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How did the Dominican Republic respond to the COVID-19 pandemic?

The following section covers the interventions that were deployed in the Dominican Republic between March 2020 and February 2022 to respond to COVID-19 and maintain essential health services (EHS). Unlike context and systems factors which cannot easily be changed when an outbreak occurs, policies or interventions can. Interventions during the early months of the coronavirus pandemic in the Dominican Republic fell into three main categories: national, governmental, and population-level measures, health system-level measures, and patient-level measures.

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

Early in the COVID-19 pandemic, the Dominican Republic was among the hardest-hit countries in Latin America and the Caribbean. In this first phase, daily case counts peaked at the end of July 2020, with nearly 1,800 new infections reported on July 31, 1 or about 135 cases per million people—more cases per million than any other country in the region except Brazil, Panama, and Colombia.2 Daily deaths spiked in early April 2020, although death counts per million people were comparatively lower than its neighbors’ (see figure below). The Dominican Republic reported 23 deaths on September 9, 2020,1 or almost two deaths per million people. During the first two years of the pandemic, the cumulative fatality rate was lower in the Dominican Republic than every country in the region except Cuba.3

Cumulative death rate in the Americas from COVID-19, April 1, 2020 – April 1, 2022

OWID

In March 2020, the National Council for Prevention, Mitigation and Response to Disasters developed a contingency plan for COVID-19 that introduced key strategic lines: leadership; intersectoral and multisectoral coordination; epidemiological surveillance; research and evaluation; laboratory and diagnosis; prevention and control of infections; management and treatment of cases; operational and logistical support; and risk communication.4

The contingency plan’s objectives were:

  • Establish intersectoral and multisectoral coordination for the preparation and response to COVID-19 cases.
  • Determine actions to contain and mitigate cases of COVID-19 through detection, surveillance, investigation, evaluation, and timely isolation of detected cases.
  • Strengthen the capacity and coordination of the health service provider network for the management of COVID-19 cases in accordance with the established protocols.
  • Ensure risk communication actions aimed at individuals, family and community, and risk groups.
  • Guarantee the operational and logistical support of supplies for the preparation and response of COVID-19 cases.4

The minister of health, as the highest health authority, is responsible for leading the preparation and response to health emergencies at the highest political and strategic level, and the director general of epidemiology oversees the epidemiological surveillance response.5

Officials soon named three more commissions to implement health, economic, and social protections: a High-Level Commission to coordinate the government’s pandemic response, the Commission for Economic and Employment Affairs, and the Commission to Address Social Affairs.6

On March 19, 2020, the Dominican government declared a state of emergency and introduced a nationwide lockdown and quarantine.7 Officials closed borders, schools, and workplaces nationwide and suspended public transportation. Collaborations also began with the private sector on testing and care coverage between March and May 2020. However, cases and deaths remained high which could be explained by lack of adherence or ineffective messaging during this administration.

When the new government was established in August 2020, they effectively mobilized the entire country toward a common goal: to protect the population from COVID-19 through mass vaccination while gradually reopening the economy to recover growth and employment. They also moved beyond typical COVID-19 response to strengthening a whole-of-government strategy and leadership at the highest levels of decision-making across prevention, mitigation, and response systems, and aligning across sectors to implement public health interventions and promote social protection for vulnerable populations.

Interventions to limit the spread of COVID-19 and maintain essential health services during the early months of the pandemic in the Dominican Republic fell into three main categories:

  • National, governmental, and population-level measures
  • Health system-level measures
  • Patient-level measures

National, governmental, and population-level measures

The Dominican Republic has a great deal of experience with disease outbreaks and other public health emergencies, and clear and effective risk communication is a government priority. In the Global Health Security Index for 2019 and 2021, the country’s risk communication strategy scored 83.3, or 15 out of the 195 countries ranked.8 Officials have relied on these strategies and guidelines during past outbreaks of epidemic disease, such as chikungunya in 2014 and Zika in 2015.9 In 2016, the country developed a specific strategy for risk communication for health emergencies.10

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Officials allowed telecommunications services, radio stations, television stations, and the written press to remain open from the Dominican Republic’s first lockdown to maintain an effective flow of official information from the government to the public. The minister of health chaired daily (then weekly, starting in August 2020) press conferences carried live on television, radio, and social media, and issued daily epidemiological bulletins.11

Starting in March 2020, the Ministry of Public Health repurposed the government’s official information helpline (*462) to provide public information on the COVID-19 pandemic, help officials notify suspected cases and contacts, and enable citizens to seek guidance from health personnel.12

A public service announcement for the governmental official informational helpline to provide public information on the COVID-19 pandemic.
A public service announcement for the governmental official informational helpline to provide public information on the COVID-19 pandemic.

