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Context

The following information is on the context and system factors in the Dominican Republic that may have played a role in the response to COVID-19 and the maintenance of essential health services. Context and systems factors cannot easily be changed when an outbreak occurs, whereas policies or interventions can.

Exemplars in COVID-19 conceptual framework for assessing epidemic preparedness and response

Contextual factors

Although our research focuses primarily on the policy choices made by officials during the COVID-19 pandemic, a country’s ability to limit COVID-19 transmission and related deaths could also be attributed to contextual factors, including those below..

A country’s population demographics, such as age structure and population density, may contribute to pandemic outcomes, such as the number of cases and deaths (see figure below).

Pre-pandemic health context in the Dominican Republic

IHME

The following underlying population-level health characteristics may have shaped the Dominican Republic’s experience in the early months of the COVID-19 pandemic:

Age structure

Although the Dominican Republic’s population has aged in recent years, it is still relatively young: the country’s median age is 28 years,1 and the average life expectancy was 74 years in 2020.2

Elderly adults are significantly more likely to die from COVID-19 than younger adults and children.3 Countries around the world vary widely in their age structures: in some African countries, fewer than 2 percent of the population is 70 years or older, while in some European countries that share is more than 15 percent.4 Some research suggests that accounting for variation in age structure between countries may explain nearly 50 percent of the variation in COVID-19 mortality.5

 

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Chronic health conditions

The Dominican Republic’s disease burden has shifted away from communicable diseases, such as diarrheal diseases and tuberculosis, and has moved toward chronic noncommunicable diseases such as ischemic heart disease, stroke, diabetes, cirrhosis, and chronic kidney disease.6,7 However, because the primary health care level has such limited capacity, treatment of these conditions at the primary level is limited and most cases are treated at the specialized level.

Despite rapid economic growth, the country continues to have high levels of maternal and child deaths, with 95 maternal deaths per 100,000 live births, and 23 neonatal deaths and 28 infant deaths per 1,000 live births.8 According to the Institute for Health Metrics and Evaluation, from 1990 to 2019, neonatal disorders were the most common communicable, maternal, neonatal, and nutritional diseases to contribute to the burden of disease in the Dominican Republic.9 These rates are substantially worse than those found in other Latin American and Caribbean countries, although the number of hospital beds, doctors and nurses, institutional deliveries, and deliveries with qualified doctors are comparatively better in the Dominican Republic. This discrepancy raises concerns about access to and quality of services, such as known gaps in access to care between urban and rural populations.

Chronic noncommunicable diseases are increasingly prevalent causes of death in the Dominican Republic. Despite this, health services for some of these diseases, such as directly observed treatment for tuberculosis and HIV treatment, were disrupted during the COVID-19 pandemic. The country faced challenges in maintaining routine maternal and neonatal services, in part because of mobility restrictions and transportation difficulties, shortages of some essential supplies and personal protective equipment, and reduction of working hours for health care providers. As a result, infant and maternal mortality remained high in 2020, with 28 infant deaths per 1,000 live births and 137 maternal deaths per 100,000 births.

Age-standardized prevalence (%) of major noncommunicable diseases in the Dominican Republic, 2019

IHME

A variety of chronic health conditions like high blood pressure, diabetes, and cardiovascular disease are associated with greater rates of mortality from COVID-19.3 HIV can make individuals susceptible to infectious diseases because of how it impacts the immune system. Similarly, cancer and cancer treatments like chemotherapy frequently disrupt the immune system, leaving individuals vulnerable to severe infection.10

 

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Smoking prevalence and ambient air pollution

The Dominican Republic is among the world’s leading exporters of cigars and tobacco, 11 and some studies show relatively high rates of tobacco use and exposure. For example, one 1990 study estimated that 66% of adult men smoked tobacco, the highest rate in the region of the Americas.12 In 2015, researchers estimated that 18% of men and 8% of women were smokers.13

According to one recent assessment, people living in urban areas of the Dominican Republic are exposed to levels of air pollution that exceed World Health Organization (WHO) guidelines. WHO attributes thousands of premature deaths to outdoor pollution exposure in the Dominican Republic every year.14

Fine particulate matter, especially matter small enough to reach the deepest part of the lungs, causes chronic pulmonary injury and inflammation.3,15 Individuals exposed to these particles may be more likely to be infected with respiratory pathogens and to have more severe outcomes.

