Evaluation of REDSALUD and 
USAID/DR Strategic Support to 
Reform of the Dominican Health 
Sector 
Submitted by: 
Deloitte Touche Tohmatsu Emerging Markets, Ltd. 
(Emerging Markets Group) 
In Association With: 
The International Science and Technology Institute 
(ISTI) 
Under Contract No.: 
GHS-I-800-03-00031-00, Order No. 02 
Date: 
May 28, 2004 
Evaluation of REDSALUD and USAID/DR Strategy i 
TABLE OF CONTENTS
EXECUTIVE SUMMARY........................................................................................................ 1
I. INTRODUCTION ....................................................................................................... 3
II. OBJECTIVES AND METHODOLOGY OF THE EVALUATION ............................................. 4
A. OBJECTIVES........................................................................................................ 4
B. METHODOLOGY................................................................................................... 4
III. CONTEXT OF THE REDSALUD REFORM .................................................................. 5
A. ECONOMIC ENVIRONMENT.................................................................................... 5
B. POLITICAL ENVIRONMENT..................................................................................... 5
C. THE HEALTH SYSTEM .......................................................................................... 5
D. PROJECTS THAT SUPPORT THE REFORM PROCESS ................................................ 7
E. NEW LEGISLATION APPROVAL .............................................................................. 8
IV. STRUCTURAL PROBLEMS THAT INITIATED THE REFORM PROCESS ............................ 10
V. THE REFORM’S RESPONSE TO THESE HEALTH CHALLENGES ................................... 12
VI. MAIN ACHIEVEMENTS OF THE REFORM PROCESS.................................................... 15
VII. FACTORS THAT HINDER IMPROVEMENTS OF THE SYSTEM ........................................ 17
VIII. COHERENCE, VIABILITY AND SUSTAINABILITY OF THE PROCESS .............................. 19
IX. USAID/DR HEALTH STRATEGY............................................................................. 20
X. THE REDSALUD PROJECT AND ITS IMPROVEMENTS.............................................. 21
A. THE ORIGINAL DESIGN OF THE REDSALUD PROJECT......................................... 21
B. THE REDSALUD STRATEGY............................................................................. 21
C. MAIN FINDINGS OF THE REDSALUD PROJECT .................................................... 23
XI. RECOMMENDATIONS FOR THE SHORT, MEDIUM, AND LONG TERM............................ 26
BIBLIOGRAPHY................................................................................................................ 31
ANNEXES........................................................................................................................ 32
ANNEX I LIST OF INTERVIEWS ...................................................................................... 33
ANNEX II THE DOMINICAN GOVERNMENTS AND HEALTH REFORM ................................... 36
ANNEX III MAIN RESULTS OF THE REFORM PROCESS ...................................................... 37
ANNEX IV PRINCIPAL STRUCTURAL PROBLEMS OF THE DOMINICAN HEALTH SYSTEM,
STRATEGIC APPROACH OF THE REFORM AND GENERAL ATTAINED RESULTS....................... 40
ANNEX V USAID OPTIONS TO SUPPORT THE REFORM IN THE MEDIUM TERM .................. 44
EVALUATION TEAM
Dr. Cesar Chelala 
Dr. Jaime Arias 
Ms. Cindi Cisek 
Mr. Alejandro Moline 
Ms. Karen Cavanaugh (USAID) 
LIST OF ACRONYMS
AD Acute Diarrhea 
ARI Acute Respiratory Infection 
ARS Health Risk Administrators 
CERSS Executive Commission for Health Sector Reform 
CMS Dominican Medical Association 
CNS National Health Council 
CNSS National Council for Social Security 
CONEP National Council of Private Companies 
DIDA Department of Information and Defense of Affiliates 
DPS Provincial Health Department 
DR Dominican Republic 
ENDESA Demographic and Health Survey 
GDP Gross National Product 
HIV/AIDS Human Immunodeficiency Virus / Acquired Immune Deficiency 
Syndrome 
IADB Inter-American Development Bank 
IDSS Dominican Social Security Institute 
INSALUD National Health Institute 
INTEC Technology Institute of Santo Domingo 
MRHSP Modernization and Restructuring of the Health Sector Project 
OAU User Care Offices 
OCT Office of Technical Coordination 
ORU Oral Rehabilitation Unit 
PAHO Pan-American Health Organization 
PAI Broad Immunization Program 
PCU Primary Care Unit 
PHSDP Provincial Health Services Development Project 
PROMESE/CAL Essential Drugs Program/Center for Logistic Support 
PROSISA Program of Reinforcement of the Health System 
SENASA National Health Insurance Agency 
SESPAS Secretariat of State and Public Health and Social Assistance 
SISASRIL Superintendence of Health and Labor Risks 
TB Tuberculosis 
TSS Social Security Treasury 
UMDI Modernization and Institutional Development Unit 
USAID United States Agency for International Development 
Evaluation of REDSALUD and USAID/DR Strategy 1 
EXECUTIVE SUMMARY
The United States Agency for International Development (USAID) collaborates with the 
Dominican Republic (DR) in various areas. In the health sector, its strategy is directed towards a 
sustainable improvement of the health of the most vulnerable populations through various 
projects. One of these projects is REDSALUD, a 5 year project initiated in July 2000 with Abt 
Associates Inc. for an amount of US$13.3 million. The REDSALUD project seeks to support 
reform and decentralization within the Dominican Republic health sector. USAID hired Deloitte 
Touche Tohmatsu Emerging Markets, Ltd. and the International Science and Technology 
Institute (ISTI) to evaluate the strategy and activities implemented by REDSALUD. This 
evaluation was carried out in the Dominican Republic between March 16th and April 4th of the 
present year. The results of this evaluation are described in this document. 
Reform Context 
In the late 1980s a discussion of the possible reforms to the health and social security sectors in 
the DR was initiated; in the year 2001, Congress approved the 42-01 (Health Sector Reform) 
and 81-01 (Social Security Reform) laws. During the 1990s, the country lived in economic 
prosperity with an increase in the GDP above 6.5%, but in 2003 there was a currency crisis that 
generated difficulties in health financing and in the implementation of the new social security 
and health systems. 
Current Situation 
Although there have been improvements in some reform processes, this has not extended to all 
areas. For example, in the creation of a new regulatory legal framework, in the structure of the 
institutions designed under the social security law, and in the partial initiation of the subsidized 
regimen of Family Health Insurance in Region IV, there are a series of disturbing factors which 
raise doubts as to the imminent and complete initiation of the reforms. During the current year, 
presidential elections will be held in the country. These elections create uncertainty due to 
possible changes in government which, in turn, could affect the continuation of the reform 
process. In addition to these contextual factors, there has been a lack of clear leadership in the 
execution of these changes, and concern by some players as to the costs of the Basic Health Plan 
(PBS) and professional fees within the sector. 
Major Health Problems in the Dominican Republic 
The DR has a traditional health system characterized by low coverage, deficient quality of some 
services, fragmentation of financing plans and benefits, low insurance levels, high and unequal 
out of pocket expenses, inefficient use of resources, emphasis on hospital care and curative care, 
and very poor government regulation, control and surveillance. The evaluation team found that 
the main structural problems are: low coverage, inequity, a very centralized system with minimal 
autonomy in the regions and provinces, inefficiency due to poor management, and weaknesses 
in the public health programs. 
As result, the DR shows very high infant and maternal mortality rates, dissatisfaction of the 
users, simultaneous presence of illness and infections associated with poverty (AD, IRA, HIV-
Evaluation of REDSALUD and USAID/DR Strategy 2 
AIDS, Malnutrition, TB and others) while degenerative illnesses such as cancer, trauma and 
hypertension appear among the most common causes of doctor visits and hospitalization. 
Response of the Reforms 
The reforms are intended to address the most critical problems in implementing the following 
policies and measures: expansion of coverage and improvement of equity, strengthening of the 
supervisory body, regulation and surveillance, separation of functions, decentralization, changes 
in the financing of supply and demand; unification of insurance plans financing, collection and 
benefits; support of basic medical care; support of public health programs; improved efficiency 
and competitiveness, greater social participation in the system, application of efficient 
management tools and adoption of integrated information systems. 
Findings on USAID Strategy and the Activities of REDSALUD 
The evaluation team found that USAIDís strategy has been correct, coherent and viable, and that 
its sustainability depends on the reform course and the health policies of the country. The focus 
of USAIDís program is relevant and has been executed according to plan. In regards to 
REDSALUD, the evaluation team found that both the original design and the changes made 
during the course of the project were reasonable. The five demonstration generations of the 
project have worked adequately. There was clear satisfaction among the Health Region V 
provincial and regional employees, as well as the health authorities at the central level and within 
the social security system. In order to guarantee viability, some projects need to be further 
developed in the next two years and others need to be maintained for a longer period of time. 
Recommendations 
The short-term (2004 to 2005) recommendation for REDSALUD is to provide support to the 
new health sector authorities who may come in to office after August; to consolidate the 
achievements of Region V; to support the acquisition of personal identification documents for 
potential subsidized members; to ensure the sustainability of the activities undertaken and to 
systemize and share the successes of the program. 
For the medium-term, the recommendation is that USAID continues to provide support to the 
three lines of action: support to local management in Region V; support to the central level 
(SESPAS and new entities); and support in the political sphere. 
For the long-term, the recommendation to USAID is that prior to evaluation of the health sector 
in 2006, USAID continue to promote reform activities by maintaining its active participation in 
dialogues and supporting the most committed key players; coordinating efforts with other 
agencies; looking for synergies with other USAID programs; supporting the creation of ìThink 
Tanks;î and strengthening public health programs that target improvement of the health of the 
most vulnerable populations (such as reproductive health, maternal and child health, HIV-AIDS, 
etc). 
Evaluation of REDSALUD and USAID/DR Strategy 3 
I. INTRODUCTION
The reform process of the Dominican Republic Health Sector was initiated in the 1990s and its 
main goals were: extension of coverage, increased equity, and improvement of the quality of 
health services. In the year 2001, The General Health Law and the Social Security Law were 
approved, establishing a legal framework for future reforms within the sector. Afterwards, on 
November 1, 2002, the subsidized regimen of Family Health Insurance was initiated in the 
countryís Region IV. The subsidized regimen refers to the part of the national health system that 
includes individuals who qualify for subsidized health insurance. 
The United States Agency for International Development (USAID) collaborates with the 
Dominican Republic in various important areas and its strategy for the health sector focuses on 
sustained improvement in the health of vulnerable populations. In July 2000 USAID signed a 
five year, US$13.3 million contract with Abt Associates Inc. to implement the REDSALUD 
project. Designed to support the reform and decentralization of the Dominican health sector, 
REDSALUD contributes to USAIDís Fourth Intermediate Result (IR4) and national strategy 
aimed at increased efficiency and equity of basic health care services at the local level. 
USAID hired the firm Deloitte Touche Tohmatsu and the International Science and Technology 
Institute (ISTI) to evaluate USAID strategy for health sector reform and activities implemented 
by REDSALUD in contribution of this strategy. Deloitte Emerging Markets and ISTI formed an 
evaluation team, composed of four international consultants, a local specialist in health reform 
and an assessor from USAID with extensive experience in the health sector and the REDSALUD 
project. This team conducted its evaluation in the Dominican Republic from March 16th to April 
4th, 2004. 