Officials also launched a massive social media campaign via Instagram, Twitter, Facebook, and YouTube. TV, radio, and digital media companies also collaborated with the government to create advertising spots and campaigns for COVID-19 communication, and official social media accounts (as well as specialized platforms, such as @vacunateRD) delivered targeted information to users.13, 14,15,16

The Dominican government also created unique webpages such as Coronavirus DR,17 which directed users to the *462 emergency helpline along with information about COVID-19 prevention and care, transit permits for health workers during lockdowns and curfews, and Pa’ Ti,18 a financial assistance program for freelance workers. Later during the vaccination campaign, the VacúnateRD19   platform included information about COVID-19 vaccination programs, the location of vaccination centers nationwide, digital vaccination certificates, and vaccination statistics, and directed users to an information line on the National Vaccination Plan (*822). More recently, the VacúnateRD platform has grown to include information about the Expanded Immunization Program for measles, rubella, and polio.

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In the early months of the COVID-19 pandemic, the Dominican Republic adopted strict mobility restrictions. In March 2020, officials closed borders, schools, and workplaces nationwide and suspended public transportation.20

Restrictions were partially lifted in early July 2020 for the national elections, but at the end of the month, the president declared a new state of emergency and reinstated nighttime curfews whose length varied from place to place according to test positivity rates.21

Airports and border crossings reopened to international tourists with a negative test result in July 2020. After President Abinader took office in August 2020, officials reopened workplaces and eased other restrictions to make tourism and travel as easy as possible.23 During the following months, opening and closing policies were reinstated according to the epidemiological situation.

In June 2021, officials reestablished a strict curfew in provinces with high rates of COVID-19. The next month, they relaxed that curfew for provinces with a 70% vaccination rate.24,25

Police patrol the streets after businesses are closed in the colonial district, after a state of emergency decreed by the government, as a preventive measure against the spread of the coronavirus disease (COVID-19), in Santo Domingo, Dominican Republic March 24, 2020.
Police patrol the streets after businesses are closed in the colonial district, after a state of emergency decreed by the government, as a preventive measure against the spread of the coronavirus disease (COVID-19), in Santo Domingo, Dominican Republic March 24, 2020.
Credit: Ricardo Rojas. © Reuters

In October 2021, officials lifted the state of emergency and eliminated the curfew.26 Social distancing was encouraged, and mask use was still mandatory for residents of the Dominican Republic. Most public places such as restaurants and shopping malls also required proof of vaccination to enter in October 2021.23

Mobility and COVID-19 cases in the Dominican Republic, March 2020 – December 2021

IHME COVID-19 projections

On April 16, 2020, the Dominican government established a mask mandate for all citizens in public places, both indoors and outdoors.22 This mandate stayed in place until February 2022.2

Mask use in the Dominican Republic, March 2020 – December 2021

According to interviews with key informants, international partners such as the Pan American Health Organization (PAHO), the US Centers for Disease Control and Prevention, and the Inter-American Development Bank helped the Dominican Republic procure key supplies such as tests, treatments, and personal protective equipment during the early stages of the pandemic. Likewise, partnerships with governments, businesses, and business groups enabled the procurement and delivery of necessary personal protective equipment and medical equipment throughout the pandemic, including to rural and remote parts of the country. 28,29

An electoral worker wearing a face mask puts on protective gloves during the COVID-19 outbreak in Santiago, Dominican Republic, July 5, 2020.
An electoral worker wearing a face mask puts on protective gloves during the COVID-19 outbreak in Santiago, Dominican Republic, July 5, 2020.
Credit: Ricardo Rojas. © Reuters

Dominican officials offered three main categories of public assistance in response to COVID-19. All three aided vulnerable groups (identified using administrative data sources such as El Sistema Único de Beneficiarios) with financial transfers.