According to the World Bank, the Dominican Republic is an upper-middle-income country17 that has experienced rapid economic growth in recent decades. Between 1990 and 2019, gross domestic product (GDP) growth per capita averaged approximately 5% per year, typically higher than its neighbors18 and much higher than average for the Latin America and Caribbean region.19

As a result of this growth, poverty has declined, and the equity of income distribution has improved in recent years. In 2016, 29% of the population in the Dominican Republic lived at or below the national poverty line and 4.5% lived in extreme poverty; three years later, 21% lived in poverty and 2.7% in extreme poverty.20,21 However, these numbers increased again during the COVID-19 pandemic: by 2021, 23.9% of the population lived in poverty and 3.1% in extreme poverty.22 Access to basic services has increased along with income: in 2019, 97% of the population had at least basic water access and 87% had access to basic sanitation,23 which is comparable to other Latin American and Caribbean countries.24

Tourism is a key economic sector in the Dominican Republic. In 2019, tourism earned more than US$7 billion in revenue, more than any other country in Latin America and the Caribbean, and officially represented more than 8% of the country’s economy (although the Ministry of Tourism calculated its impact as nearly one-third of the economy that year).25 Tourism thus played a large role in the onset of COVID-19 in the Dominican Republic. The first confirmed case in the Dominican Republic was a tourist from Italy, 26,27 and the first death was a traveler who had recently returned from Spain. In March 2020, the borders were completely closed, which had a substantial effect on the economy. In July 2020, the borders reopened, with important public health measures adopted in tourist areas to avoid transmission and protect tourists. To entice visitors and keep hospitality workers and others safe from infection, the country relied on mass vaccination of its citizens when vaccines became available. It also offered tourists free health and travel insurance, subsidized by the Dominican Republic Ministry of Tourism,28 in case they became infected with COVID-19 and needed to quarantine.

Many of the emergency preparedness structures in place were developed in response to earlier public health emergencies in the Dominican Republic, such as other infectious diseases outbreaks and extreme weather events.

Since 2000, the Dominican Republic has experienced outbreaks of diseases with epidemic potential such as Zika in 2016–201729 and chikungunya in 2014,30 as well as the avian influenza virus (AH5N1) and dengue.31 In 2002, a new law on risk management created a National System for Prevention, Mitigation, and Response to Disasters.32 The National Council for Prevention, Mitigation and Response to Disasters, chaired by the country’s president, coordinates multiphase emergency response plans. These plans include pre-outbreak monitoring and community outreach aimed at preventing the spread of disease, mid-epidemic prevention and response strategies aimed at treating patients and mitigating further spread, and post-epidemic reporting aimed at synthesizing lessons learned before the next outbreak.33

The outbreak preparedness and response plan officials put together for the 2014 chikungunya outbreak was the first of its kind in the Americas.34

As part of the country’s disaster response system, officials developed national communication plans, with radio and television messages in plain language addressing prevention, posters, and booklets for schools. The law also requires officials to prepare contingency plans with procedures for coordination, alert, mobilization, and response to emergency events such as epidemics or pandemics.35   Although these plans were not directly leveraged because of the evolving nature of the pandemic, they provided the government and community with a practice of collective mobilization toward containing health emergencies, which would serve them well in their response to COVID-19

System factors

Beyond policy interventions, other modifiable factors under the short-term control of countries and governments that can help shape countries’ pandemic outcomes (such as testing strategies, disease surveillance, laboratory capacities, contact tracing programs, case management, mobility restrictions, and surge response coordination), it is also important to consider preexisting system factors, such as the strength and structure of a country’s health care system and supply chains, in any analysis of a country’s COVID-19 preparedness and response.

In 2020, Forbes magazine called the Dominican Republic “the island of medical devices” for its status as the third leading supplier of medical and pharmaceutical devices in Latin America.36 This topic was not a high priority in our research; however, you can read more about the Dominican Republic’s work in medical devices below.

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In 2001, the Dominican government approved a new organization for its public health system. Law 87-01, which was meant to address ongoing challenges such as inequities in access to care, lack of financial protection for patients in the system, and a lack of accountability and quality in the public providers’ network, created a universal health insurance scheme.37 This Family Health Insurance system originally had three funding mechanisms: (1) a contributory regime financed by payroll taxes, (2) a subsidized regime for low-income and unemployed people financed by general taxes, and (3) a hybrid contributory-subsidized regime that was never implemented because it proved too difficult to collect contributions from the informal sector.