Evaluation of REDSALUD and USAID/DR Strategy 4 
II. OBJECTIVES AND METHODOLOGY OF THE EVALUATION
A. OBJECTIVES
The objectives of the evaluation, specified in the Statement of Work are the following: 
1. Evaluate recent progress in the design and implementation of the reforms and point out the 
key problems of the Dominican health system, placing special emphasis on its relevance, 
coherence, viability and sustainability. 
2. Examine the relevance, coherence, viability and sustainability of the USAID strategy and the 
activities implemented by the REDSALUD project. 
3. Make short, medium and long-term recommendations that may be used to re-design or adjust 
the strategies and interventions supported by USAID. 
B. METHODOLOGY
The evaluation process began with the review and analysis of extensive documentation related to 
the reform sector. This included the General Health Law--which serves as the basis for creation 
of the new Dominican Health System of Social Security--as well as the main regulations and 
documents of the REDSALUD project, which included the plans, programming and results of 
yearly exercises. 
At the beginning of the evaluation, meetings with the USAID/DR and REDSALUD personnel 
were held, and a series of visits and in depth interviews were conducted with key players from 
the Secretariat of State of Public Health and Social Assistance (SESPAS), the National Council 
for Social Security (CNSS), the Superintendence of Health and Labor Risks (SISASRIL), the 
Board of Directors of the Department of Information and Defense of Affiliates (DIDA), the Pan￾American Health Organization (PAHO), the Dominican Medical Association (CMD), the 
Executive Commission for Health Sector Reform (CERSS), the National Health Insurance 
Agency (SENASA); the National Health Institute (INSALUD) and other relevant entities. In 
addition, managers from the World Bank, the Inter-American Development Bank, Prosisa and 
the European Community Program were interviewed in order to gain other perspectives and a 
fuller understanding of the issues. 
Once the evaluation team analyzed the information from these interviews, the team conducted 
Health Region V field visits in order to meet some of the local authorities, tour the clinics, and 
liaise with community organizations linked to the activities of the project. Furthermore, a 
provincial hospital in Health Region I was visited, with the purpose of comparing results, and 
provincial SESPAS employees were interviewed. See Attachment I for a list of interviews 
conducted. 
When the field information was processed and organized, meetings among the members of the 
evaluating team were held; a preliminary version of the report was written and a presentation to 
be shown to USAID/DR was prepared for receiving observations and suggestions. As a final 
step, this report was prepared. 
Evaluation of REDSALUD and USAID/DR Strategy 5 
III. CONTEXT OF THE REDSALUD REFORM
A. ECONOMIC ENVIRONMENT
According to information from the Dominican Central Bank, at the end of the 1990s, the 
Dominican Republic had a 9.4% economic growth rate, sustained by a strong flow of public and 
private investment. Health expenses (mainly private) remained at near 6.5% of the Gross 
National Product (GDP), yet no sustainable improvements were made in the principal health 
indicators. The current decade has not maintained the economic growth of the 1990s, and during 
2003 GDP declined 0.4% due to the depreciation of the national currency, the high cost of fuel 
and the banking crisis that shook the national financial system. 
The crisis and macroeconomic imbalance of the recent past forced the government to turn to the 
International Monetary Fund (IMF) on February 11 of this year. The IMF Board of Directors 
gave their approval to an agreement between the IMF and the Dominican Republic. This 
agreement presents several conditions and controls, which will impose restrictions and discipline 
in the fiscal and monetary sectors. Most importantly, it will necessarily affect the governmentís 
investments in social sectors and will negatively impact public spending in health. 
B. POLITICAL ENVIRONMENT
The Dominican Republic is a representative democracy with separation of the Executive, 
Judicial and Congressional branches. The country has made institutional advances after long 
years of dictatorship, becoming a more open political society, yet still shadowed by the interests 
of the political parties, particularly during the pre-electoral season. 
This political environment has a strong influence on the public sector, where many institutions 
are submerged in a functional lethargy during the pre-electoral season; for example, some 
officials leave their duties to become involved in political campaigns, which spreads an air of 
uncertainty throughout the sector. In 1991 the country enacted the law of Administrative Career 
and Civil Service, which sought to address some of these issues. However, the law has had a 
slow application, particularly in the health sector, due in part to the complexity of the human 
resources component. 
Last year, Congress eliminated the legal restriction to presidential reelection. Presidential 
elections will be held May 16 with the most likelihood of success among the candidates of the 
Dominican Liberation Party (PLD), the Dominican Revolutionary Party (PRD) and the 
Reformist Social Christian Party (PRSC). If a change in government should occur, a turnaround 
in the high echelons of the governmental institutions in the health sector is quite likely; these 
changes at the national level often reach the regional, provincial and local levels, and could 
affect the continuity of current reform activities. In Annex II we present a summary of the 
participation of the recent governments in the Dominican health sector reform process. 
C. THE HEALTH SYSTEM
ORGANIZATION OF SERVICES
The health services system, a mixed one by nature, is made up of public institutions, the private 
sector and NGOs. The public sector includes a series of institutions such as the Public Health and 
Evaluation of REDSALUD and USAID/DR Strategy 6 
Social Assistance Secretariat (SESPAS), the Essential Drugs Program/ Center for Logistic 
Support (PROMESE/CAL), and the Dominican Social Security Institute (IDSS), as well as new 
entities established by the 2001 law. SESPAS is a government department organized at the 
central, regional and provincial levels. It encompasses nine Health Regions, over 30 Provincial 
Health Directorates, and the Directorates of Health Areas. 
Urban and rural clinics and physiciansí offices constitute the first level of care. These health 
facilities are the center of the PCUs (Primary Care Units) of which there is one or more per 
facility. The second level of care includes the municipal and provincial hospitals, and the third 
level is made up of regional hospitals. According to SESPASís records for 2002, there were six 
specialized hospitals, eight regional hospitals, 107 municipal hospital, 22 provincial hospitals, 
615 rural clinics, 90 medical dispensaries, 30 health centers and 159 physiciansí offices. 
CARE MODEL
The current predominant care model in the country is curative, with an emphasis on 
hospitalization. Health establishments offer a total 12,057 beds, i.e., one bed per every 720 
inhabitants. It is estimated that in 2002 there were an average of nine doctors for every 10,000 
inhabitants. These statistics indicate that good quality public heath services could be provided to 
the entire population. However, even though the average number of doctors is adequate in 
general terms, this resource is concentrated in urban centers. In regards to professional nurses, 
there are too few, and a large percentage of them are not adequately qualified for their duties. 
The public sub-sectorís care model has been characterized by the free provision of health 
services through state funding, even though other care provision financing models have been 
introduced, such as a cost-recovery fee. Expenditure analyses show that users are obligated to 
make considerable out of pocket contributions. Another issue is that public health care is 
designed for groups in extreme poverty, but a large percentage of the non-poor population uses 
these free public services, especially in cases of hospitalization, surgery and high-cost 
treatments. 
The country has an important private health care provision sector that is fundamentally supported 
by direct payment. Over the past few decades, a pre-paid care system has been growing, mainly 
through medical stipends that also serve as insurance. While SESPASís facilities expand 
throughout the national territories, the IDSS, some NGOs and private clinics primarily focus 
their activities in the countryís urban areas. The NGO sector plays an important role in the 
provision of primary care services, particularly in sexual and reproductive health programs, 
aimed towards low-income populations in marginal areas. 
CURRENT HEALTH SITUATION
The Dominican Republic has experienced a reduction in morbidity by transmissible diseases. 
According to the Pan-American Health Organization (PAHO), the five main reasons for seeking 
medical consultation are Acute Respiratory Infection (ARI), Acute Diarrhea (AD), Arterial 
Hypertension, pregnancy and skin diseases. Malnutrition remains a serious problem among the 
most poor, particularly children, and the rate of diarrhea and respiratory diseases remains high 
among children under five years of age. The infant and maternal mortality rates are higher than 
those of other countries with a similar degree of socioeconomic development. According to 
Evaluation of REDSALUD and USAID/DR Strategy 7 
official sources, the estimated infant mortality rate is 34.4 per 1,000 born living for 2000-2005 
(Basic Health Indicators 2002. Dominican Republic, SESPAS, PAHO). 
Maternal mortality is a useful indicator in measuring not only the health situation, but also the 
access to and quality of care. It is important to point out that despite the fact that approximately 
98% of births are institutional, the maternal mortality rate remains very high. According to the 
statistics provided in the 2002 Demographic and Health Survey (ENDESA) mortality during the 
first year of life for 1997-2002 was estimated at 31 for every 1,000 born living and the rate of 
maternal mortality for the period 1992-2002 was 178 for every 100,000 births. Inadequate 
nutrition in pregnant women causes a high percentage of low birth weight babies, which reduces 
their chances of survival. 
The health sector shows a series of inequities in insurance coverage, levels of expenditure and 
quality of service. For instance, only 4.2% of the low-income population have health insurance 
coverage, compared to 41% coverage for these services in the mid to high level income 
populations. In regards to expenditure in health, the poorer populations spend a greater 
percentage of their income on health services than do the richer populations. For example, it is 
estimated that about 30% of the income of the poorest homes are spent on health services, which 
is higher than in the richer sectors. In addition, it should be noted that 30% of the population in 
the higher income sector uses SESPASís services, while at the same time 30% of the poorest 
fifth of the population have to pay for services in the private network. By 1995, the main sources 
for health financing in the Dominican Republic were each homeís personal finances (75.1%), 
with the State having a very low level of participation (14.4%). The low coverage from health 
insurance, (particularly for the poorest individuals) the high out of pocket expenses for health 
care, the high rate of diarrhea and respiratory diseases in children under five, and the high infant 
and maternal mortality rates contributes to an environment of inequity and low quality of 
services. 
D. PROJECTS THAT SUPPORT THE REFORM PROCESS
World Bank (WB) 
The World Bank provided support to health reform in the Dominican Republic with the 
Provincial Health Services Development Project (PHSDP). This project included a $30 million 
loan and a $12 million grant for a total value of $42 million; it began in 1998 and is scheduled to 
end June 30th, 2004. The project has three components: the first is to finance new ways of 
offering basic services to unattended populations; the second is to develop mechanisms to 
strengthen financing and resource allocation in the health sector and to promote local hiring; and 
the third is to support SESPASís policymaking and service regulating functions. The project is 
applied intensely in Heath Region IV. The project has aided SESPASís vaccination efforts, 
hospital rehabilitation, training in hospital reform, introduction of a computerized information 
system, strategic planning for the reorganization of the health service network, an inventory of 
the health personnel for the provinces in Region IV, and vehicles acquisition. 
Inter-American Development Bank (IADB) 
The Inter-American Development Bank has supported health sector reform with the 
Modernization and Restructuring of the Health Sector Project (MRHSP). Approved in 1997 with 
Evaluation of REDSALUD and USAID/DR Strategy 8 
financing of US$75 million, the project began in 1998 and will conclude in 2005. The project has 
four components: policy formulation; aid to SESPAS and PROMESE; support to the IDSS and 
the Social Security System; initiation of pilot programs in primary and specialized care areas. 
