Advances in health insurance coverage for the poor in the Dominican Republic

Background In 2001, the DR set up a social health insurance program with three different risk and financing pools for formal workers, independent or informal workers, and non-working poor and chronically disabled. USAID, through Abt's REDSALUD project, provided technical assistance in the development of this program.

Methods Managed by the National Insurance Fund (Seguro Nacional de Salud – SENASA), a semi-autonomous agency, the “subsidized” family health insurance program is funded by tax-based per capita contributions allocated by the government on behalf of the uninsured. These allocations are part of targeted social welfare subsidies made using geographic targeting of high-poverty areas and a poverty assessment tool. Families in the lowest two income levels are eligible for enrollment in SENASA after verification by community-based committees. Enrollees receive a SENASA card and may attend government clinics and hospitals free of charge. SENASA currently transfers funds to MOH service providers through performance agreements to supplement salaries, drugs, and supplies. In the future, SENASA will sign contracts with MOH providers.

Results In 2004, SENASA covered approximately 85,000 individuals. By the end of 2006, coverage increased to 513,641, a 600% increase, or 6% of the total population. The target is to cover 35% of people under poverty. In addition to increased enrollment, SENASA has strengthened institutional capacity, including implementation of information systems, contracting mechanisms, monitoring and control tools (audits), and customer service practices. SENASA is active in 4 regions with 16 provinces. Today, a greater number of poor in the DR have better opportunities to access quality medical care. Results suggest that this insurance program contributes to improving vertical equity in health financing.

Recommendations and policy implications Equity gains are important outcomes of health financing reforms. Efficiency is, however, another important result. Dominican reforms have thus far focused on improving equity. Through strategic purchasing, risk pools have the potential to introduce powerful incentives to improve provider structure and performance, along with efficiency and quality. We recommend that policymakers in the DR recognize this positive externality of purchaser-providers schemes and move towards greater accountability in health financing.