable focus on chronic illness, including efforts to address affordable access to medication, long-term care support, and socioeconomic factors.
The Dominican Republic’s health system is working to respond proactively to this shift. The 2001 General Health Law, which put primary health care as a central goal, was written with an ambitious vision, but implementation has been slowed by lack of coordination, health infrastructure, and resources. The Ministry of Health recognizes the problem of NCDs and indeed has funding available for NCD treatment, control, prevention, and health promotion, but to date there are no integrated programs that address the spectrum of NCDs and their risk factors. At the same time, the UN Summit on Non-Communicable Diseases in September 2011 — only the second UN Summit in history to be dedicated to a health issue, the first having been HIV/AIDS – reflects a growing recognition that the burden of NCDs worldwide has reached epidemic proportions, contributing significantly to morbidity and mortality, poverty, and health disparities. This confluence of factors points to the fact that there is now a window of opportunity to focus on chronic illness management within the context of public health and health systems strengthening.
1. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases. Geneva: World Health Organization, 2008.
2. Preventing chronic diseases: a vital investment. Geneva: WHO, 2005.
3. Global Burden of Disease. Death and DALY estimates for 2004 by cause. Dominican Republic. Geneva: WHO; 2008.
4. NCD Country Profiles. Dominican Republic. Geneva: WHO, 2011.
5. Health Systems Profile Dominican Republic: Monitoring and Analyzing Health Systems Change. Santo Domingo: Pan American Health Organization. 2007.
6. Indicadores Básicos de Salud:Dominican Republic 2008. Santo Domingo: Pan American Health Organization. 2008.