European Union (EU) 
The European Union supports health reform through the Program of Reinforcement of the Health 
System (PROSISA), which began in 2000 and will end its operations in 2005. This program has 
a European Union donation of 12 million Euros, and a 1.5 million euros donation from the 
National Controller of European Development Funds. PROSISA has three components: 
institutional support; resource management; and medication. The program is implemented in the 
Northeast region of the country. 
United States Agency for International Development (USAID) 
USAID supports health sector reform with the $13.3 million Health Reform and Decentralization 
Project (REDSALUD) that began in 2000 and continues to 2005. The project has three 
components: the first is to support the local management of health services, implemented solely 
in Region V (Eastern Region); the second is to provide support to SESPAS at the central level; 
the third is to provide support at the national policy level. The project is implemented through a 
contract between USAID, Abt Associates and five partnersóDevelopment Associates, the 
National Health Institute (INSALUD), Family Health International, George Washington 
University and American Manufacturers Export Group (AMEG). 
E. NEW LEGISLATION APPROVAL
In March and May of 2001 two seminal laws were approved, which set the legal framework for a 
new phase in the health and social security field -- the General Health Law (42-01), and the law 
that creates the new Dominican Social Security System (87-01). The 42-01 law establishes that 
the health system supervisory body is SESPAS, while the 87-01 law establishes that the 
supervisory body of the social security subsystem will be the National Council for Social 
Security (CNSS). 
In addition, the General Health Law dictates that SESPAS must promote a gradual separation of 
the supervisory and service provision functions, indicating that its health establishments must 
conform to a new modality of service provision. In addition, the law calls for the creation of the 
National Health Council (CNS) as an entity for social participation, assessment and support for 
SESPAS. Consequently, the law establishes that SESPAS be the highest health authority, 
responsible for the design and application of health policy and plans throughout the country. The 
law creates general provisions concerning the accreditation and functioning of the health services 
provision institutions, be they private or public. 
The Social Security law determines the financing of the system, the general health provisions 
and the way in which members will have access to them. The goal is to have the entire 
populationís basic health needs covered through a universal social security system, that does not 
discriminate by condition or affiliation within the system. 
To foster development of the system, the law mandated the creation of several entities such as: 
The National Social Security Council (CNSS), the Superintendence of Health and Labor Risks 
(SISASRIL), the Social Security Treasury (TSS), the Directory of Information and Affiliate 
Evaluation of REDSALUD and USAID/DR Strategy 9 
Defense (DIDA) and the National Health Insurance Agency (SENASA), among others. The 
National Health Insurance initiative began with the subsidized program of Family Health 
Insurance in Region IV, on November 1st, 2002. Restructuring of public health services has 
already begun in the region and presently there are 35,000 members that have been recognized 
by the TSS. 
Evaluation of REDSALUD and USAID/DR Strategy 10 
IV. STRUCTURAL PROBLEMS THAT INITIATED THE REFORM 
PROCESS
A series of structural problems brought on a crisis in the Dominican Health System, which then 
motivated modernization and reform proposals of the system. Among the problems, are the 
following: 
a) Insufficient Coverage and Lack of Equity 
The coverage of basic health services has been insufficient and deficient for Dominicans, 
particularly for the poorest groups, who make up almost half of the population. Several studies 
estimate that organized and regular health services barely reach three fourths of the population. 
Despite the fact that the country has allocated a great quantity of doctors and hospital beds, these 
have been distributed inequitably, privileging major urban centers and the most developed areas. 
There has been a marked difference in opportunity, integrity, effectiveness and quality among 
the services received by the richest and the poorest populations. At the same time, the country 
has also exhibited high infant and maternal mortality rates and a high incidence of transmissible 
diseases that have affected the poorest groups. Over 80% of the population ñ91% in the rural 
zonesólacks any form of health insurance, which escalates the impact of health care on family 
expenditure. 
b) Vertical and Centralized Health Institutions 
An analysis of the structure that until recently prevailed in SESPAS allows for the conclusion 
that the institution has been organized according to the traditional model of Health Ministries in 
the region. This entails a concentration of functions in a rigid and vertical structure, with little 
capacity to effectively adapt to the modifications of a changing environment and with leadership 
limited by the rigid internal structure. In addition, there was very little institutionalism and 
transparency in general operations, along with the strong presence of a paternalistic and client￾centered culture in the management of financial and human resources. 
c) Inefficiency and Management Problems 
Administrative inefficiency manifests itself through low human resource, equipment and 
infrastructure productivity, as well as underutilization of hospital beds, operating rooms, etc. 
Management problems have also become evident in the use of outdated systems for managerial 
operations, an authoritarian organizational culture, little space given to community participation, 
the existing minimum obligation for accountability on the part of the authorities, the deficient 
selection systems and promotion of personnel, and the low utilization of controls and information 
management systems. 
d) Multiplicity of Insurance Schemes 
In the Dominican system several insurance schemes have coexisted, each with their own method 
of organization and financing. For example, the richest groups are insured with stipends or in 
private insurance plans; some workers are affiliates of the IDSS; military and police have their 
own services, as do others from the public financial sector such as educators, doctors and nurses; 
Evaluation of REDSALUD and USAID/DR Strategy 11 
and a vast majority of the population lacks any formal insurance. It is clear that the insurance 
sector has functioned in a fragmented manner and without regulation schemes. 
e) Insufficient and Inadequate Public Health Spending 
According to statistics from National Accounts (Cuentas Nacionales), national health 
expenditure in 1996 was 6.5% of the Gross National Product (GDP), with 1.5% of that figure 
from the public sector. Annual expenditure in health per capita was US$72, of which 
hospitalization was 20%, consultation 60% and only 10% going towards preventative care. In 
addition, according to the same source, 61% of the total expenditure in ambulatory family care 
was for medications. 
f) Weaknesses in Public Health Programs 
There is a large high-risk population that has been unprotected, due to the fact that in general 
collective care programs have been administered only at the national level and operated 
vertically. There are various programs that are maintained with international support, but if 
international support was suspended, these programs would become unsustainable or irrelevant. 
The sanitary situation is deplorable in many zones of the country, particularly in relation to the 
disposal of trash and waste, zoonosis transmission and potable water supply. 
Evaluation of REDSALUD and USAID/DR Strategy 12 
V. THE REFORM’S RESPONSE TO THESE HEALTH 
CHALLENGES
Once the structural problems in the Dominican Health System were identified at the end of the 
1980s, a series of projects and programs were designed in order to effectively respond to them. 
While revising and analyzing proposals for these new projects--including the Health Sector 
Modernization and Reform Program--along with the existing legislation, health sector officials 
identified a series of common strategic courses of action with the following key objectives: 
equity, efficiency, effectiveness and quality. These are presented bellow. 
a) Expansion of Coverage 
An expansion of coverage, at least of the priority health services, is the main goal and is at the 
center of almost all the reform proposals. The aim is not only to offer integrated and higher 
quality services, but to also ensure that these services are provided through formal insurance. 
b) Separation of Functions and Reinforcement of the Health Sector Governance, 
Regulation and Supervision 
The Dominican Health System has been characterized by a few centralized and vertical 
institutions that carry out a wide array of functions, which makes them inefficient and 
ineffective. The reforms contemplate the separation and specialization of functions in a smaller, 
rational and horizontal structure that will allow the different entities to concentrate on the 
exercise of their specific functions with greater quality and efficiency. The proposed separation 
of financing and provision of services is particularly important, because with this modality 
resource allocation can generate a type of buyer/seller relationship with better quality services 
and transparency in the use of resources. The proposed model aims to reinforce the central role 
of the state institutions for the exercise of regulation and supervision functions. For a complex 
system composed of so many institutional entities, it is very important to train employees and 
supply state institutions with adequate technical instruments, so they are better able to perform 
their functions. 
c) Changing from Supply to Demand Financing 
Historically, the Dominican public health system has directed financing towards the supply of 
services and not towards the demand. The budgeting model that prevailed for years was merely 
historical and institutional, without considering variables in production. The implied modality in 
the proposed reforms would generate a variation in the system, allowing financing to be carried 
to the health centers by the users, which would be subsidized. This shift seeks to create healthy 
competition between the care centers, which would represent a progressive improvement in the 
levels of quality and user care. 
d) Public Health Strengthening 
 One of the objectives of the separation of functions is the strengthening of the essential 
functions of public health, which would emphasize SESPASí role as supervisory body and 
regulator, as well as those relating to important works in collective health. A substantial part of 
Evaluation of REDSALUD and USAID/DR Strategy 13 
the 42-01 Law deals with the modernization of the structure and functions of the public health 
sector, and would be considered an updated Health Code. 
e) Normative Centralization and Operative Decentralization 
Another goal is to progressively transfer the decision and operation management powers to the 
local levels, since they are closer to the users and have better information and more motivation to 
serve the public. However, with the de-concentration and decentralization of functions, there 
should still be an adequate normative frame and an effective supervision system at the central 
level that can guarantee security in the transparency and effectiveness of the use of resources 
throughout the health system. Norms, general policies, administrative systems and standard 
procedures will have a central definition. Even when the Decennial Health Plan is instituted, the 
planning and operation of services will be de-concentrated and decentralized. 
f) Resource Allocation by Results, Penalization and Incentives 
Instruments such as agreements and contracts will mediate the acquisition of services and 
resource allocation; the terms and conditions of the agreement shall be established within them. 
These agreements and contracts will define the payment by results and establish penalizations 
and incentives, depending on the level of compliance between the parties. 
g) Development of a Formal Universal Insurance System with a Basic Health Plan and 
Capitation 
An integrated universal insurance system will be implemented, with a basic care package for all 
affiliates, which uses a capitation payment mechanism for the Health Risks Administrators 
(ARS) as well as for other forms of public and private insurance. 
h) Higher Levels of Social Participation and Accountability 
The spirit of participation, control and accountability intersects all the proposed reforms; 
moreover, the legislation establishes various instances for exchange, coordination and 
negotiation between players. Also, the reforms look at the possibility of social management and 
supervision in various situations. 
i) Activities that Benefit Primary Care 
The reformís legal framework, its programs and projects, and a large number of institutional 
proposals and actions all aim for the development and reinforcement of health promotion and 
disease prevention activities. It is understood that this orientation will result in better health 
levels for the population and, in a context of material and economic difficulties, will promote 
more cost effective interventions in the country. The Social Security Law establishes primary 
care as the entry point to the system with the assumption that this will result in a high level of 
service rationalization and cost containment. 
j) Development of Extensive and Integrated Information Systems 
The Dominican Health System suffers from deficiencies in the recording, processing and 
utilization of information when making decisions. The reform considers information a 
fundamental asset and a key to effective management. In this sense, it seeks to arrange a single 
Evaluation of REDSALUD and USAID/DR Strategy 14 
Information and Epidemiological Vigilance System for the health sector, as well as a single 
Affiliation and Information System. The information systems should be automated, so that 
equipment, networks and specialized software can be easily procured. The systems would be 
standardized so that there are no differences between them and the systems could be easily 
integrated. 
k) Development of a Single System for Collection and Affiliation 
It is proposed to have a single system for collection that controls duplicity and multiple 
affiliations, as well as manages integrated information, and can be easily controlled and 
supervised. 
