When Community Becomes Healthcare

By Anlys Matos — Eleventh Grade —

Sometimes the first person to notice that you're sick isn't a doctor. It's your mother, your

neighbor, your teacher, or the person living next door. In much of the Dominican Republic,

that isn't just an informal reality — it's a formal, documented part of how the health system

actually functions.

Health doesn't happen exclusively inside hospitals:

The World Health Organization has increasingly emphasized community engagement and

primary healthcare as core components of effective health systems — not an add-on to

hospital-based care, but a genuine first layer of it. Community health workers (CHWs),

sometimes called promotores de salud or cooperadores de salud in Spanish-speaking

contexts, are the clearest embodiment of that idea: members of a community, trained to

provide basic health education, screening, referrals, and prevention work, precisely because

they already have something hospitals often lack — trust, proximity, and local knowledge.

Written into Dominican health policy for over two decades:

This isn't a recent improvisation in the Dominican Republic — it's built into the country's

health system on paper. Under the 1999 National Ordinance for Hospitals, community health

workers were formally identified as part of the healthcare referral system, specifically tasked

with detecting high-risk pregnancies and referring patients to healthcare centers they might

not otherwise reach in time.

Proof it works: malaria in Santo Domingo

The clearest evidence that this model delivers real results comes from the Dominican

Republic's push to eliminate malaria. Between 2019 and 2022, a structured community

health worker network operating in the three main urban malaria hotspots of Greater Santo

Domingo helped drive malaria cases down from 1,243 to just 6 — even while absorbing

disruptions from the COVID-19 pandemic. A separate evaluation found that without

CHW-collected data specifically, only 52% of health facilities could confirm they'd been

malaria-free for the required 13-month period; adding community-level data substantially

improved that picture, meaning CHWs weren't just treating patients — they were providing

surveillance data the formal health system couldn't generate on its own.

The "double burden" rural CHWs are navigating right now.

Outside the cities, the picture is more complicated but just as central. Research published in

2025 interviewed community health cooperadores working in rural Dominican communities

through a decades-long program run by the NGO ILAC, active in the region since 1989.

What they described wasn't a simple story of infectious disease declining as chronic disease

rises — the pattern epidemiologists usually expect as a country develops. Instead, these

CHWs described a genuine double burden: they're managing infectious disease and rising

non-communicable disease (like diabetes and hypertension) simultaneously, without the

resources or role clarity that would normally accompany that kind of transition.

The CHWs interviewed saw themselves clearly as change-makers — crediting their work

with measurable improvements in child mortality and broader social determinants of health in

their communities. But that same research found their responsibilities have expanded faster

than their support has: they described low pay, heavy workloads, and — notably — added

pressure tied specifically to gender expectations, since the CHW workforce in these

communities is predominantly women navigating both professional and unpaid caregiving

roles simultaneously.

Why this model exists in the first place:

The honest answer is structural necessity, not just philosophy. The Dominican Republic has

a limited formal health workforce relative to its population, and CHWs have been deployed

by both government and NGO programs specifically as extensions of a healthcare system

that can't reach everyone through hospitals and clinics alone. In communities where the

nearest formal facility is hours away, or where transportation and cost create real barriers to

seeking care, the people who actually catch problems early are rarely doctors — they're the

community health worker who already knows every household, the neighbor who notices a

child hasn't been eating, or the church leader a family trusts more than an unfamiliar clinic.

Moving healthcare outward, not just inward:

The conceptual shift this whole model represents is worth naming directly: hospital →

community, instead of only hospital → patient. In the traditional model, healthcare happens

when a sick person manages to get themselves to a facility. In the community model,

healthcare moves outward — into homes, schools, and neighborhoods — through

education, prevention, and screening that happen before someone is sick enough to need a

hospital bed at all.

That outward movement is exactly what shows up across the Dominican examples here: a

cooperador catching a high-risk pregnancy before it becomes an emergency, a malaria CHW

network generating surveillance data no clinic alone could produce, or a neighbor

recognizing dengue warning signs early enough to matter, because dengue prevention itself

— as covered elsewhere in Dominican public health — depends heavily on community-level

participation, not hospital treatment.

What strengthening this model could look like:

Based on what Dominican CHWs themselves describe needing, and what's already been

proven to work:

● Fair compensation for a workforce currently relying heavily on volunteer or underpaid

labor, despite carrying real clinical and surveillance responsibilities

● Formal role clarity as CHW responsibilities expand into non-communicable disease

management, so the job doesn't quietly grow without matching support

● Investment in CHW data systems, given the malaria evidence that community-level

data materially improves what the formal health system can actually confirm and act

on

● Recognition of the gendered labor underpinning much of this workforce, and support

structures that account for it rather than treating it as invisible

● Continued integration between formal government health referral systems and

NGO-run CHW programs, so neither operates in isolation from the other

Community health work here isn't a stopgap for a health system that can't yet cover

everyone — it's already the layer that catches what the formal system misses. A country in

the Dominican Republic's position, dealing with a widening double burden of infectious and

chronic disease, has direct evidence that the fastest wins come from strengthening that

layer, not sidelining it.

Works cited

● PLOS Global Public Health / PMC, "Navigating double burden: Community

health workers in rural Dominican Republic living and working through the

epidemiologic transition" (2025)

● PMC, "The role of a structured community health worker network in achieving

malaria elimination goals in the Dominican Republic: An impact evaluation

amid COVID-19 disruptions"

● CHW Central, "Incorporating Community Case Management in Risk-Based

Surveillance for Malaria Elimination in the Dominican Republic"

● Agency for Healthcare Research and Quality (AHRQ), "Community Health

Workers (Promotores de Salud)"