  • The Quédate en Casa (Stay at Home) program, established April 1, 2020, aimed to help the country’s poorest and most economically vulnerable people along with workers in the informal economy. It gave additional subsidies (a total of 5,000 Dominican pesos [RD$] per month) to those already participating in the Tarjeta Solidaridad social protection program,30 and added some 800,000 new households from the roster of the Comer es Primero (Eating is First) program. Some recipients received additional payments for food and first aid supplies.22 Officials started phasing out this program at the beginning of 2021. The program had more than 1.5 million participating households in January 2021, and about 1.2 million in March. The program ended in April 2021.31
  • The Fondo de Asistencia Solidaria al Empleado (Employee Solidarity Assistance Fund), established on April 2, 2020, protected the income of workers who were laid off during the national lockdown. Its first phase paid 70% of the salaries (between RD$5,000 and RD$8,500) to employees who lost jobs in the formal sector. Its second phase paid RD$5,000 to employees of manufacturers and other companies that had continued operating. By the time the program ended on April 1, 2021, it had paid more than RD$50 million to nearly 1 million community members.32
  • The Pa’ Ti program, established in June 2020, gave freelance workers a similar RD$5,000 monthly stipend. The people selected for the aid were identified through the registry of independent workers of the Ministry of Finance; they were not subject to an application process, and the government deposited the stipend directly into their bank accounts.33 When Pa’ Ti concluded in December 2020, it had paid nearly 200,000 community members.

As of March 2022, the Dominican government had spent more than RD$145 billion on nearly 3 million community members.32

Dominican officials acted quickly to develop platforms for COVID-19 data reporting and management that showed disaggregated case data across the country, according to interviews with key informants.

In April 2020, the Dominican government asked the Ministry of Defense’s Command, Control, Communications, Computers Cybersecurity and Intelligence Center (C5i) to integrate the health system into its digital platform. With the support of C5i, the National Health Service could integrate data on public and private hospitals, clinics, laboratories, pharmacies, and insurance. In addition, the platform could show key data, such as the number of available hospital beds, intensive care units (ICUs), ventilators, and ambulances in real time. It could also create predictive models to help policymakers allocate resources and make other important decisions.34

With this information, officials could work with partners in the private sector to procure necessary resources. The data also helped prevent hospital overload. For example, it ensured that large hospitals that attracted the most patients never reached their maximum capacity, by using occupancy data to send patients with less complex or less severe health problems to less occupied health centers. The platform also had an artificial intelligence system that could use data analysis to make projections and develop epidemiological profiles.10

Data gathering started as soon as a patient was diagnosed through a positive test and sent to a public health center that treated COVID-19 cases, according to interviews with key informants. These centers gathered case information twice daily and sent it to the National Health Service, which used it to produce daily COVID-19 bulletins and update the digital platform with data and visualizations including case and death counts and test positivity and occupancy rates by region, province, and hospital. Private health centers did their own reporting to the Ministry of Public Health, so that this process accounted for all the hospitals in the Dominican Republic.

In October 2021, the Technological Institute of Santo Domingo introduced a model that could predict the epidemiological behavior of COVID-19 and help manage and monitor data on cases, mortality, nonpharmacological intervention, and health planning.35 The university’s researchers had also aided in case detection in the early days of the pandemic, offering software that worked as a fast diagnostic test for COVID-19 and helped limit the burden on the health system.36

At the beginning of the pandemic, the Dominican Republic’s capacity to carry out tests was limited and concentrated in the National Laboratory, a reference public laboratory, according to policymaker key informant interviews. Despite this limited testing capacity, at the end of March 2020, officials announced the government would cover the costs of polymerase chain reaction (PCR) tests for people older than 59 with comorbidities and symptomatic people with a medical prescription.37

In those first weeks, according to interviews with key informants, the National Laboratory’s capacity to provide COVID-19 tests was overwhelmed. However, informants reported that the laboratory soon adjusted available resources, reorganized the workflow, and added a third work shift, increasing its capacity to 2,500 tests per day. The Ministry of Public Health purchased new equipment, supplies, and enough reagents to increase the laboratory’s capacity to 9,000 PCR tests per day. On March 30, 2020, coverage of PCR tests was guaranteed by the Superintendent of Health and Labor Risks (SISALRIL) through National Health Insurance (SeNaSa) and all private insurers.38

Collaboration with private laboratories enabled a further increase in testing capacity beginning in April 2020, making tests accessible to all. Private laboratories tested symptomatic patients and contacts in the contributory regime, while those in the subsidized regime had free access to tests in public hospitals. In May, officials set up testing centers in the most affected provinces.22 Donations from international partners, such as the World Health Organization and PAHO, of key supplies (laboratory refrigerators, dry ice blocks, swabs, and reagents) also helped boost the National Laboratory’s testing capacity through the middle of 2020.39

Interviews with key informants indicate that officials quickly activated a network for sample transport from collection centers around the country. They also established new processes for digitizing data from collection to laboratory to results. Notifications of positive tests were sent to patients and to the General Directorate of Epidemiology.