Evaluation of REDSALUD and USAID/DR Strategy 15 
VI. MAIN ACHIEVEMENTS OF THE REFORM PROCESS
At present, the reform process can only exhibit some intermediate achievements that are 
primarily process-oriented. In addition, these achievements have not yet demonstrated a 
significant impact on the fundamental variables of coverage and quality. The main identifiable 
achievements during the study are presented in a specific and detailed manner in this documentís 
Annex II. The following are a general description of these achievements: 
a) Establishing a New Legal and Regulatory Framework 
With the passing of the General Health Law (42-01) and the law that created the new Dominican 
Social Security System (87-01) the country built the basic legal framework that sustains the 
health sector reform process in a coherent an integral manner. In addition, the regulations 
required for the operationalization of both laws have been developed, a significant percentage of 
them have been approved and published, and almost all the rest are in the process of being 
approved. 
b) Creation of the new Social Security System’s Institutions 
The New Social Security System includes a vast constellation of official institutions, which 
already have been created and are functioning in an initial phase of development. The most 
important among these new institutions are the National Social Security Council (CNSS), the 
Superintendence of Health and Labor Risks (SISALRIL), the Social Security Treasury (TSS), 
The Directory of Information and Defense of Affiliates (DIDA) and the National Health 
Insurance Agency (SENASA). All institutions have basic and adequate equipment and supplies, 
and are staffed with personnel with appropriate technical and administrative skills 
c) Generation of Spaces for Social Coordination, Negotiation and Supervision Among the 
Sector’s Main Players 
Both laws are equipped with an ample democratic and participatory spirit. The laws have 
clearly promoted numerous opportunities for normative and operative institutional plural spaces 
of coordination, negotiation and supervision, where the government, representatives of the 
systemsí users, business guilds, the Medical Association, syndicates and civil society participate. 
The functioning of the National Health Council (CNS) and the National Social Security Council 
are evidence of this. 
d) General Awareness of the Reform Process 
Practically all the players are positively sensitized to and understand the general benefits of the 
health reform process and Social Security. Past ideological contradictions about the basic health 
system model have given way to confrontations between corporate interests or concrete technical 
aspects. However, this does not signify universal antagonist differences, but rather occasional 
differences that can be overcome through collective negotiation. 
e) Initiation of the Subsidized Regimen of Family Health Insurance in Health Region IV 
On November 1st 2002, the subsidized regimen of Family Health Insurance in Health Region IV 
began. This formal event started a process that has shown some achievements. Among these are 
Evaluation of REDSALUD and USAID/DR Strategy 16 
the following: the reorganization activities of the regionís Primary Care Units (PCUs) in order to 
be able to supply care corresponding to the Basic Health Plan; the formal compliance and 
internal efforts to create SESPASís country-wide network of establishments, such as the Sur 
Profundo Regional Health Service; the signing of the first Management Agreement between two 
public institutions--SENASA, as buyer, and the Sur Profundo Regional Health Service, as seller; 
the provisional supply of the public network and other health establishments made by SESPAS 
in the region; the affiliation of close to 35,000 subsidiaries of SENASA in the region and 
provision of the first social security identification cards to these members; and the fulfillment of 
the first payment by SENASA to Sur Profundo for services provided to their members after the 
presentation of an invoice. 
f) Separation of SESPAS’s Functions 
Slowly but irreversibly the separation of the main functions concentrated in SESPAS has begun. 
In a way, the de-concentration of governing functions and service provision functions began with 
the approval of the regulation and authorization from central level SESPAS for the formation of 
Deep South Regional Heath Service, by allowing this regional health service to manage the 
financing obtained from SENASA from the agreement for sale of its services. 
g) Initial Preparation of a Critical Mass of Technical and Administrative Personnel 
Both the extensive training activities and the experiences gained from the process itself have 
been instrumental in fostering the development of key personnel in the technical and 
administrative areas of the systemís institutions. This personnel development and formation is 
one of the most important legacies of the process. This critical mass of qualified personnel is still 
a minority in relation to the whole system, but it is an institutional asset that will likely make a 
major contribution to the process. 
h) Improvements in Infrastructure, Equipment and Implementation of Software 
Although this was not a central objective, the reformís activities have led to periodic 
contributions to the infrastructure of public institutions within the system, both at the central and 
local levels. In addition, a positive accumulation of intervention activities can clearly be seen in 
the endowment of computer equipment, communication networks and automated information 
systems. These improvements provide important support to the institutional strengthening 
activities. 
Evaluation of REDSALUD and USAID/DR Strategy 17 
VII. FACTORS THAT HINDER IMPROVEMENTS OF THE SYSTEM
The section outlines the main general factors identified as current obstacles to the reform 
process, including implementation of a viable social security system in the health sector. 
a) Social Security Financing Problems 
During the last year and a half, the U.S. dollar, a fundamental variable in the price level due to 
the high external component of the goods and services produced in the country, has practically 
tripled. This generated an inflationary process, which has unfavorably altered the cost of the 
Basic Health Plan (PBS). Likewise, the Dominican Republic has signed an agreement with the 
International Monetary Fund (IMF), which restricts government-spending possibilities. 
Furthermore, more than 40% of the National Budget will have to be allocated to external 
obligations. Such factors considerably question and threaten the possibilities of an extended 
financing of the subsidized system by the Government. This is exacerbated by the fact that the 
crisis that the country is undergoing has elevated unemployment, which reduces the contributory 
mass and increases the financing volume, which the State would have to contribute. On the 
contributory side, salaries have been increased to a maximum that does not exceed 20% and 
studies indicate that employee and employer budgets are not enough to cover the per capita 
amount required with the new estimates of PBS. 
b) Overlap of Roles and Conflicts among the System’s Main Players 
The definitions of the functions of some of the institutions created with the new Social Security 
Law have led to certain confusions among the governing and regulatory roles; this in practice 
tends to generate overlap and conflicts among them. These conflicts, exacerbated by an excess 
number of players, have obstructed the coordination needed to start the system. 
c) Lack of Leadership and Coordination among the Projects and Programs of the Reform 
The system lacks an evident and localized leadership, which contributes to a diffusion of the 
main players. This lack of leadership has hindered the necessary construction of a systematic 
vision which would allow for the programming and harmony of the efforts made by the different 
institutions that work in the management and implementation of the system. The reform process 
lacks an adequate strategic vision of implementation since neither SESPAS nor any other State 
institution has assumed this function in practice. The non-existence of a strategic reform plan 
and the lack of a true space for coordination of the reform projects and programs have led to non￾coordinated efforts; in fact on occasion efforts have been contradictory, redundant and 
duplicative. 
d) Lack of Sufficient Trained Personnel to Implement a Very Complex Process 
In the meetings and interviews held, the evaluation team found that the majority of players with 
important responsibilities in the system were qualified, both in technical and executive functions. 
However, this is not the case for all personnel in the system, and the country may encounter 
difficulties due to insufficient critical managerial mass to impulse a change process with such 
high levels of complexity, particularly at the regional, provincial and local levels. 
Evaluation of REDSALUD and USAID/DR Strategy 18 
e) Absence of a Clear Course of Action for the Reforms 
In the area of social security, the country has established deadlines for the start of the system, 
which have not been met. There are apparent difficulties in the identification of the key 
necessities, the answers that should be given to them, and the monitoring of the fulfillment of the 
agreed responsibilities; this is just a reflection of certain weaknesses in the leadership and global 
management of the process and the absence of a critical route for the introduction of reforms. 
f) Labor Instability 
The changes in government every four years and occasional replacement of the leadership of an 
institution within one government causes personnel changes; this often means that experienced 
government employees in the technical and administrative areas must exit. Thus, parts of the 
training efforts achieved are lost; furthermore, the possibility of generating a historic memory-- 
which identifies and registers the progressive change of its institution--is lost. 
g) Low Institutionalization of SESPAS 
The Public Health and Social Security Assistance Secretariat (SESPAS) is the key institution in 
the health sector reform process. However, there are a series of weaknesses which prevent it 
from properly assuming the leadership of the process. Likewise, there exists a great internal 
inertia, which resists or does not incorporate in sustainable form many of the current reform 
activities. Furthermore, there has not been an internal socialization process that would allow for 
the active integration of its personnel into the process of change and modernization. 
Evaluation of REDSALUD and USAID/DR Strategy 19 
VIII. COHERENCE, VIABILITY AND SUSTAINABILITY 
OF THE PROCESS
In attachment IV a table is shown which clearly outlines the main historical structural problems 
of the Dominican Health System, strategic approaches to address these problems, and general 
results. From its analysis, it can be said that the reform actions have been coherent with relation 
to the systemís structural problems and that important improvements have been achieved, even 
when not definite. The process is viable and sustainable when backed by political support. 
THREATS TO THE REFORM
The reform process and social security initiatives have improved slowly due to factors that may 
threaten the current viability of the process and its future sustainability. Some of these are: 
a) The economic situation, particularly the increases in the exchange rate that have affected 
the initially defined budgets. 
b) Unemployment, which decreases the number of employed potential contributing 
members and increases the subsidy burden of the government. 
c) The ambiguousness of the professional fees and the cost of the Basic Health Plan (PBS). 
d) The governmentís fiscal commitments related to external debt payments limit the 
availability of resources for the subsidized healthcare regimen ñ both in terms of the 
governmentís contribution and the co-contribution of individuals in the subsidized 
program. 
e) That the government institutions continue without effective coordination and that the 
State continues to present itself as weak and fragmented when confronted with a series of 
key decisions for the improvement of the process. 
f) Uncertainty about the continuity of the process by the new authorities if there is a change 
in government. 
g) Some sectors may abuse their veto capacity in the National Social Security Council 
(CNSS), to promote their own particular interests. 
Both social security and the transformation and modernization of the health sector are 
implemented under a gradual scheme that works to progressively generate the necessary 
conditions of the process without producing unexpected and catastrophic traumas in the main 
players of the system. The universal access, the financial equilibrium of the system, the efficient 
provision of services, and the improvement in the health conditions of the population would be 
the key factors that could make the process sustainable. To achieve this requires effective 
leadership from the governing entities at the highest levels: namely SESPAS and the new social 
security management entities. 
Evaluation of REDSALUD and USAID/DR Strategy 20 
IX. USAID/DR HEALTH STRATEGY
Since the 1970s, USAID has supported the Dominican Republicís efforts in the health sector and has 
been the main support organization for national programs in reproductive health (RH) and family 
planning (FP), which has allowed for important advances in these areas. In addition, USAID has been a 
key supplier of resources and assistance for the improvement of infant-maternal health. For example, 
USAID supported the Dominican government in the implementation of the primary care programs after 
the Alma-Ata meeting. USAID was also the main source of resources and assistance for the launch of the 
HIV/AIDS prevention program at the end of the 1980s, and continues to make a fundamental 
contribution in this area. 
