Literature review
In this report, the authors reviewed qualitative and quantitative data sets and interviewed experts for clarification and further information. The primary sources for descriptive data were the Dominican Republic Ministry of Public Health, the Pan American Health Organization basic indicators data sets, and various national surveys, such as SEIA-Red Actúa and the World Health Organization (WHO) pulse surveys. These were used to contextualize the country’s health system, analyze disruptions in services, and identify important events and relevant policy during the pandemic. Furthermore, gray literature in the form of official documents from the Ministry of Health, Office of Epidemiology, National Health Service, and international sources such as WHO and the Global Health Security Index were analyzed. Newspaper articles were reviewed to identify specific policies and events in time. Information was also sought from peer-reviewed, published articles in Google Scholar regarding vaccination and treatment in the Dominican Republic; however, these were less relevant because few were specific to the country.
For quantitative analyses, we collected data from government institutions. The official online portals and daily bulletins of the Ministry of Public Health, General Directorate of Budget (Dirección General de Presupuesto, DIGEPRES), National Health Service (Servicio Nacional de Salud, SNS), National Health Insurance (Seguro Nacional de Salud, SeNaSa), and the Superintendent of Health and Labor Risks (Superintendencia de Salud y Riesgos Laborales, SISARIL) enabled us to follow the trajectory of health services, COVID-19 data, and immunizations. Statistics from Oxford’s Our World in Data, the World Development Indicators, the Health Information Platform for the Americas, and the Institute for Health Metrics and Evaluation were also used to contextualize and fill gaps in data.
We analyzed the reports and data and synthesized main findings that were relevant to the proposed objectives. With these data collected, analyzed, and synthesized, we then conducted interviews with key informants. After each interview, if applicable, other relevant recommended data were consulted.
Key informant interviews
In addition to reviewing documents and statistics, the research team conducted interviews with experts and other key informants. Experts were chosen based on their involvement in key facets of the COVID-19 response, knowledge of specific programs (e.g., vaccine rollout, protocol development), and for their general expertise in several fields. All personnel spoke about their general areas of expertise and no personal health or demographic information was included.
To identify the key actors, we focused on clarifying the objectives of the interview. We identified the level of knowledge and information on the subject and the type of relationships between the actors and their role in relation to COVID-19. We compiled a list of these actors, considering the previous context. We adapted the list as the interviews progressed and made changes based on obtained recommendations and findings, as well as availability and access.
We developed a general interview guide based on recommendations from the Johns Hopkins/Brown/Gates Ventures technical support team. The guide was then adapted according to the key informants interviewed because some of their knowledge and information was more specific to an essential service or to a particular or general topic; however, we allowed all respondents to reflect broadly, and we did not stick strictly to the guide.
Before conducting an interview, we adhered to Law No. 172-13, which establishes a framework for the comprehensive protection of personal data. The interviewer first informed the interviewee of the purpose for which the data might be used and who might be its recipients. Interviewees then explained the purpose of the project, as well as the possibility of the interested party to exercise the rights of access, rectification, and deletion of the data. The interviewer’s email, telephone number, and mailing address was also recorded for later contact if required. Permission was obtained before recording the conversation. After introductions and presentations, the interviewer began by following the guide in a semi-open manner, allowing the person to elaborate on any questions. After the interview was over, we transcribed the main conclusions, recommendations, and findings, and adapted the guide for subsequent interviews if required.
Qualitative data
Qualitative information extracted from the literature review and interviews with key actors was based on:
- Timelines of policies, government orders, and implemented decisions relevant to the COVID-19 pandemic and the maintenance of essential services.
- Characteristics of the COVID-19 epidemic in the country compared with other countries.
- National challenges faced in the context of maintaining essential services during the COVID-19 pandemic.
- Financial challenges and technological challenges.
- Strategies to respond to COVID-19, such as the national testing strategy, relevant policies enacted, lockdown measures, procurement, and national deployment of COVID-19 vaccines, among others.
- Identified challenges of the country in the COVID-19 pandemic and how they were addressed, and strengths and weaknesses of the response to COVID-19.
- Strategies to maintain essential health services that were prioritized over others and why. Changes in health-seeking behavior about specific essential health services.
- Successes and best practices in the country’s ability to maintain essential services and lessons learned from their experience during the COVID-19 pandemic.
- Other particularly interesting highlights or challenges that were discovered during the literature review and interviews.
We synthesized our findings from the quantitative and qualitative data as reflected in this report.
We monitored the behavior of multiple indicators during the pandemic, recording daily data as the public organizations published it. To explain the impact of COVID-19 and the effectiveness of the response, we relied on the number of COVID-19 cases, deaths, and tests; the positivity rate and death rate; and the bed and intensive care unit occupancy—in conjunction with interview results, implemented policies, and comparisons with other countries’ results. We also tracked data on COVID-19 immunization rates, including the number of first, second, and third doses administered, and the percentage of vaccinated people with each dose by age group.
The data used to draw conclusions on the maintenance of essential health services originated mostly from government institutions. Changes and reallocations in the Ministry of Health’s spending were reviewed for specific programs, which suggested the number of resources dedicated to maintaining essential services during the pandemic. In addition, we analyzed changes in the quantity of consultations and services provided in the public network, at a yearly and monthly level, to measure variations during the pandemic, based on data from the National Health Service databases. Data from government and private health risk administrators and providers were also observed for any changes in services provided and their paid value. This information enabled us to monitor health service delivery and prevention efforts, and the differences between primary and secondary care behavior.
Data sets
Data sets from government organizations that depicted the services provided and paid for and resources designated to certain programs were helpful to understand how essential health services responded during the pandemic. In this sense, databases from the SNS, SISALRIL, SeNaSa, and DIGEPRES proved to be the most efficient. The datasets were at times limited, however, and did not always provide the level of detail needed. Instead they were sometimes reported in a summary format without the raw data readily available for the public to manage. Most data sets did not enable specification. Having access to data with more detailed disaggregation (such as monthly data or more specific branches of certain services) would have been ideal.
Data for the year 2021 were also limited, as some organizations did not immediately update their information. The Dominican Republic government tracked COVID-19 indicators and vaccination data and published them daily, but it would have been preferable for the information to be compiled in a more accessible way. For example, the COVID-19 daily reports are published in PDF format, which made arranging that data more time-consuming than if it had been updated in a single data file. This is especially the case for vaccination, in which rates are updated daily, and therefore finding historical compilations was more challenging. International organizations helped fill these gaps, such as Oxford’s Our World in Data, which collected the vaccination status from the beginning. Data sets from the Institute for Health Metrics and Evaluation, the World Bank, the World Health Organization, and Pan American Health Organization were also useful to provide context and cross-country comparison.
In terms of accessibility, we had to continually request permission to use specific and detailed information, which usually did not pose any problems, but it made data collection more challenging than if the data were available with enough detail on official websites. In some cases, however, we were unable to obtain sufficient information. For example, when the research team asked DIGEPRES for detailed information about COVID-19 spending, they were unable to obtain solid data and received only isolated information from different sources (including DIGEPRES itself, the memory of the Ministry of Public Health, and the accountability speech of the President of the Republic before the National Assembly in 2022).