Why was the Dominican Republic selected?

Executive summary

The COVID-19 pandemic struck the Dominican Republic during a political process that included municipal and the national elections which forced the postponement of the national election until July 2020. Daily COVID-19 case counts peaked at the end of July, with nearly 1,800 new infections reported on July 31, 2020,¹ or about 135 cases per million people—more cases per million than any other country in the region except Brazil, Panama, and Colombia.² Hypotheses for these early, high case counts include lack of adherence to public health and social measures and ineffective messaging in the early parts of the pandemic. By the time a new president was elected in early July, the country was among the hardest hit in the Caribbean, with more than 37,000 confirmed cases and 800 deaths from COVID-19.³ Starting in August 2020, however, officials prioritized the COVID-19 response and embraced policies, such as mass testing and vaccination, to keep case counts low and carefully reopen the economy, especially the tourist sector. This leadership mobilized the entire country, including the private sector, toward a common goal. Between October 2020 and October 2021, the number of confirmed COVID-19 deaths per million people in the Dominican Republic was the second lowest in Latin America.⁴

Although the Dominican Republic’s primary health care system was relatively weak, a limitation that disrupted the delivery of essential health services early in the pandemic, officials and health providers were able to adapt quickly to restore them. They used the Ministry of Defense’s Command, Control, Communications, Computers Cybersecurity and Intelligence Center (C5i) in conjunction with the National Health Services (SNS) and the ambulance system to monitor health system saturation, reallocate resources, and make important time-sensitive decisions. The country was also able to close many of these gaps via committed government leadership and public-private partnerships.

Additionally, social protection measures enacted by the government included extension of insurance coverage and three public assistance programs: (1) the Fondo de Asistencia Solidaria al Empleado (Employee Solidarity Assistance Fund or FASE); (2) Pa’Ti, an independent worker assistance program; and (3) the Quédate en Casa (Stay at Home) program. These programs ensured that citizens had financial support throughout the pandemic while following health guidelines.

How did we select the countries we studied?

Differences in testing, surveillance capacities⁵, and reporting criteria have made it difficult to quantify⁶ and compare the impact of COVID-19 in countries around the world. Yet some countries were able to strengthen and sustain health system capacity, maintain essential health services, and target public health and social measures to mitigate the overall impact of the COVID-19 pandemic. Identifying the strategies, policies, and practices that enabled these successes can give us a better understanding of health system resilience, adaptive health policies, and emergency response strategies that could be applied to other countries and future infectious disease outbreaks.

To select positive outlier countries with transferable lessons for pandemic preparedness and health system resilience, we used data from March 2020 through the end of 2020 to identify countries with best-practice responses to the early phases of the pandemic. This snapshot in time does not account for subsequent waves of the pandemic, nor for the later availability of COVID-19 vaccines in the selected countries.

The six countries were selected by evaluating COVID-19 indicators (including age-standardized death rates, cases per million, and testing rates) and essential health services indicators (including disruption to routine immunization) after screening for the availability of high-quality data and the transferability of the findings. After identifying potential Exemplar countries, we completed validation research including an examination of the COVID-19 epidemiological curve over time, testing policies and strategies, interventions to maintain essential health services, survey data, and interviews with local and regional health experts. The final six countries (Dominican Republic, Costa Rica, Sri Lanka, Thailand, Uganda, and Ghana) were selected after considering linguistic, demographic, and geographic diversity as well as government structure and data availability (see figure below).

For the Dominican Republic and the other five countries, we conducted a literature and policy review, key informant interviews, qualitative analysis, and quantitative analysis. We synthesized findings to develop key recommendations on health system resilience and pandemic preparedness. Through this country selection process we reviewed indicators through the end of 2020, but our research covers the time period at least through the end of 2021.

Key insights: Dominican Republic

Several key factors and interventions, summarized below and detailed in the following pages, contributed to the Dominican Republic emerging as a positive outlier in the COVID-19 response and the maintenance of essential health services.

Preexisting disease response capacities

Previous experience with outbreaks of contagious diseases such as dengue, Zika, and chikungunya (and other potentially catastrophic events, such as weather emergencies) gave officials and health care providers in the Dominican Republic an abundance of strategies and tools. These enabled the country to develop and implement outbreak preparedness and response plans and public communication plans to effectively respond to the COVID-19 pandemic.

Community mobilization and engagement

Officials in the Dominican Republic invested considerable time and effort building trust in local communities and among health workers. Their aim was to ensure broad adherence to public health and social measures, especially immunization, and to retain health workers even as their work became more challenging. Social protection measures, especially the extension of health insurance to most people in the Dominican Republic, also inspired public confidence.

Public–private partnerships

Alliances between the Dominican Republic’s public and private sectors provided essential resources and funding for the country’s COVID-19 response. For example, these alliances enabled mass testing and vaccination campaigns; boosted hospital and intensive care unit capacity to prevent system saturation during pandemic surges; and enabled free COVID-19 testing via the country’s private laboratory system and insurers (known as health risk managers).

Mass COVID-19 vaccination

The newly established national government in August 2020 immediately prioritized mass vaccination against COVID-19. The public and private sectors collaborated to obtain and deliver large amounts of vaccine doses in a short time. As of May 2022, 77% of the population over 18 years of age had received their first dose and 66% had received the two full doses.⁷

Challenges

Even before the COVID-19 pandemic began, decades of weak investment (5% of its gross domestic product vs. a 9% worldwide average⁸) in the Dominican Republic’s health sector had resulted in a primary care system that was unequipped to respond to a large-scale health emergency while maintaining the delivery of essential health services.

Due to limited capacity at the primary health care level, the health system in the Dominican Republic is more reactive than preventive: it focuses primarily on delivering acute care rather than preventing the spread of disease. The country’s COVID-19 case counts were among the region’s highest between March and August 2020, and mitigating interventions such as contact tracing were difficult to implement.⁴

Early in the pandemic, the health care system was not equipped to maintain the delivery of essential health services alongside COVID-19 care. Some essential services were more affected than others, such as directly observed treatment for tuberculosis and treatment for HIV patients. Efforts to mitigate COVID-19 spread—including mobility restrictions for patients—and shortages of supplies and personal protective equipment also undermined the delivery of key maternal and neonatal health services.