In 2002, USAID defined its Health Sector Strategy for the period 2002-2007, with its main objective 
being sustained improvement in the health of vulnerable populations in the Dominican Republic. As part 
of this strategy, it has identified four areas of action/intermediate results (IRs). The first three areas 
respond to high risk health situations for the Dominican population, such as: prevention and care of 
HIV/AIDS, infant survival and reproductive health/family planning. A fourth area is the reform of the 
health sector, which cuts across all three IRs and serves as their organizational basis. Even though the 
ìsustained improvement in the health of vulnerable populations in the Dominican Republicî will not be 
achieved solely with USAIDís efforts, it is expected that this organization can substantially contribute to 
the reduction of these health problems. 
USAIDís strategy focuses particularly on vulnerable populations (defined as those that live below the 
poverty line) placing emphasis on children, adolescents and women of reproductive age. Consequently, 
interventions in HIV/AIDS will also be aimed at high-risk populations. It is clear that improvements in 
the health of the population will contribute to the reduction of poverty; that is, a healthy workforce will 
have to spend less on medication and will be productive for longer periods of time, which will allow 
families to maintain their income. The health sector reform strategy is inextricably linked with larger 
political and social reforms that promote civil society participation and local government, both municipal 
and provincial. In addition, the health strategy supports USAIDís efforts in related topics such as 
reduction of poverty, policy reform, civil society, local governance and strategic collaboration with other 
organizations. 
USAIDís strategy is based on the assumption that other financial institutionsí programs--such as the Inter￾American Development Bank and the World Bank, along with donors such as the European Community 
and the technical support organizationsí programs, such as the Pan-American Health Organization (OPS), 
the United Nations Childrenís Education Fund (UNICEF) and the United Nations Population Fund 
(UNFPA)--continue their activities without any major delays or alterations. It is also expected that future 
governments will continue to maintain and foster the reforms that have been carried out under the current 
presidentís administration, and that the positions of the current technical personnel are stable. 
USAID has three important reasons to support health reform in the Dominican Republic. First, USAID 
wants to ensure that its efforts and programs are sustainable, which is only guaranteed through a 
financially stable system that can provide basic services to the population. Second, it promotes a focus on 
infant-maternal care, reproductive health and combating infectious diseases, especially HIV/AIDS, 
tuberculosis and malaria, with an emphasis on the most vulnerable populations. Third, the relationship 
between the Dominican Republic and the United States is an important one; USAIDís support for 
Dominican health reform will contribute to a more democratic society and an economy better prepared to 
face globalization and fight poverty. 
Evaluation of REDSALUD and USAID/DR Strategy 21 
X. THE REDSALUD PROJECT AND ITS IMPROVEMENTS
A. THE ORIGINAL DESIGN OF THE REDSALUD PROJECT
A team of consultants from the Latin American Center of Health Systems Investigations 
conceived of the REDSALUD Project in December 1998. The original design emphasized the 
need to have flexibility to adjust the priorities and orientation according to the changes that may 
arise during the execution of the project, as well as the importance of the diversification of risks 
to achieve diversity in governmental and non-governmental players. Also, the consultants 
created ìfundsî to stimulate and impel organizations willing to take the initiative in the 
implementation of reform activities. The conceptual design has two main components: 1) 
strengthening the decentralization process and 2) creation of positive conditions for health 
policies and long-term reform with governmental and non-governmental players. The design 
was successful and has established the basic program framework, allowing for adjustments as 
necessary. 
B. THE REDSALUD STRATEGY
USAID hired Abt Associates for the implementation of the REDSALUD Project, which 
presented a proposal with three primary strategies: 1) implement innovative health service 
networks in 14 DPSs, 2) strengthen the capacity of SESPAS to support decentralization, and 3) 
develop a favorable political environment at the national, provincial and local level. 
Although the original project contemplated the participation of REDSALUD in a maximum of 
14 DPSs (Provincial Health Departments), in actuality local supporting actions are held in five 
provinces that make up Region V of the country. The concentration of REDSALUD efforts in 
this region was a result of a government initiative to organize the health reform support projects. 
REDSALUDís strategies are described in more detail below. 
1. IMPLEMENT INNOVATIVE HEALTH SERVICE NETWORKS IN THE PROVINCES
REDSALUD developed several generations of demonstration projects, which are shown below: 
1st Generation: Innovative activities to strengthen public health 
The focus of the first generation of demonstration projects has been to fundamentally strengthen 
the managerial capacity of those responsible for these programs: the DPS and the first level 
providers. The programs have been used as a vehicle to introduce and develop support 
interventions to management, with the hypothesis that better management would help improve 
the programs and their impacts; and that it would also improve the execution of current 
programs. 
In the El Seibo Province, REDSALUD supports various Primary Care Units (PCUs) to 
strengthen the effective treatment of acute diarrheic illnesses (AD). The Provincial Health 
Department (DPS) identified this as a priority due to various environmental causes. The project 
also helped hospitals and the PCUs in the installation of Oral Re-hydration Units (UROs) to treat 
dehydrated children. Also, in the La Romana and Hato Mayor provinces, REDSALUD is 
helping strengthen the Broad Immunization Program (PAI) to extend coverage of vaccines. 
These projects have been successful in increasing coverage of vaccines as well as in reducing the 
Evaluation of REDSALUD and USAID/DR Strategy 22 
incidences of diarrheic illnesses. Another important component of this strategy is the creation of 
community support groups around the PCUs. The purpose of such groups is to promote the 
services, offer information and education, and supervise the care given. 
2nd Generation: Innovative activities for the encouragement of a user-focused culture 
REDSALUD helped install User Care Offices (OAU) in 14 hospitals of the region. This support 
has allowed the furnishing of the offices, including the installation of internal and external signs, 
computer training for personnel, human relations courses and the design of a verification of 
rights program (patient registry), as well as discussions and sensitivity meetings for the hospital 
personnel. It is important to highlight that this idea grew in the region as a result of activities 
undertaken by the FONHOSPITAL project in the Antonio Mussa Hospital; due to its success and 
relevance, it was extended and offered to other hospitals. The OAUsí Regional Committeeís 
main responsibility is to oversee the development and proper functioning of these offices in the 
hospitals. This committee also develops the internal regulation and strategies to respond to the 
reform process. 
The team had the opportunity to visit various OAUs in Region V, and noted that the users appear 
to value them highly. The majority of the offices are working well and their usage will be 
increased with the introduction of the social security system. It is important to point out that an 
OAU in the Antonio Mussa Regional Hospital was unstaffed during the visit by the evaluation 
team and in others it was noted that there is still a need to further develop the user-focused 
culture. In general, the achievements depend greatly on the capacity and disposition of local 
agents, and the experiences vary in every facility in the region. 
3rd Generation: Activities that foster hospital management 
REDSALUD has signed seven agreements with 14 hospital establishments to analyze the service 
portfolio and determine costs, productivity, prospective budgeting and improvement of the 
management information system. REDSALUD has already finished the services portfolio 
exercises and costs and productivity analysis; the next step is the prospective budgeting training. 
Based on the information obtained through the work of portfolio services, costs and hospital 
productivity determination, a negotiation workshop with SENASA was held in which they 
determined the type, quantity and quality of services Region V could offer the Public Health 
Risks Administrator. 
The postgraduate program in health services management also represents a key contribution to 
the future of the health system in the region. The evaluation team witnessed several examples of 
the motivation of personnel who participate in the program, and their capacity to apply what they 
are learning in their daily work. 
4th Generation: Activities to support initiation of social security 
The essential goal of this project is to support the creation and development of the necessary 
conditions for social security to be initiated in Region V. Many of the activities of this project 
have supported the new social security institutions. For example, support was provided to 
SISLRIL in defining its operational structure, in the elaboration of its basic rules, and in the 
definition and costing of the Basic Health Plan (PBS). Likewise, REDSALUD has supported 
SENASA in gathering information from the subsidized members of the region, in the design of 
Evaluation of REDSALUD and USAID/DR Strategy 23 
software for its registry, and in the definition and payment of the service packages that will be 
purchased from the various providers, and in the development of payment and contracting 
mechanisms. REDSALUD has also supported the DIDA in the definition of its strategy for 
organization and defense of the social security affiliates in Region V, and in its general 
information, education and communication strategy. 
The subsidized regimen of Family Health Insurance officially began in Region V on April 1, 
2004. However, there is still a lot of work that remains to be done before the system functions 
properly in the region. 
5th Generation: Activities to foment the creation of a service network 
This recent project objective is to foment the creation of a Service Network in Region V. This 
includes the design of an administrative and control platform, services, human resources, 
physical and financial resources, and information so that the health facilities in Health Region V 
can begin to function and organize themselves as a network of providers. 
2. STRENGTHEN SESPAS’S CAPACITY TO SUPPORT DECENTRALIZATION
The main objective of this component is to support SESPAS in the development of its strategy of 
de-concentration and decentralization, along with the development of its role as a supervisory 
body. Moreover, this component seeks to promote SESPASís transition from a centralized and 
inefficient entity to a more flexible, horizontal and better qualified institution for the exercise of 
essential functions. In interviews during the evaluations several players pointed out that initially 
technical support by REDSALUD to the Central SESPAS was difficult, because the entity 
resisted the concepts of decentralization; in addition some said that the interest of the project was 
to privatize health services. With time, these confusions were clarified and currently, this 
componentís purpose is to serve as a link between the support to the local management and the 
central level. This collaboration has culminated in a mechanism that can replicate and 
institutionalize the successful results achieved by the demonstration projects. 
3. DEVELOP A FAVORABLE POLITICAL ENVIRONMENT
The objective of this component is to contribute to better understanding and coordination among 
technical and political players in the health sector, and to create a favorable environment for the 
planning and execution of the reform process. REDSALUD supported, through technical 
assistance, the participation in commissions, the formation of coalitions and promotion of 
proposals, and the formulation and approval of two large legislations within the system, along 
with the complementary regulations. This component has also contributed to the social 
participation and the political viability of Region Vís demonstration projects. In addition, it has 
carried out a continuous training process on the topic of reform, aimed towards the players in the 
health system, community organizations and journalists. 
C. MAIN FINDINGS OF THE REDSALUD PROJECT
The following matrix demonstrates the correspondence between USAID/DR strategy and the 
structure of the REDSALUD project. 
Evaluation of REDSALUD and USAID/DR Strategy 24 
CORRESPONDENCE BETWEEN USAID/DR HEALTH STRATEGY AND THE REDSALUD PROJECT STRUCTURE
USAID Strategy REDSALUD 
IR 4: Increase efficiency and equity of basic 
health care services at the local level. 
General Objective: Contribute to the 
improvement of access, equity, quality and 
sustainability of basic health services, especially 
for the most vulnerable. 
Strengthen management capacity in the areas of 
health and the provincial directorate. 
a) Support the strengthening of local health 
Increase the heath system’s capacity to 
implement an effective decentralization strategy. 
b) Provide support to SESPAS at the central level. 
Improve the health policy environment for reform. c) Support the development and sustainability of a 
policy environment favorable to health sector 
reform. 
