Programs offered through the Secretariat of State for Public Health and Social Welfare (Secretaria de Estado de Salud Pública y Asistencia Social--SESPAS) covered 70 to 80 percent of the population in the late 1980s. The Dominican Social Security Institute (Instituto Dominicano de Seguro Social) covered another 5 percent (or 13 percent of the economically active population), and the medical facilities of the armed forces reached an additional 3 to 4 percent. SESPAS had a regionally based, fivetiered health care system designed to bring primary care to the whole population. The services ranged from specialized hospitals in the National District to rural clinics scattered throughout the countryside.

Both personnel and facilities were concentrated in the two largest cities (see table 4, Appendix A). There were roughly 3,700 inhabitants per physician nationally, for example, but this figure ranged from about 1,650 in the National District to roughly 5,000 in some southeast provinces and in the southcentral provinces. Similarly, more than half of all hospital beds were in the National District and the central Cibao.

SESPAS began a major effort to improve rural health care in the mid-1970s. By the early 1980s, the government had set up more than 5,000 rural health clinics, health subcenters, and satellite clinics. Doctors, performing their required year of social services, as well as a variety of locally hired and trained auxiliary personnel staffed the facilities. Critics charged that lack of coordination and inadequate management hampered the program's effectiveness, however. Preventive services offered through local health workers (who were often poorly trained in disease prevention and in basic sanitation) were not coordinated with curative services. In addition, absenteeism was high, and supplies were lacking. In 1982 there were approximately 2,500 physicians in the country (a ratio of one physician to 2,600 inhabitants) and 516 dentists.

Life expectancy at birth was 62.6 years for the 1980-84 period, 60.9 years for males and 63.4 for females. The crude mortality rate was 4.7 per 1,000 population in 1981. The infant mortality rate was 31.7 per 1,000 live births in 1982--down from 43.5 per 1,000 in 1975. Early childhood mortality declined from 5.9 per 1,000 in 1970 to 3.2 in 1980. The main causes of death in the population as a whole were pulmonary circulatory diseases and intestinal diseases (see table 5, Appendix A). Enteritis, diarrheal diseases, and protein energy malnutrition were the major causes of death in those under four. Maternal mortality in 1980 was 1.66 deaths per 1,000 live births. The main causes were toxemia, hemorrhages, and sepsis associated with birth or abortion. Roughly 60 percent of births were attended by medical personnel. As of late 1988, the Dominican Republic had reported 701 cases of Acquired Immune Deficiency Syndrome (AIDS) of these, 65 had died. Studies of the human immunodeficiency virus conducteded7 ed in 1986 among sample groups of Dominican homosexual and bisexual males indicated an infection rate of 8.3 percent, much lower than the 70 percent rate detected in some similar sample groups in the United States.

Social security coverage included old-age pensions, disability pensions, survivors' and maternity benefits, and compensation for work injuries. General tax revenues supplemented employer and employee contributions. Wage earners, government employees (under special provisions), and domestic and agricultural workers were eligible, although the benefits that most domestic and farm workers received were quite limited. Permanent workers whose salaries exceeded 122 Dominican Republic pesos (RD$--for value of the peso, see Glossary) per week and the self-employed were excluded. In the early 1980s, more than 200,000 workers were enrolled. They represented only about 13 percent of the economically active population, or approximately 22 percent of wage earners. Most of those enrolled were in manufacturing, commerce, and construction.

Although the level of government services exceeded that of the republic's impoverished neighbor, Haiti, limited resources, inefficiency, and a lagging economy circumscribed the overall impact of these programs. In 1985 some 8.8 percent of the national budget supported health services and an additional 6.9 percent funded social security and welfare programs. From the perspective of the late 1980s, there appeared little prospect for major improvement in the quality of life for most Dominicans by the end of the twentieth century.

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There is a wealth of information on rural life and the changing rural-urban context in the Dominican Republic. Kenneth Sharpe's Peasant Politics, Glenn Hendricks's The Dominican Diaspora, Patricia R. Pessar's works, and Malcolm T. Walker's Politics and the Power Structure, all give a sense of the constraints most Dominicans must deal with. Jan Knippers Black's The Dominican Republic: Politics and Development in an Unsovereign State and H. Hoetink's The Dominican People are both valuable background reading. Sherri Grasmuck's "Migration within the Periphery: Haitian Labor in the Dominican Sugar and Coffee Industries" details the contemporary situation of Haitians in the Dominican Republic. José del Castillo and Martin F. Murphy describe the broad outlines of emigration and immigration in "Migration, National Identity, and Cultural Policy in the Dominican Republic." "Agricultural Development, the Economic Crisis, and Rural Women in the Dominican Republic," by Belkis Mones and Lydia Grant, describes the ways in which rural women earn a living. (For further information and complete citations, see Bibliography.)

Data as of December 1989