As a result of these interventions and partnerships, the country’s capacity to carry out PCR tests increased considerably, from 4 tests per confirmed case at the beginning of the pandemic to 43 tests per confirmed case at the end of 2021.40

PCR testing in the Dominican Republic, May 2020 – June 2022

MOH Daily Bulletins, Fundación Plenitud

Early contact tracing efforts relied on preexisting emergency response and disaster relief organizations, according to interviews with key informants. Organizations included the Emergency Operations Center, which coordinated with the Ministry of Public Health, and other agencies and operated initial platforms for public information, such as the call center charged with monitoring contacts of confirmed cases.41

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Using a source code devised by researchers at the Santo Domingo Technological Institute (INTEC), the official COVID-RD contact tracing app42 enabled users to:

  • Anonymously report symptoms to the General Directorate of Epidemiology to receive follow-up and medical guidance
  • Receive contact tracing notifications if they had contact with an infected person
  • Map the closest hospitals and laboratories providing COVID-19 services
  • Access bulletins and statistics from the Ministry of Public Health
  • Access communications and recommendations from the High-Level Commission for the Prevention and Control of Coronavirus
  • Access the Ministry of Public Health’s chatbot, Aurora to ask COVID-19 related questions
  • Receive notifications of “epidemiological discharge” and “serological discharge” if they had tested positive for COVID-19
A healthcare worker prepares to administer a dose of the Oxford/AstraZeneca vaccine against COVID-19, in Santiago, Dominican Republic, February 17, 2021.
A healthcare worker prepares to administer a dose of the Oxford/AstraZeneca vaccine against COVID-19, in Santiago, Dominican Republic, February 17, 2021.
Credit: Ricardo Rojas. © Reuters

Since February 2021, when the first COVID-19 vaccine was delivered to a health worker in the Dominican Republic,43 vaccination has been the country’s primary measure aimed at containing the pandemic. The country did not require proof of vaccination for incoming travelers but did encourage workers in the tourism industry to be vaccinated—and according to the Ministry of Tourism, by the end of 2021, nearly 100% of those workers had their shots.23

The vaccination process was carried out by the Expanded Immunization Program through the Ministry of Public Health with the collaboration of private-sector partners. Officials eventually established more than 1,400 vaccination centers in schools, stadiums, shopping centers, and public transport stations, according to interviews with key informants. The VacúnateRD platform19 enabled users to check the location of nearby vaccination centers and download electronic vaccination certificates.

Informants reported that several private companies contributed resources to buy vaccines, while others offered their premises to serve as vaccination centers. Those that had refrigerators contributed their spaces to ensure the cold chain, because the country originally had the capacity to store just 1.2 million vaccine doses, according to a key policymaker interview. Beer and milk distribution companies provided refrigerated trucks for the transport of vaccines, according to interviews with policymakers. International partners and partners from the private sector also offered key assistance. In some border provinces, such as Elías Piña, military carts facilitated transportation of medical supplies during the vaccination process, according to an interview with a policymaker, and WHO and PAHO donated cold chain and other equipment.44

After Dominican officials stopped requiring citizens to present vaccination certificates to enter public places such as workplaces, schools, gyms, shopping malls, restaurants, bars, clubs, and public transportation in February 2022, demand for vaccination decreased (more than 60% of the entire population had received one dose of the vaccine). By April 2022, just 800 vaccination centers remained open.19

Share of people who completed the initial COVID-19 vaccination protocol with milestones in the Dominican Republic, January 2021 – March 2022

Prepared by Fundación Plenitud, OWID

Note: Total number of people who received all doses prescribed by the initial vaccination protocol. If a person receives the first dose of a two-dose vaccine, this metric stays the same. If they receive the second dose, the metric goes up by one. Therefore, the graphic only counts people fully vaccinated with two doses.

Starting in July 2021, the Dominican Republic became one of the first countries in the world to offer a third vaccine dose (booster),46 and by the end of 2021 had delivered nearly 14 booster doses per 100 people (usually of the Pfizer vaccine).43,47 A few people, mostly health workers and older adults or immunocompromised people, have received a fourth booster.48 As of May 2022, 77% of the population over 18 years of age had their first dose and 66% had the two doses.