As shown in the above table, there is a strong relationship between REDSALUD project 
components and USAID/DR Intermediate Result 4. In analyzing REDSALUDís activities, it can 
be concluded that the efforts and results have been consistent with USAID/DRís strategy, even if 
they have not been achieved in totality. These represent significant contributions within a 
complex process that surpasses the dimensions and duration of the project. It is important to note 
that REDSALUDís activities in Region V support not only public health at the primary care 
level, but also at the specialized level. For this reason REDSALUD actually surpasses IR 4ís 
scope because IR 4 only deals with primary care services. 
With the current state of the Dominican Health system reforms, it is difficult to find significant results 
in the coverage and quality of services. However, the REDSALUD project can show many 
intermediate results, mainly through the technical contributions it made in Health Region V. This 
region is presently in the process of preparing for the transformation required by the introduction of the 
Social Security System. Its preparation level is superior to other regions, which led CNSS to select it as 
the second region to be incorporated into the new system. Without a doubt, the difference between 
Region V and some of the other Health Regions in the country is clearly due to the support offered by 
REDSALUD. 
One of the main results that the evaluation team observed in Region V was intangible, but of 
great importanceóthere was a complete change in mentality and total support for the reform 
process, which was revealed by every person interviewed. 
In analyzing the evidence of this evaluation, it can be affirmed that the REDSALUD project has 
made and is making important contributions to health sector reform in the Dominican Republic, 
and that all key players within the system who were interviewed have proclaimed their 
appreciation and clear satisfaction with the project. 
In addition, the REDSALID project is staffed by very capable and professional personnel who 
showed a good understanding of the activities, players, geography, culture and organizations that 
work with the project. The legacy of these national human resources, trained and formed during 
the execution of the project, will be an additional contribution to the system. 
The following paragraphs show more specifically the results of REDSALUDís actions, as found 
by the evaluation team. 
• Support to PCUs in strengthening effective care of acute diarrheic diseases (AD). 
Evaluation of REDSALUD and USAID/DR Strategy 25 
• Installation of Oral Rehabilitation Units (ORUs) to attend to dehydrated children. 
• Strengthening the Expanded Immunization Program (PAI) in order to improve management 
and increase coverage. 
• Support in the creation of community support groups for the PCUs. 
• Installation of User Care Offices (OAU) in 14 hospitals within the region. 
• Symposiums and workshops for the sensitization of the hospital personnel. 
• Organization of the OAU Regional Committee. 
• Signing of seven agreements with 14 hospital establishments for the: 
■ Analysis of the portfolio of services. 
■ Determination of costs and productivity. 
• Support for SISALRIL in: 
■ The definition of an organic and operational structure. 
■ The elaboration of basic rules. 
■ The definition and costing of the Basic Health Plan (BHP). 
• Support for SENASA in: 
■ Gathering information from the subsidized affiliates in Region V. 
■ Designing software for recording this information. 
■ Definition and costing service packages to be acquired from different suppliers. 
■ Elaborating a contracting and payment mechanism. 
■ Relating experiences from two important Latin American contexts (Chile and Colombia). 
• Support for DIDA in: 
■ The definition of an organizational and defense strategy for Social Security members in Region 
V. 
■ The development of information, education, and communication strategy. 
• Support of the discussion and dissemination of topics on the Dominican health reform 
process. 
Evaluation of REDSALUD and USAID/DR Strategy 26 
XI. RECOMMENDATIONS FOR THE SHORT, MEDIUM, AND 
LONG TERM
FOR REDSALUD 
The recommendations for the remaining 15 months of the Project are aimed at consolidating the 
improvements in the Region V environment and establishing the basis for the next phase from 
2005 to 2007. 
a) Provide support to the new health sector authorities who may come into office after 
August 2004. 
It is suggested that REDSALUD elaborate and develop an explicit strategy of support that 
provides orientation and training to the new professionals responsible for Health Region V and 
the national level. Such a strategy should continue to be available in case there are any authority 
personnel changes after August of the present year. It is also recommended that this be applied 
to other bodies that contribute to the reform (such as CERSS and PROSISA). 
b) Consolidate the achievements in Health Region V 
It is recommended to continue the actions already initiated and those about to begin, such as the 
ambulatory medication service and the referral system, among others. Furthermore, it is also 
recommended that the community support experience, which has been supporting the Acute 
Diarrhea Illnesses (AD), and the Broad Immunization Program (PAI) be expanded to other areas 
such as HIV/AIDS, maternal and child health, and reproductive health. 
Special emphasis should be placed on technical support to the structure of the Regional Health 
Service in the Eastern Region, so that the Provincial Health Departments (DPS) are established 
with the needs of provincial supervision and public health of the region in mind. 
c) Support the acquisition of documents for Social Security registration of the subsidized 
populations in Region V 
It is common that people lack personal identification cards or birth certificates in the subsidized 
population of the Region; however personal identification will be necessary to register in the new 
social security system. Thus it is suggested that REDSALUD support any regional initiative that 
aims to speed up as well as facilitate the acquisition of such documents. 
d) Assure the sustainability of REDSALUD’s Programs 
To guarantee the sustainability of the activities which REDSALUD has been carrying out, the 
following is suggested: 
• Analyze with INTEC the possibility of institutionalizing the postgraduate program in health 
services management and/or expand it to a masterís degree. If possible, support INTEC in 
the formulation of a business plan to achieve sustainable financing of such program. 
Short Term: the remaining 15 months of the REDSALUD Project; from April 2004 to July2005. 
Evaluation of REDSALUD and USAID/DR Strategy 27 
• Analyze the viability of computer use in the primary care units that have low volumes of 
users, low electricity flow, and poor security conditions. Also, analyze the possibility of 
correcting underutilization by looking for complementary uses, as well as the possibility of 
transferring responsibility for maintenance of the information equipment to the users 
themselves. 
• Expand links with organized civil society like FINJUS, Foro Ciudadano, ParticipaciÛn 
Ciudadana, ANJE, and COPADEBA, so they assume and support health reform. 
• Analyze whether it is appropriate for the Project to support the creation of a consensus 
concerning critical subjects, such as, lack of agreement on the costing for the Basic Health 
Plan, the delay of the beginning of the contributory regimen, and the financial viability and 
sustainability of the system. 
• Study the possibility of hiring personnel that reside in Region V since the transportation 
burden is very large if the entire team lives outside the region. 
• Analyze the possibility of having an advisor on political matters since these require special 
attention, particularly a year from now when, whatever the results of the elections, great 
changes are anticipated. 
e) Systematize and share the positive experiences of the Project in Region V 
It is recommended to document, evaluate, systematize, and share the experiences and tools which 
have worked well in the region, highlighting the changes which have resulted from innovations. 
For its dissemination, turn to the health system, along with the universities, the press and other 
means. Among the experiences, the following can be emphasized: 
• The analysis of cost accounting exercises in hospitals, including the training process, the 
exchange of experiences, and incentives which have been used to recognize those who have 
performed very well 
• The functional and practical orientation of the postgraduate program and the competitive 
selection process of the participants 
• The User Care Units as a mechanism to improve the quality of service and the organization 
of visits. Furthermore, the information system installed in such units allows for the 
identification of members of the social security system and supports invoicing 
• The Community participation with the PAI and EDA 
FOR USAID 
In the short term, the following is recommended: 
a) Take advantage of available opportunities to spread the advancement of health sector 
reform, as well as discussing certain important topics such as: 
• The civil service and the public health sector administrative career track based on Decree 
1282-100 
• The decentralization and strengthening of the Regional Health Services 
Evaluation of REDSALUD and USAID/DR Strategy 28 
• The family health insurance affiliation problem due to a lack of identification documents, 
which especially affects poor women and children 
• The social security public financing guarantee for subsidized members, public contributors, 
and subsidized contributors 
b) Assure that other activities in the health area, such as Project CONECTA, work in firm 
collaboration with the reform process and with the anticipated changes in the health 
system. 
c) Encourage SESPAS, as a supervisory institution of the sector, to assume the 
coordination of cooperation and external financing activities; be it through the 
Institutional Modernization Unit or at the request of any other body. 
d) Support the collection, analysis and dissemination of health sector performance 
information that feeds the debate and improves decision making, such as the national 
health accounts, studies based on Endesa, user satisfaction studies, services costing, 
productivity analysis, and public investment in the construction and the furnishing of 
hospitals. 
FOR USAID 
It is recommended that in the medium term USAID should continue the three lines of action 
established in the REDSALUD Project: a) support to local management in Region V; b) support 
at the central level; and c) support to the political environment. Furthermore, in view of the needs 
of the new institutions that have arisen with the social security system, supporting them is 
suggested, which in practice has already begun under REDSALUD. 
a) Support the management of Health Region V in: 
• Strengthening and replicating tools and processes developed through REDSALUD 
• Consolidating local supervisory public health functions of DPSís 
• Services management, including services portfolios, costs, budgets, accounting, and 
invoicing 
• Legal and operational consolidation of the Regional Health Service 
• The active participation of the community 
• The modernization of hospital management systems 
• Strengthening the technical, financial, and clinical auditing systems 
• The creation of alliances among the public and private sectors to make the health services 
more agile and efficient 
Medium Term: the 26 month period between the conclusion of the REDSALUD Project in July 2005, and the end 
of the actual USAID strategy in September 2007. 
Evaluation of REDSALUD and USAID/DR Strategy 29 
b) Support to the central level of the SESPAS in: 
• The design and development of the monitoring and evaluation system of the Decennial 
Health Plan 
• The supervisory functions (surveillance, regulation, norms) 
• The essential functions of public health 
• The provision of public facilities, starting in Region V 
• The direction and formation of human resources, including the implementation of civil 
service and management career tracks 
• The coordination of external cooperation 
• The definition and standardization of operational instruments, as well the implementation 
de-connected and decentralized requests (DPS and Regional Health Services) 
c) Support to the political environment 
• The evaluation team suggests that USAID take advantage of every opportunity to insert the 
administrative career theme and the topic of decentralization of the regional services in the 
national dialogue. They could also disseminate the experience of merit based recruiting, such 
as in the justice, environment and public ministry sectors. 
• Provide support to organized civil society in: 
■ monitoring the health systemís performance, especially in regards to out of pocket 
expenses, the access and use of public and private services according to income level, the 
problem of citizens without personal identification, and the productivity of public 
services 
■ disseminating information and defining a strategy with clear means of communication 
■ developing human resources training initiatives in health and nursing management 
■ mobilizing and integrating communities and management in requests for management 
and supervision of health system performance 
d) Support the new social security institutions (CNSS, SISLRIL, SENASA, DIDA) 
• Through technical assessment and support for institutional development activities and 
technical assessments 
• In the development and implementation of the subsidized regimen, including its promotion, 
the identification and affiliation of higher risk people, organization of provider networks, 
hiring of services, auditing, etc. 
• In initiatives that search for sustainable financing of the system. 
Some of the options that USAID would need to undertake in order to continue supporting reform 
in the medium term can be found in Attachment V. 
