The national health system of the Dominican Republic reaches only about half the population and has a high urban-rural disparity. The majority of the inhabitants of the Dominican Republic live in urban areas (78%) (World Bank 2016). In these areas, in addition to state hospitals, the so-called “hospitales”, there are also private hospitals known as “clinics”. The care in private hospitals is of good quality, but for most Dominicans it is not financially manageable. In the state hospitals, on the other hand, the services are relatively cheap and accessible to all people, yet the poorer sections of the population only have difficult access to medicines. In rural areas of the Dominican Republic there is a lack of medical care and personnel (Rathé & Moliné 2011, Canario et al. 2016). In 2008, the nationwide doctor-patient ratio was 1.3/1,000 and the nurse-patient ratio 0.25/1,000 (in comparison, Germany has 95.2 nurses per 1,000 patients (Aiken et al. 2012/2014)). The majority of the older population over the age of 65 is not covered by social security systems, which poses major challenges for the health and social services (Medrano et al. 2014, Falk et al. 2017). At the same time, pension coverage in the Dominican Republic is very low and older Dominicans often live in precarious housing conditions (Prince et al. 2008). 11.7% of over-65s are dependent on support and care. Globally, these figures are expected to increase significantly in the coming years, especially in low and middle income countries (WHO 2018). On average, people have to spend 30% of their income on care services. There is currently no social support system for carers in the DR (Sousa et al. 2009).
According to the WHO, 42% of years of life lost are due to communicable diseases and 42% to non-communicable diseases (Boslaugh 2013). Among the most urgent health problems in the Dominican Republic are malnutrition and lack of access to clean (drinking) water, especially for young children in rural areas, as well as infectious diseases such as diarrhoea, pneumonia and HIV/AIDS. The number of HIV-infected adults aged 15 to 49 is currently around 67,000 (0.9% of the population, [51,000 – 91,000]) in the DR and 150,000 (1.9% of the population, [140,000 – 170,000]) in Haiti (UNAIDS 2017).
However, rising life expectancy also makes noncommunicable diseases such as dementia a global problem for the health system and its service providers. The same applies to diabetes, depression, musculoskeletal disorders, chronic obstructive pulmonary disease, obesity (30% of the population), hypertension and other cardiovascular diseases (Sousa et al. 2009, Canario et al. 2016). The collective term dementia (ICD-10-Code F00-F03) describes chronic diseases of the brain that coincide with a creeping decline in cognitive, emotional and social abilities. Although prevalence rates in low and middle-income countries are currently lower than in high-income countries, the number of people affected in these countries is expected to rise disproportionately in the future due to the rapid ageing of the population (Prince et al. 2015). Of the approximately 9.9 million new cases per year, 63% are recorded in low and middle-income countries. According to WHO (2017), the number of people with dementia worldwide will rise to about 251 million by 2050 (WHO 2017). This expected increase will hit countries with health systems that are unprepared and underfunded particularly hard (Rodriguez et al. 2008). Especially in countries with low incomes, a high number of HIV-associated dementias must also be expected. Although the incidence of HIV-associated dementias has fallen slightly in recent years in the DR, the number of people affected remains high due to a lack of use of drug therapies and a high prevalence of infections (Rosca et al. 2012).
Another problem is the relationship between dementia and weight loss, which increases the risk of mortality. A comparison of prevalence data on weight loss and dementia showed that the Dominican Republic had the highest prevalence in the comparison group with 26%, while China had the lowest prevalence (2%) (Albanese et al. 2013). Other classical dementia symptoms are also important. In addition to limitations in orientation and behavioural changes with increasing life expectancy, these also include multimorbidity and limitations in the area of physical activity, including fall problems. Currently, only very few studies from low and middle-income countries can be used for this purpose, which clearly shows the increased need for research (Llibre Rodríguez 2013, Arinzechi et al. 2016).
Since the health and social system of the Dominican Republic is fully available to only a few inhabitants, the families and the social environment have to bear the burden of caring for the sick. This creates a high burden within the family structures. In particular, the occurrence of stress, anxiety and depression is increasingly described. In addition to the lack of support from the health system, the main problem is the lack of outpatient and local support services (Medrano et al. 2014).