The country was also one of the first to vaccinate adolescents 12 to 17 years of age, starting in June 2021.49 In mid-February 2022, officials began to vaccinate children 5 to 11 years of age in schools (with parental approval).50

Percentage of people vaccinated by age group and dose, December 2021 and May 2022

MOH, Fundacion Plenitud

The Dominican Republic’s vaccination campaign was successful in part because Dominicans were willing to be vaccinated. In one study by researchers at the Universidad Iberoamericana, 72% of respondents surveyed in February and March 2021 expressed interest in getting the vaccine. Eighteen percent were not sure, and just 10% said they had no interest.51This willingness could be explained by the government’s trust building and effective COVID-19 risk communication and health education.

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Health system-level response measures

The Dominican Republic’s health system-level response measures fell into two main categories: direct responses to COVID-19, and interventions for the maintenance of essential health services.

Supply- and demand-side barriers to essential health services maintenance in the Dominican Republic during the COVID-19 pandemic

In many countries around the world, the COVID-19 pandemic and efforts to mitigate it caused supply- and demand-side barriers to essential health service delivery—including provider and patient fear of infection in health facilities; inability to travel because of lockdowns; budgetary shortfalls; and delays and stockouts of essential health commodities such as personal protective equipment, reagents, some vaccines, and critical diagnostic tools (such as GeneXpert cartridges).

In the Dominican Republic, COVID-19 affected both the supply and demand for essential health services, especially at the beginning of the pandemic from March until August 2020. During that period, mobility restrictions and fear of infection in public places kept most people at home and away from health facilities. This was particularly true in Santo Domingo and Santiago, the country’s two major cities.

However, the interruptions to essential health services delivery in the Dominican Republic were less substantial than in many other countries, and most services had fully recovered by the middle of 2021.

In 2020 and 2021, the World Health Organization’s PULSE survey measured pandemic interruptions to the delivery of 25 essential health services in 127 countries around the world.

Degree of disruption to selected essential health services in the Dominican Republic, January 2021 – March 2021

WHO Pulse Survey

Individual service use statistics from the Dominican public providers’ network (National Health Service) and public insurer (SeNaSa) reflect these findings. According to National Health Service data, individual services—such as primary care consultations, visits with specialists, visits to emergency departments, laboratory visits, and imaging—substantially declined between 2019 and 2020. As WHO found, this was especially true in large cities such as Santo Domingo and Santiago.52 There was an overall 34% decrease in services provided by the National Health System between 2019 and 2020, however the system was able to increase services by 35% between 2020 and 2021.

Researchers found that the shortage of some supplies and equipment and the redirection of the flow of resources and workforce to pandemic response also interrupted the delivery of maternal and neonatal services. They identified a 27% drop in maternal health service delivery in the Dominican Republic in 2020, less than the regional average of 44%.52 WHO researchers also identified social distancing measures, and patient reluctance to visit health facilities also disrupted services such as directly observed treatment for tuberculosis and in-person treatment for HIV patients.

Maternal deaths in the Dominican Republic also increased during 2020 and 2021, but preliminary results show that 2022 rates in the first half of the year are trending back to pre-pandemic rates.53

Maternal deaths per 100,000 births in the Dominican Republic, 2017-2022

DIGEPI Weekly Bulletins

According to a self-reported survey (see figure below), the Dominican Republic’s health system was able to provide services to populations that reported higher barriers to access in the beginning of the pandemic and lower these rates of interruption. The survey followed people that declared not having access to medical services, people with disabilities without access, children younger than five without access to vaccination, and pregnant women without access to regular checkups.

Interruption in access to medical services during the COVID-19 pandemic in the Dominican Republic, May 2020 – March 2021

UNDP SEIA-Red Actua Survey

The pandemic’s effects on the delivery of mental health services in the Dominican Republic have not yet been evaluated.

Statistics from SeNaSa reflect similar trends that demonstrate a relative maintenance of essential health services for ambulatory care, high-cost interventions (complex surgeries such as angioplasty, open heart surgeries, joint replacement, hemodialysis, burn care, cancer, and other interventions), normal deliveries, and cesarean sections (see figure below).

Number of services by type covered by Dominican Republic national health insurance, 2017 – 2021

SeNaSa

Overall, ambulatory care consultations suffered a great drop in the first months of the pandemic but began to recover in August 2020, high-cost care did not suffer reductions in the subsidized regime, except in the months of April and May 2020, and both normal deliveries and C-sections generally stayed consistent except for the early part of the pandemic. Note that in the Dominican Republic, almost all births take place in health facilities under the care of specialized doctors.