Evaluation of REDSALUD and USAID/DR Strategy 30 
RECOMMENDATIONS FOR USAID 
It is difficult to anticipate the support needs of the system for the long term in an unstable and 
changing environment. Furthermore, a diagnosis of the health sector in 2006 would be necessary 
in order to create the new strategy. By all means, the evaluation team considers that USAID, in 
the long term, should continue to support the country in the reform process and public health, 
which improves the living conditions of the poorest and most vulnerable groups. For the public 
health sector, the teamís recommendation is a concentration on the priority services of 
reproductive health, maternal and child health, and the combating of infectious diseases 
including HIV/AIDS. In the area of reform, key considerations are presented: 
• USAID should maintain its place at the dialogue table in regards to health reform. 
• USAID should support players who are highly committed and well-oriented in the efforts of 
change. 
• USAID should coordinate efforts with other cooperation and financial agencies, avoiding 
duplication. 
• USAID should look for contacts and synergy points with USAID projects in other sectors, 
especially democracy and governance. 
• USAID should promote extensive social participation in the reform process. 
• USAID should support the creation of independent ìthink tanksî to generate a critical mass 
of civil society members who can participate in the health sector and contribute to the 
creation of political consensus during the next stages of reform. 
Long Term: The seven to ten year period will begin after the elaboration of the next USAID strategy in the year 
2007. 
Evaluation of REDSALUD and USAID/DR Strategy 31 
BIBLIOGRAPHY
SESPAS/ONFED/UE/PROSISA. Una Reforma para estar en salud. Rep˙blica 
Dominicana. 2004. 
Rathe, M. Salud y Equidad: Una Mirada al Financiamiento de la Salud en la 
República Dominicana. Macro International Inc. 2003. 
Consejo Nacional de Salud. Reglamento de Provisión de las Redes de los 
Servicios Públicos de Salud. Rep˙blica Dominicana. 2003. 
Consejo Nacional de Salud. Reglamento de Rectoría y Separación de Funciones 
del Sistema Nacional de Salud. Rep˙blica Dominicana. 2003. 
Consejo Nacional de Salud. Reglamento Sobre los Regímenes de Contratación de 
la SESPAS Para la Provisión de los Servicios de Salud Pública. Rep˙blica 
Dominicana. 2003. 
Consejo Nacional de Seguridad Social. Reglamento del Régimen Subsidiado del 
Sistema Dominicano de Seguridad Social. Rep˙blica Dominicana. 2003. 
SESPAS/DIGEPI. Análisis de Situación de Salud de la República Dominicana 
2003 (Borrador). 2003. 
SESPAS/OPS. Indicadores Básicos de Salud 2002. Rep˙blica Dominicana. 
CNSS/DIDA/CERSS. Cosas Que Hay Que Saber Sobre la Seguridad Social.
Rep˙blica Dominicana. 2002. 
OPS. Perfil del Sistema de Servicios de Salud de la República Dominicana.
Rep˙blica Dominicana. 2001. 
REDSALUD. Planes de Trabajo y Acciones llevadas a cabo desde el comienzo 
del proyecto (2001-2004). 
Ley General de Salud No. 42-01. 2001. 
Ley que crea el Nuevo Sistema Dominicano de Seguridad Social No. 87-01. 2001. 
Saltman, R.B. y Figueras, J. Reformas Sanitarias en Europa. Ministerio EspaÒol 
de Sanidad en Europa. 1998. 
Oficina de CoordinaciÛn TÈcnica (OCT). Salud: Visión de Futuro. Rep˙blica 
Dominicana. 1996. 
Evaluation of REDSALUD and USAID/DR Strategy 32 
ANNEXES
Evaluation of REDSALUD and USAID/DR Strategy 33 
ANNEX I LIST OF INTERVIEWS
WEDNESDAY 03/17/04 
9:00 a.m. Meeting to coordinate team 
4:00 p.m. Mr. Patricio Murgueytio ñ REDSALUD￾THURSDAY 03/18/04 
8:30 a.m. Mr. David Losk, Mrs. Sarah Majerowicz, Mrs. Marina Taveras -USAID￾12:00 p.m. Dr. Manuel Tejada - SESPAS ñ 
3:00 p.m. Mr. Patricio Murgueytio and the REDSALUD team 
FRIDAY 03/19/04 
9:00 a.m. Evaluation team meeting 
Saturday 03/20/04 
9:00 a.m Dr. Ignacio De Oleaga Usategui - PROSISA￾10:00 a.m. Alberto Fiallo ñ Former Executive Director of CERSS￾MONDAY 03/22/04 
9:00 a.m. Lic. Chanel Rosa - SENASA ñ 
10:00 a.m. Dr. Mena ñ ANDECLIP - 
11:00 a.m. Dra. Socorro Gross, OPS Representative, Dr. Gerardo Alfaro 
3:00 p.m. Mr. Patricio Murgueytio ñ REDSALUD￾5:00 a.m. Mrs. Jaqueline Gonzalez, Consultant SENASA, Mrs. Maria Elena Tapia, SISUM 
Coordinator, Dr. Adolfo Sagredo, PROMESA 
7:30 p.m. Dr. Fulgencio Severino, Manager of the SS in the Dominican College of Medicine 
TUESDAY 03/23/04 
11:00 a.m. Dra. Alma Bobadilla ñ SENASA- 
 4:00 p.m. Dr. Bernardo DefillÛ ñ SISALRIL￾WEDNESDAY 03/24/04 
 9:00 a.m. Lic. NÈlsida Marmolejos - DIDA ñ 
Evaluation of REDSALUD and USAID/DR Strategy 34 
10:00 a.m. Lic. Arismendy DÌaz Santana ñ Gerente General SS￾1:00 p.m. Gisela Quiteria -BANCO MUNDIAL￾2:30 p.m. JosuÈ Ceballos ñ BID￾7:30 p.m. Carmen Adames -INSALUD￾THURSDAY 03/25/04 
9:00 a.m. Dra. Martha Butler, Director of CONECTA 
2:15 a.m. Sarah Majerowicz, Marina Taveras -USAID￾3:00 a.m. Luis Gonz·lez, Manuel Ortega, Don Harrinton, Lissette Dumit -USAID￾FRIDAY 03/26/04 
9:00 a.m. Work-team meeting 
SATURDAY 03/27/04 
9:00a.m. Work-team meeting 
SUNDAY 03/28/04 
Trip to Bayahibe, Region V 
MONDAY 03/29/04 
8:30 a.m. Visit to Los Mulos, Meeting with community representatives and technician 
10:00 a.m. Hospital Provincial La Altagracia, Higuey, Meeting with Dr. HÈctor Peguero, 
Director. 
12:00 a.m. Dr. Mercedes Torres, Director of El Seybo Province 
2:00 p.m. Dr. Francisca Gil, Director, El Seybo Provincial Hospital 
3:30 p.m. Miches Rural Clinic 
TUESDAY 03/30/04 
9:30 a.m. Provincial Management of Hato Mayor, Meeting with Dra. Raquel Ogando 
11:00 a.m. Villa Ortega Rural Clinic, Hato Mayor 
12:00 a.m. Visit of Antonio Mussa Hospital, San Pedro de MacorÌs, Dr. Mazzara, Director. 
Evaluation of REDSALUD and USAID/DR Strategy 35 
WEDNESDAY 03/31/04 
10:00 a.m. Dr. Milton Ray Guevara - State Secretariat of Employment - 
THURSDAY 04/01/04 
10:00 a.m. Nuestra SeÒora de Regla Hospital, BanÌ 
4:00 p.m. Team Meeting 
5:30 p.m. Foro Ciudadano 
FRIDAY 04/02/04 
8:00 a.m. Sarah Majerowicz, Marina Taveras USAID 
11:00 a.m. Report Presentation, USAID-REDSALUD 
SATURDAY 04/03/04 
Team Meeting 
Evaluation of REDSALUD and USAID/DR Strategy 36 
ANNEX II THE DOMINICAN GOVERNMENTS 
AND HEALTH REFORM
During the administration of Joaquin Balaguer, an environment for health reform began to 
grow, due to accumulated deficiencies and dissatisfaction with the current system, and through 
the reform example set by other countries in Latin America. Likewise, reform processes in the 
education sector following the Decennial Plan paved the way for reforms in other areas. In 1992, 
the government of Joaquin Balaguer arranged for technical assistance through the United Nations 
Development Program (UNDP) to analyze the health sector and to propose answers to its 
problems. This assistance was led by Dr. Guido Miranda, a consultant from Costa Rica, with the 
participation of approximately 50 Dominicans. 
Based on the results of this process, the government formed the National Health Commission 
(CNS) under the leadership of the then Minister of Health. This commission was staffed through 
the Technical Coordination Office (OCT) with the leadership of Dr. Fernando Rojas. In 1993, 
the government solicited support from the World Bank and The Inter-American Development 
Bank to support the CNS and its OCT in the formulation of an investment plan to improve the 
Dominican health system. The OCT, with the support of the WB and the IDB, formulated the 
influential health document: A Vision of the Future/Una Vision del Futuro, which contained a 
proposal for wide reform. Furthermore, the Pan-American Health Office (OPS) provided 
technical assistance to a group of technicians from SESPAS to formulate a plan for the reforms. 
INSALUD sought the participation of NGOs in formulating any reform. Meanwhile, the 
business sector, through the National Council of Private Companies (CONEP), was attempting to 
change the Social Security system since many companies were receiving double quotes; one 
from the Dominican Institute of Social Security (IDSS) and others from the insurance or medical 
stipend, which they also paid. 
In 1996, the administration of Leonel Fernández began by focusing on the decentralization of 
the central government. This was reflected in the health sector by the creation of the Provincial 
Health Management Units (DPSís) in 1997. Based on the technical assistance arranged by the 
previous administration, the government of Leonel Fern·ndez signed and initiated the operation 
of loans from the World Bank and the IDB to support the reform, and in 1998, the Executive 
Commission for the Health Sector Reform (CERSS) was created and these newly created health 
sector institutions began operations. 
The current administration of Hipólito Mejía, which began in the year 2000, continues the 
previous efforts of reform, signaled in great part by the approval of the General Health Law and 
the creation of a new Social Security System. The year 2000 also marked the start of the 
PROSISA and REDSALUD projects. Later, on November 1, 2002, the Family Health Insurance 
subsidized scheme in Region V of the country began operations. 
Evaluation of REDSALUD and USAID/DR Strategy 37 
ANNEX III MAIN RESULTS OF THE REFORM PROCESS 
REGULATION 
a) Development of evaluation/rating/authorization/accreditation norms, placing 
responsibility for this function within the Authorization and Accreditation Unit of 
SESPAS, and initiation of the provisional accreditation of establishments. 
b) Development and diffusion of the healthcare norms. 
c) Development of the 220 pharmaco-therapeutic protocols with the cooperation of the 
societies of the main pathological clinics. 
d) Development and dissemination of healthcare prevention and treatment norms for the 
primary diseases present in the country. 
STATE SECRETARIAT OF PUBLIC HEALTH AND SOCIAL ASSISTANCE
Internal Unit of Modernization 
a) Launch of the Modernization and Institutional Development Unit (UMDI) of SESPAS, 
which is currently fully operational. 
Health Plan 
a) The Decennial Health Plan, which will establish the main objectives of the health sector 
for the next 10 years and the necessary actions to achieve them, is in progress. 
Organizational Structure 
a) The new organizational structure of the Secretariat was designed and implemented. 