Health system financing in the Dominican Republic

Rathe and Moline (2011)

Insurance in the contributory regime is provided by private (i.e., for-profit and nonprofit) and public companies, which contract with a network of mostly private providers organized by levels of care. In the subsidized regime, one public insurer, the Seguro Nacional de Salud, contracts with public providers in the National Health Service network. If the Seguro Nacional de Salud cannot find quality services within the network, it can pay private providers for them instead.37

The reformed health system promised to provide universal coverage with access to the same basic package of services for the whole population. Under the supervision and stewardship of the government, a network of public and private providers and insurers would operate in a context of regulated competition for workers in the formal sector, which includes a little more than half of all workers in the Dominican Republic.37

Universal health care coverage index for health services in the Dominican Republic

GBD 2019 Universal Health Coverage Collaborators

 

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The Ministry of Public Health oversees governance, regulation, service provision in the public system, and essential public health functions. The National Social Security Council (CNSS) regulates the social security system, including the Family Health Insurance (SFS). The Superintendent of Health and Labor Risks (SISALRIL) is in charge of the supervision function of risk management. The Social Security Treasury is the public entity that collects all funding from different sources and transfers payment to health risk managers who, in turn, contract with health providers.37

The National Health Service, which coordinates the network of public providers, was meant to organize the network in an integrated, multilevel system whose first “gateway” level delivers essential health services to communities nationwide. However, this directive has not yet been implemented well, and the capacity of that gateway level is limited. As a result, the Dominican health system tends to be reactive and focused on treating acute cases, without a true preventive approach or strong community-based services.37

In 2019, the public provision network comprised 1,834 public health facilities, including 184 hospitals (11 regional, 27 provincial, and 124 municipal. The public network employed about 15,000 doctors in 2019, but only 27% were at the primary care level.38

Dominican Republic Ministry of Health executed budget by program, 2018–2021 (millions, Dominican pesos*)

DIGEPRES

Investment in the health system has been relatively low, with public spending on health care amounting to 2.7% and overall health expenditures amounting to 5% of the Dominican Republic’s GDP in 2019.39 The country’s lack of investment in public providers has resulted in low levels of service quality, especially at the primary care level, and limitations in infrastructure and equipment.

Overall health expenditure in the Americas as a proportion of gross domestic product, 2019

WHO Global Health Expenditure Database

Because this public system is most often used by low-income Dominicans, its shortcomings perpetuate inequity. Higher-income people avoid it by seeking care in the private sector, which serves the entire contributory regime (some 4.3 million people) plus subsidized patients for whom adequate services do not exist in the public network. Without this substantial private-sector support, the system would have fared worse.37

In response to the COVID-19 pandemic, public spending on health care increased to 3.4% of GDP in 2020 and 3.5% of GDP in 2021. This increased spending paid for the acquisition of tests, treatments, vaccines, infrastructure, and personnel.40   It also covered the cost of extending public insurance to 2 million unemployed people (many of whom work in the informal sector), or 20% of the population, after the new government took office in August 2020.41 As of June 2022, 98% of Dominicans have health insurance: 57% in the subsidized regime and 43% in the contributory regime.

The Dominican Republic, with its high-end private hospitals, is increasingly becoming a preferred destination for medical tourism. Findings from a study published in 201942 on medical tourism identified 19 high-end health facilities that provide services to these travelers, as well as the Dominican population of higher income or affiliated with the contributory regime. These facilities, some of which are internationally accredited, employed more than 1,000 medical specialists and treated more than 90,000 international patients (most from English-speaking Caribbean islands, the United States, and Canada) in 2017. That year, health tourism generated approximately US$247 million, 3% of total tourism income.

According to the 2019 Global Health Security Index,43 the Dominican Republic scored 38.3 (slightly below the average score of 40.2) in an assessment and benchmarking of health security and related capabilities. It ranked 91 out of 195 countries worldwide and 14 out of 34 countries in the Americas. In 2021, it scored 34.5 and ranked 103 out of 195.44 Among the greatest weaknesses the evaluation identified were the absence of a plan to address the shortage of human resources, the lack of evidence of an effective multisectoral communication system that can be deployed in the event of a health emergency, low priority for the care of health workers, and lack of a monitoring and evaluation plan.