Services provided in the subsidized regime of the Dominican Republic, 2019-2021 (in thousands)

SISALRIL

The Family Health Insurance (Seguro Familiar de Salud, SFS) subsidized regime protects the unemployed and informal population with incomes below the minimum wage. Most of the health services this population uses are provided by the public network of the National Health Service, just like the uninsured. The difference is if the public network provider does not have the required service or quality, SeNaSa contracts these services in the private sector. In 2020 a substantial proportion of the population was uninsured (about 23%). By the end of that year, in part because of the pandemic, almost all the uninsured population became insured through the subsidized regime.

The table above shows many of the services covered by SeNaSa within the subsidized regime. A reduction of 34% in service coverage can be seen in 2020 compared with 2019. However, there was a complete recovery in 2021.

Services provided in the contributory regime of the Dominican Republic, 2019-2021 (in thousands)

SISALRIL

The population in the contributive regime uses the private network. As shown in the table above, the number of services provided was reduced by 18% in 2020 with respect to 2019 and they have almost recovered by 2021. The most crucial reductions were in dental services, emergencies, surgery, and rehabilitation. Most services almost recovered by the end of year 2021.

Therefore, the subsidized regime suffered much more disruption to their essential health services than the contributive, thus putting more burden on low-income citizens in the Dominican Republic.

Specific services provided in the contributory regime of the Dominican Republic, 2019-2021 (in thousands)

SISALRIL

Specific services (examples shown above) provided in the contributory regime experienced minor variations. A large increase was seen in services provided through the Expanded Immunization Program due to the Dominican Republic’s extensive COVID-19 vaccination program. Overall, these specific services declined by 11% in 2020 and 5% in 2021.

Disruption in DTP3 vaccine doses in the Dominican Republic

IHME

Based on an analysis from the Institute for Health Metrics and Evaluation of administrative data, the figure above shows the ratio of the monthly number of doses of DTP3 vaccine (third dose of diphtheria, tetanus, and pertussis vaccine) given to children younger than one year old in 2020 as it compares with the same month in 2019. A value of 1 represents no change and values less than 1 indicate delivery disruption.

In March 2020 at the beginning of the pandemic, there was a substantial decline in the number of children younger than one year of age who received the third dose of the diphtheria-pertussis-tetanus (DTP3) vaccine in the Dominican Republic. However, this indicator began to recover in April 2020 and continued to climb throughout 2020.

Political leaders in the Dominican Republic were committed to reversing and mitigating the interruptions to essential health services experienced throughout the pandemic. They developed innovative initiatives using digital media and social networks to deliver health services—consultations, follow-ups, and other key services such as digital prescriptions—and created or strengthened important platforms for data management across the health sector. These digital innovations are transforming healthcare delivery more broadly.

Case study: guidelines for essential health services maintenance in the Dominican Republic

The Dominican Republic’s Ministry of Public Health, with the technical support of the Pan American Health Organization, the US Centers for Disease Control and Prevention, and the US Agency for International Development, produced a set of “guidelines for the normalization of the provision of health services in the face of the COVID-19 pandemic” in June 2020.54,55 The guidelines noted the importance of maintaining key essential health services even during the pandemic emergency and outlined steps officials and providers could take to normalize the delivery of outpatient services, public health programs (e.g., HIV, tuberculosis, maternal and child health, sexual and reproductive health, family planning and vaccinations), and elective surgeries—all of which had reduced capacity during the state of emergency in the early months of the pandemic.

The guidelines established specific regulations for service delivery to key populations. For example, people with HIV who had stabilized their viral load should receive remote care and six months of antiretroviral drugs via remote dispensing; people with sexually transmitted infections should receive care via telephone consultations or virtual visits; tuberculosis patients should be supervised remotely through video calls with providers; and patients with chronic noncommunicable diseases should be monitored and treated remotely where possible. The guidelines also suggested that officials strengthen epidemiological surveillance for vector-borne diseases, including delivering repellents and mosquito nets to the populations at greatest risk.56

Telemedicine

In 2018, the Dominican Republic had established a private United Telemedicine Network, but it was aimed primarily at medical tourists and Dominicans living abroad.56,57 Within several months of the beginning of the COVID-19 pandemic, however, health care providers across the Dominican Republic had adopted online platforms such as Zoom, Skype, Webex, Microsoft Teams, WhatsApp, and others for exchanges between physicians, for consultations with patients, and to build and share electronic medical records. In July 2020, SeNaSa began to offer online telemedicine consultations with primary care providers and specialists in pediatrics, family medicine, cardiology, and gynecology.58