Financial Management 
a) Formulation of the 2003 and 2004 budgets with a new methodology that is based per 
program on the national and institutional health priorities. 
b) Implementation, in Central SESPAS, of a financial management computer system. 
c) Assets inventory of the institution and installation of the computer system for asset 
management. This system covers Central SESPAS and its hospitals. 
DE-CONCENTRATION AND DECENTRALIZATION
a) In 1997, 38 Provincial Managements (DPS) and Health Areas (AS) were established, 
which initiated the institutional decentralization process. The structure, function, position 
profiles and teamsí performance expectations within these organization were also 
defined. 
b) Promulgation of the Separation Regulation of SESPAS, which legally establishes the 
separation of the governing/management of public health and the provision of individual 
service delivery. 
Evaluation of REDSALUD and USAID/DR Strategy 38 
General Information System 
a) Conceptual Design of a single system of epidemiological information and surveillance. 
b) Development of the Geographic Health Information System. 
c) New Payroll System 
Health Services 
d) Completion of a statutory proposal that defines the organization of the regional health 
services. 
e) The basic functions of public health were defined and an institutional commitment was 
made to assume such functions. 
f) A new model of care has been defined which emphasizes and establishes territorial 
service delivery areas, each with a population between 500 and 700 families. Various 
basic instruments of the operation of primary healthcare services have been defined as 
well as developed: family files, community participation guide, file processing system, 
etc... 
g) Implementation of pilot primary care experience with a mixed network of supply, a new 
method of financing and top user satisfaction in the Azua, San Juan and Elias PiÒa 
provinces benefiting approximately 250,000 people. 
h) Development and support for the signing of six management agreements with five of the 
main clinical establishments of the country. However, these agreements did not receive 
proper follow up or an effective evaluation. 
i) Establishment of an office and a user care system in six hospitals of Health Region V. 
j) Various modernization activities in the area of hospital management have been executed. 
The six hospitals of the FONHOSPITAL project and of Jaime Mota can be highlighted. 
Also, a Hospital Management Strengthening Project in Health Region V is being carried 
out. 
Human Resources System 
a) Human Resources census and development of the computer system for the handling of 
the database. The database is currently not updated. 
b) Design of six human resources subsystems. However, there are no implementation 
actions currently in place. 
MEDICINE AND SUPPLY SYSTEM 
a) Promulgation of the Presidential Decree 991-00 which converts PROMESE into a 
Logistical Support Center (CAL). 
b) New public procurement methodologies in PROMESE/CAL that since 2002 have 
increased transparency of the procurement process and the quality of the acquired 
medicines. 
c) Advanced phase of the development of new rules for medicines. 
Evaluation of REDSALUD and USAID/DR Strategy 39 
d) New organizational chart, procedure manuals, product approval/ homologation guide, 
physical modernization and new management module of the PROMESE/CAL 
warehouse. 
e) Experience in 20 pharmacies of the main hospitals of the country, which has allowed the 
rationalization of the acquisition, dispensation and storage of supply. Likewise, the 
dispensation of unitary doses (UNIDOSIS) has been initiated. 
f) Equipping, new organizational structure design, identification of basic functions, and 
furnishing of the Pharmacy and Drugs Division of SESPAS in order to execute a 
management role within medicines subsystem. 
g) Reorganization, furnishing and training of personnel at the Dr. DefillÛ National 
Laboratory. 
THE DOMINICAN INSTITUTE OF SOCIAL SECURITY (IDSS) 
a) Separation of funds by Business Units. 
b) Structuring of the Secure Health ARS (Salud Segura ñARS). 
c) Institutional preparation for administration of the Labor Risks Insurance. 
d) Creation of Analytical Management Units in the main office, 17 hospitals and 28 
policlinics (outpatient clinics) and execution of productivity and cost studies for these 
establishments. 
TRAINING 
a) Large quantity of technical and administrative training activities. 
b) Various working days have been approved for formal training such as Masterís degree 
and postgraduate studies work. 
Evaluation of REDSALUD and USAID/DR Strategy 40 
ANNEX IV PRINCIPAL STRUCTURAL PROBLEMS OF THE 
DOMINICAN HEALTH SYSTEM, STRATEGIC 
APPROACH OF THE REFORM AND GENERAL 
ATTAINED RESULTS
STRUCTURAL PROBLEM: INSUFFICIENT COVERAGE 
Strategic Approach of the Reform: 
• Coverage Extension 
• Change from Supply Financing to Demand Financing 
• Regulatory Centralization and Operative Decentralization 
• Allocation of Resources by Results, including Penalties and Incentives 
• Development of a Formal Universal Insurance System with a PBS (Basic Health Plan) and 
training 
• Focus on Primary Care 
General Results of the Reform Process: 
• Creation of a new legal and regulatory framework 
• Generation of social coordination, negotiation, and supervision among the main players of 
the sector 
• Creation of the New Social Security System Institutions 
• Initiation of the Subsidized regimen of Family Health Insurance in Health Region IV 
STRUCTURAL PROBLEM: LACK OF EQUITY 
Strategic Approach of the Reform: 
• Coverage Extension 
• Change from Supply Financing to Demand Financing 
• Reinforcement of the State Governing Function, Regulation, and Supervision 
• Strengthening of Public Health 
• Normative Centralization and Operative Decentralization 
• Development of a Formal Universal Insurance System with a PBS and Training 
• Greater Levels of Social Participation and Accountability 
Evaluation of REDSALUD and USAID/DR Strategy 41 
General Results of the Reform Process: 
• Creation of a new legal and regulatory framework 
• Creation of the New Social Security System Institutions 
• Initiation of the Subsidized regimen of Family Health Insurance in Health Region IV 
• Separation of SESPAS functions 
STRUCTURAL PROBLEM: CENTRALIZED AND VERTICAL HEALTH INSTITUTIONS 
Strategic Approach of the Reform: 
• Separation of Functions 
• Regulations Centralization and Operative Decentralization 
General Results of the Reform Process: 
• Creation of a new legal and regulatory framework 
• Separation of SESPAS functions 
STRUCTURAL PROBLEM: INEFFICIENCIES DUE TO POOR MANAGEMENT
Strategic Approach of the Reform: 
• Separation of Functions 
• Change from Supply Financing to Demand Financing 
• Strengthening of Public Health 
• Regulatory Centralization and Operative Decentralization 
• Allocation of Resources by Results, including Penalties and Incentives 
• Greater Levels of Social Participation and Accountability 
• Focus on Primary Care 
• Extended and Integrated Information Systems 
• Encouragement of New Management Methods 
• Development of a Single Collection System 
General Results of the Reform Process: 
• Generation of social coordination, negotiation and supervision among the main players of the 
sector 
• Creation of the New Social Security System Institutions 
Evaluation of REDSALUD and USAID/DR Strategy 42 
• Preparation of a critical mass of technical and administrative personnel to manage the system 
• Improvement of the infrastructure, furnishing, and implementation of the computer systems 
• Separation of SESPAS functions 
STRUCTURAL PROBLEM: MULTIPLICITY OF INSURANCE SCHEMES
Strategic Approach of the Reform: 
• Develop a formal Universal Insurance System with a PBS and Training 
• Develop a single Collection System 
General Results of the Reform Process: 
• Creation of a new legal and regulatory framework 
• Creation of the New Social Security System Institutions 
• Initiation of the Subsidized regimen of Family Health Insurance in the IV Health Region 
STRUCTURAL PROBLEM: LACK OF COMMUNITY PARTICIPATION IN MANAGEMENT 
AND SUPERVISION
Strategic Approach of the Reform: 
• Greater Levels of Social Participation and Accountability 
General Results of the Reform Process: 
• Creation of a new legal and regulatory framework 
• Generation of social coordination, negotiation and supervision among the main players of the 
sector
• General public awareness of the reform process 
STRUCTURAL PROBLEM: INSUFFICIENT AND INADEQUATE PUBLIC HEALTH EXPENDITURE
Strategic Approach of the Reform: 
• Separation of Functions 
• Shift from Supply Financing to Demand Financing 
• Strengthening of the Public Health sector 
• Regulatory Centralization and Operative Decentralization 
Evaluation of REDSALUD and USAID/DR Strategy 43 
• Allocation of Resources by Results, Penalties and Incentives 
• Development of a formal Universal Insurance System with a PBS and Training 
• Greater Levels of Social Participation and Accountability 
• Focus on Primary Care 
• Encouragement of New Management Methods 
STRUCTURAL PROBLEM: WEAKNESSES IN THE PUBLIC HEALTH PROGRAMS 
Strategic Approach of the Reform 
• Separation of Functions 
• Shift from Supply Financing to Demand Financing 
• Reinforcement of the State Governing Function, Regulation, and Supervision 
• Strengthening of Public Health 
• Regulatory Centralization and Operative Decentralization 
• Allocation of Resources by Results, Penalties and Incentives 
• Focus on Primary Care 
• Extended and Integrated Information Systems 
General Results of the Reform Process 
• Preparation of a critical mass of technical and administrative personnel to manage the system 
• Improvement in the infrastructure, furnishing, and implementation of the computer systems 
• Functional separation within SESPAS 
Evaluation of REDSALUD and USAID/DR Strategy 44 
ANNEX V USAID OPTIONS TO SUPPORT THE REFORM 
IN THE MEDIUM TERM 
There are various ways in which USAID can continue its support of the reform process in the 
midterm. 
1. Extend REDSALUD’s Contract 
This option has the advantage of the project already operating, a highly experienced team, and 
continuous contact with key players in the process. A disadvantage may be that an extension 
without competition could be negatively perceived by alternative technical assistance 
contractors. Furthermore, if USAID wishes to redirect its support, it will be more difficult with a 
team which already has a defined approach. 
2. Exercise the option of reform support that the CONECTA contract contains 
The advantage of this option is that the mechanism is already established and that the project is 
already operating in the country. Given that REDSALUD and CONECTA are executed by some 
of the same agencies (Abt and FHI), an easy transition can be expected. Another possible 
advantage is that the integration of support activities to the reform process under CONECTA 
could lead to a larger focus towards reform within the CONECTA project. There is the risk, 
however, that the process may be altered if the multiple CONECTA lines of action and priorities 
dilute or hinder an adequate orientation towards reform support activities. 
3. Acquire technical assistance through field support from the Global Health Bureau 
The advantage of this option is that various projects with health reform components already exist 
and are already operating with highly experienced teams. It could also be easily executed by 
USAID. Depending on the focus given to this phase, USAID could use PHRplus, POLICY, 
M&L, Measure Evaluation, QAWD and/or others. 
4. Acquire technical assistance through a task order under TASC II 
In addition to the current projects mentioned above that have health reform experience, the 
Mission has the option of looking for a tailored response through the TASC II IQC mechanism. 
The advantage of this mechanism is that it includes a wide range of possible contractors who are 
already pre-qualified, which allows the Mission to save time and effort. The Mission could also 
consider issuing a task order with an extension option to continue the activities under the new 
strategy as long as they are compatible. The disadvantage of this mechanism is that the Mission 
would not have access to all possible contractors who may have experience in health reform, 
since there are a limited number of TASC II contract holders.