Lessons in health systems resiliency from Thailand and the Dominican Republic

In the early days of 2020, Dr. Wasin Laohavinij was working in Bangkok’s King Chulalongkorn Memorial Hospital as a preventative medicine physician treating a growing caseload of non-communicable diseases. “Thailand is an elderly country. Non-communicable diseases are rising. The prevalence of disease has increased and about one in 10 people have diabetes, and maybe one in five have hypertension,” he said.

Some 16,000 kilometers away, Magdalena Rathe, a health economist and co-founder – with her biologist sister Laura Rathe – of Fundación Plenitud, were busy studying health system resiliency and the need to strengthen primary health care, especially among the most vulnerable populations.

Neither had a way of predicting the impact of the incoming COVID crisis. But that quickly changed.

On the heels of the Seventh Global Symposium on Health Systems Research (HSR2022), held between October 31 and November 4, we spoke with Dr. Laohavinij and Rathe, two EGH partners who presented at the "Maintaining Essential Health Services in the Midst of a Pandemic" session. Both shared stories of how Thailand and the Dominican Republic worked to make health systems more resilient during the pandemic, and how in doing so, they developed exemplary practices.

On January 13, 2020, Thailand reported the first case of COVID outside China, kicking off what would become the first global pandemic of its size in more than 100 years. “I had to [encourage] academic institutions to cope with maintaining essential health services,” while mitigating the mounting crisis, said Dr. Laohavinij, who would later become a coordinator at his hospital, planning patient flow and optimizing human resources during the pandemic.

In Santo Domingo, COVID-19 would take another two months to arrive, but Rathe was already forming a hypothesis: a successful response to the virus in the Dominican Republic would require political leadership and governance driven by science. She believed that officials in her island nation would have to “work in a very agile and flexible way,” she said.

The pandemic would bring the world to a standstill, and with it, unprecedented disruptions to essential health services (EHS). According to the WHO, “90% of countries experienced interruptions to the essential health services since the start of the pandemic.”

For Dr. Laohavinij, maintaining care meant going to patients. To control disease, he said, “you don't have to come to hospital. We can have your blood checked in the community, near your home, and we can send results to doctors so they can evaluate them. Then, doctors can send needed medicine back to the patient’s house,” he said, sharing one of the ways in which local community health workers maintained essential health services in his country. “It decreased time, [including] time the patient had to spend in health facilities and the costs they had to spend to travel.”

Just as Rathe had hypothesized, Dr. Laohavinij credited strong governance as the main component of maintaining strong health services during the crisis. “I think every country, they do the same thing, they try to establish a holistic approach, and have a central command, with each ministry and stakeholders who can come together and discuss how to deal with the situation. The decisions from each ministry work in a holistic way and are not informed just by the ministry of finance or the ministry of health,” he said. Helping the dots stay connected during a crisis, he added, allowed Thailand to fight COVID-19 while keeping up the delivery of essential health services, including treating non-communicable disease patients.

In the Dominican Republic, Rathe said, the “whole-of-government approach” turned out to be essential to fighting COVID and maintaining EH.

“There was a health cabinet led by the vice president of the republic and the president was very attentive all the time to the pandemic but also to the recovery of the economy,” she said. Rathe added that the country's pandemic response was also boosted by its vaccination process, the significant financial resources invested, and good risk communication and data management. “The main conclusion is that, in the case of the Dominican Republic, we protected the population through vaccination, restored essential health services, and recovered employment, tourism, recruitment currency,” she said.

In a recent Delphi study published in the journal Nature, nearly 400 multidisciplinary experts from 112 countries agreed that “three of the highest ranked recommendations to end the COVID pandemic call for the adoption of whole-of-society and whole-of-government approaches, while maintaining proven prevention measures using a vaccines-plus approach that employs a range of public health and financial support measures to complement vaccination.” The study found that, “with at least 99% combined agreement… governments and other stakeholders must improve communication, rebuild public trust, and engage communities in the management of pandemic responses.”

Both the Dominican Republic and Thailand took such complementary measures to combat the pandemic, including prioritizing health spending and transfers to low-income families in the Caribbean nation, and creating social protection schemes in the Thailand that allowed some 44 million Thais to receive assistance. COVID, Dr. Laohavinij would say, “is not just the health problem, it was also an economic problem, because a lot of people didn't have work to do and therefore, they don't have income.”

Then, both nations focused on safeguarding the integrity of their health systems, despite the disruptions caused by the novel coronavirus. In an interview with Global Citizen, Dominican Republic Vice President Raquel Peña said that her government was “committed, from the start, to strengthening digital government tools, to guaranteeing education, production chains, food safety, and above all the integrity of the health system. [We did] all this in order to continue offering the services that we are called to provide, beyond COVID-19, and [to] guarantee effective care, despite the systemic gaps that the sector suffered.”

In Thailand, a similar scenario played out, with the government focusing on addressing barriers to accessing health care, particularly those faced by vulnerable populations, such as migrants, and enhancing universal health coverage through primary health care in urban areas. “Three keywords to capture Thailand’s COVID-19 response are flexibility, adaptability and pragmatism," the WHO Thailand Representative would later say, were what made Thailand respond so effectively to COVID, while maintaining its health system resiliency.

Both Dr. Laohavinij and Rathe have high hopes that the lessons from the COVID-19 pandemic will improve health system resiliency their countries. “I hope this crisis has created consciousness on the need to strengthen the health system because, for decades, the public investment had been low, and if it was possible to do [all that we did] in in a moment of crisis, it is also possible to assign more resources now to strengthen particularly the public networks,” said Rathe, adding that there is an increasingly visible need to strengthen primary health care, capacity building, and community health care.

Dr. Laohavinij said the lessons for Thailand will stay with them long after COVID-19 is history. “During the early phase, we had the uncertainty, we did not know a lot. So, the whole-of-government approach helped us to know in which direction we’d have to go,” he said. What came later would be just as important. “After, I think, you have to learn from those in the local context, the local area.”

Understanding emerging health crises and the disruptions they cause across all services, as well as the locally driven mitigation strategies that can help maintain service delivery, both agreed, may be the best path forward.