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The Dominican Republic scored 52% on WHO’s 2019 Joint External Evaluation (JEE) of the International Health (IHR) core capacities.45 It scored 60% on the 2020 State Party Self-Assessment Annual Reporting (SPAR) score, which is an average of scores (out of 100) on key WHO health indicators in order to quantify a health system’s capacity.

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The SPAR identified weaknesses in the following areas of the Dominican Republic’s health system capacity: multisectoral coordination mechanisms, financing mechanisms and funds for the timely response to public health emergencies, human resources, planning for emergency preparedness and response, access to essential health services, and resources for emergency detection and response.45

Outbreak factors

The Dominican Republic experienced five pandemic waves between March 2020 and June 2022. After the initial wave in March 2020, peak case counts in July 2020 were associated with the relaxation of restrictions during the electoral campaign for the delayed national elections. In January 2021, the holiday season and relaxation of restrictions and enforcement of public health and social measures contributed to the third wave. Finally, the Omicron variant was responsible for high case counts at the end of 2021 and in early 2022.

Daily new confirmed COVID-19 cases per million people in the Dominican Republic, March 6, 2020 – December 31, 2021

OWID
The Dominican Republic’s case fatality rate, which exceeded 5% in March and April 2020, declined to less than 2% by September 2020, partially due to health personnel learning to better treat cases, and using aggressive treatment protocols in severe cases. In 2021, the case fatality rate hovered at approximately 1% of confirmed cases.46

Moving-average case fatality rate of COVID-19 in the Dominican Republic, September 1, 2020 – December 31, 2021

OWID

The case fatality rate in the Dominican Republic is low compared with other countries in Latin America and the Caribbean. Some researchers attribute it to the country´s young population, although other countries in the region, such as Mexico, have the same demographics and epidemiological characteristics but have worse outcomes.47 According to interviews with key informants, the Dominican Republic’s low fatality rate since August 2020 can be explained in part by the country’s aggressive treatment strategy for moderate and severe cases, and their commitment to early vaccination.48

The relative importance of the drivers of outcomes of interest during an epidemic or pandemic will depend on the nature of the specific pathogen. In the case of the COVID-19 pandemic, the SARS-CoV-2 virus is characterized by respiratory transmission by both symptomatic and asymptomatic individuals. The virus disproportionately impacts older adults and those with compromised immune systems and comorbidities. Although vaccines and therapies to reduce severe disease and fatal outcomes from SARS-Cov-2 were developed relatively quickly, this is not always the case for other pathogens with epidemic and pandemic potential.

For more information, please see How Does COVID-19 Compare With Past Epidemics and Pandemics?

Global and regional factors

The Dominican Republic shares the Caribbean Island of Hispaniola with Haiti.The Dominican Republic shares the Caribbean Island of Hispaniola with Haiti. On March 19, 2020, Haiti and the Dominican Republic closed their borders to tourists and visitors. The risk of COVID-19 transmission across the Haitian border into the DR was comparatively low, and viral spread from travelers from other countries was a much greater concern. The borders started to require testing on April 7 for those crossing between the two countries, however it was still limited for commercial purposes.49 Borders were reopened for tourists and visitors in July 2020 with safety measures, and testing and vaccination requirements were suspended in February 2022.

Respiratory viruses spread more easily through thin, dry air (and consequently at higher elevations) than through humid air.50 In different climates, outdoor temperature ranges can lead to increased congregating in climate-controlled indoor settings that can increase viral transmission potential.3 All these factors may influence how rapidly COVID-19 spreads in different countries and at different times of the year.

 

As climate change worsens, the risk of infectious disease outbreaks has increased, with climatic conditions becoming increasingly fertile ground for pathogenic transmission.51  Research has shown that many infectious diseases are susceptible to climate variability, flooding, droughts, and the animal and human migratory impact of a changing climate, leading to a rise in vector, food, and water-borne illness.52

A woman coming from Haiti wears a face mask as she gets her temperature checked and receives sanitizer gel at the border between Malpasse, in Haiti, and Jimani, in Dominican Republic, as the border remained open for commercial purposes, Jimani, Dominican Republic, October 29, 2020.
A woman coming from Haiti wears a face mask as she gets her temperature checked and receives sanitizer gel at the border between Malpasse, in Haiti, and Jimani, in Dominican Republic, as the border remained open for commercial purposes, Jimani, Dominican Republic, October 29, 2020.
Credit: Andres Martinez Cesares. © Reuters
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Appendix