In November 2020, the National Health Service and the Emergency and Health Management Committee to Combat COVID-19 launched the Critical Care Telemedicine Project to connect personnel at provincial hospitals with their counterparts in critical care facilities. For example, an “expert” critical care center such as the Cardio-Neuro Ophthalmological and Transplant Center might build a collaborative relationship with the provincial Juan Pablo Pina hospital in San Cristóbal. This connection makes it possible for providers to optimize the referral system and manage the flow of COVID-19 patients to higher-level care centers while creating a network of experts, thereby improving the efficiency and quality of health services in critical care (for COVID-19 and other illnesses) and promoting collaborative work between teams of professionals.59

The Dominican Republic also has some private telemedicine platforms such as Hulipractice, which enables remote consultation, digital scheduling, and electronic prescriptions.60 The IMG Hospital in Punta Cana has a proprietary service that enables providers to schedule patient appointments electronically and treat them remotely.61 By July 2020, the company TELEMED had begun to provide audio and videoconferencing services with its network of doctors; MAPFRE Salud ARS (previously ARS Palic) had introduced AudioDoctor; and ARS Universal had implemented its Universal en Línea app, which offers guidance on COVID-19 testing, laboratories, and other services.62

Pulmonologists, rheumatologists, and physicians in other specialties formed WhatsApp groups to maintain effective communication between different practice communities, according to key informant interviews.

Electronic health records

Some pilot trials were carried out in pediatric services, which have long had access to electronic perinatal clinical records via PAHO’s Perinatal Information System.63 However, it is still necessary to develop tools for different stakeholders—such as insurers, health centers, service providers, and patients—who can interact with one another as necessary.64

In 2021, the Government Office of Information and Communication Technology’s 2030 Digital Agenda and 2021–2024 Action Plan established a National Telemedicine Policy to create the conditions for connectivity, infrastructure, and regulations in the Dominican Republic. The policy mandates the creation of a single interoperable digital health record and proposes a Balanced Scorecard for the Health Sector that enables the integration of insurance systems and measures hospital performance in the public sector along with a National Blood System connecting all blood banks nationwide. This process, catalyzed by the COVID-19 pandemic, can enable the Dominican Republic to build a more resilient health system for the future.65

According to interviews with key informants, a strength of the Dominican Republic’s pandemic response was its health personnel. They were, as one said, “willing to face anything, even to give their lives to be there during the pandemic and working on the front lines. There was never an exodus [of health care workers] or strikes, as happened in other countries.” Sources reported that officials hired more than 3,700 physicians and other health workers and awarded substantial incentive bonuses to frontline staff.

During the first two years of the COVID-19 pandemic, the Dominican health system never exceeded the availability of hospital beds or ICUs for COVID-19 patients. Collaboration between the government and the private sector made this possible: the C5i system centralized information on patient flow and made it possible to modify the availability of hospital and ICU beds according to demand. The country saw its highest rates of hospital occupancy from June through July 2020; even then, only 52% of hospital beds and 77% of ICU beds were occupied.

Health officials pushed to triage and hospitalized only patients with complicated cases of COVID-19 and those with comorbidities. At the same time, policies reserved several public hospitals exclusively for patients with COVID-19 to keep those patients from mixing with (and possibly infecting) those who needed other services. These policies were established with the previous government and continued with the new one.

Total ICU bed occupancy rate in the Dominican Republic, November 2020 – June 2022

MOH Daily Bulletins, Fundación Plenitud
Case study: public–private partnerships in the Dominican Republic during the COVID-19 pandemic

In the Dominican Republic, the private sector was an important ally in the country’s efforts to contain COVID-19. Private partners boosted the supply of tests, hospital beds, intensive care units, cold chain storage, and vaccines.

Laboratory testing:

The private laboratory system, whose strength already existed, was made available to government authorities through public-private partnerships. Private hospitals and providers, as well as insurers, participated in this partnership. Therefore, all testing and treatment became free of charge, public and private insurers advanced payments for those laboratories’ services, and the government reimbursed them in full. Monetary incentives were also provided to front-line health workers who conducted testing and other tasks . This collaboration strengthened the testing capacity throughout the country and made testing accessible to all citizens. In the second year of the pandemic, restrictions were established to one test per year per affiliated person that would be covered with public funds.

Hospital beds and intensive care units:

The Dominican health system was able to withstand the pandemic without exceeding the availability of hospital beds or intensive care units for COVID-19 patients because of a collaboration between the government and the private sector under the leadership of the Health Cabinet.

Vaccines:

Several private companies contributed resources to buy vaccines, others provided premises for vaccination centers, those with refrigerators contributed their spaces to ensure the cold chain, and even companies that distribute beer in the national territory provided their refrigerated trucks for the transport of vaccines.

Public-private partnerships also allowed for distribution and allocation of necessary medication (such as remdesivir), personal protective equipment, and necessary funds for COVID-19 treatment. The contributory regime and subsidized regime collaborated in the care of patients suspected of or confirmed with COVID-19 and established effective and fluid communication mechanisms to communicate between public and private hospitals.

Patient-level measures

According to interviews with key informants, during the early parts of the COVID-19 pandemic (March 2020 through August 2020) in the Dominican Republic, symptomatic patients with negative test results still had to complete a diagnostic imaging procedure such as a chest X-ray. Depending on those results, the patient was kept in quarantine for 14 days, mostly at home.

Provincial health directories then located the patient’s family and any close contacts, sent personnel to test them, and quarantined them even if they tested negative and showed no symptoms. These contacts were mainly quarantined at home. The National Health Service opened quarantine centers for people at increased risk (such as those with comorbidities) who did not test positive, but interviewees indicate they served primarily as overflow beds for health centers that had reached capacity.

During 2020 and 2021, the National Health Service implemented a strategy to ensure that large, in-demand hospitals did not reach their maximum capacity. According to interviews with key informants, health officials made an agreement with the 911 emergency unit to ensure a sufficient number of ambulances at selected hospitals and to refer patients who were not in need of high-level treatment to less-occupied health centers.

Interviews with key health officials and providers attributed the Dominican Republic’s comparatively good pandemic outcomes like their low death rate to the treatment protocols it used from the beginning, both for mild and severe cases, however this is challenging to verify.66 These protocols were quite aggressive in patients requiring hospitalization: Dominican health facilities used new drugs such as tocilizumab, remdesivir, and REGEN-COV before they were approved by the FDA. These treatments were available to all patients that required them and were financed by the government.67

Case Study: Treatment for COVID-19 in the Dominican Republic

From the beginning of the pandemic, the Ministry of Public Health published a series of guidelines aimed at standardizing treatment for COVID-19 patients nationwide.68 They included isolation frameworks, instructions on determining levels of care, and recommended medicines, and were designed for use in tertiary care centers with CT scanners and multidisciplinary care teams.69

According to the guidelines, suspected COVID-19 patients were to isolate in private rooms with (ideally) negative pressure capabilities. If private rooms were not available, COVID-19 patients could room together. The guidelines emphasized the proper use of personal protective equipment and the need to limit the number of people in contact with suspected and confirmed COVID-19 patients. Initially, the official COVID-19 case definition included fever, X-ray evidence of pneumonia, low or normal white blood cell count, and no improvement after three days of standard antibiotic treatment for pneumonia; it also accounted for contact with another case or travel to a region where there was community spread.69 This definition changed as knowledge of COVID-19 symptoms evolved to include diarrhea and loss of smell and taste, and to account for the possibility of asymptomatic infection alongside greater availability of testing.69 Level of care was determined by variables including level of oxygen saturation and patient comorbidities.

As the pandemic evolved, the most substantial change in the standard of care guidelines was associated with the medications recommended for treatment. In March 2020, the guidelines recommended antipyretics and vitamins, not empiric antibiotics or steroids. Chloroquine, hydroxychloroquine, remdesivir, and lopinavir/ritonavir were not routinely recommended, but were considered on a case-by-case basis.69 In April 2020, the medication protocol was updated to add the routine use of hydroxychloroquine, azithromycin, lopinavir/ritonavir, and dexamethasone.70

In January 2021, a second version of the comprehensive protocol made more specific recommendations for treatment:

  • For symptomatic but mild cases without comorbidities, the 2021 guidelines recommended ibuprofen, N acetylcysteine, esomeprazole, and vitamins. Patients with comorbidities were advised to add favipiravir. Ivermectin was not routinely recommended.
  • For patients with moderate cases, the 2021 guidelines recommended remdesivir, tocilizumab, and dexamethasone for those whose oxygen saturation was less than 94% on room air. In severe cases, they also recommended convalescent serum.69

A third protocol published in November 2021 recommended the use of REGEN-COV antibodies for ambulatory patients.69

Another hospital group, Clinica Union Medica, published their own guidelines for treatment in May 2020.71,72 These alternative guidelines added hydroxychloroquine, chloroquine, N acetylcysteine, deferasirox, azithromycin, and other empiric antibiotics to the medications the government guidelines recommended based on clinical severity. It is unclear how long this protocol was used or if other hospitals developed their own guidelines.
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