From Protocol to Performance

How the Dominican Republic Integrated HEARTS and Digital Health to Transform Hypertension Control

A Systems Approach to a Silent Epidemic

Hypertension remains the leading modifiable risk factor for cardiovascular disease across the Caribbean and Latin America. For the Dominican Republic, the challenge was not simply clinical—it was structural.

Uncontrolled hypertension reflected:

• Inconsistent treatment protocols
• Variable medication access
• Limited follow-up adherence
• Fragmented performance monitoring

The national adoption of the HEARTS Initiative, supported by the Pan American Health Organization (PAHO), marked a turning point. HEARTS was first introduced in the Dominican Republic in 2019 through a pilot in 18 primary health care centers across four health regions. Its expansion was temporarily slowed by the COVID‑19 pandemic, but beginning in 2022 the country relaunched the strategy at scale, integrating it into broader reforms aimed at strengthening primary health care.

What distinguishes the Dominican Republic’s implementation is not only clinical standardization — it is the integration of digital monitoring systems and quality improvement mechanisms to track performance at scale and guide system‑wide decision making.

Beyond Protocols: Building a Performance Architecture

The HEARTS technical package, developed by the World Health Organization and implemented regionally through PAHO, emphasizes six pillars: healthy lifestyle promotion, evidence‑based treatment, access to essential medicines, cardiovascular risk management, team‑based care, and monitoring systems.

The Dominican Republic operationalized these pillars through two critical reforms:

• Standardized treatment algorithms across primary care, including national clinical pathways for hypertension and type 2 diabetes developed with the endorsement of national scientific societies.
  
  
• Digital performance tracking embedded within the national health information system.

These clinical pathways also facilitated the update of treatment protocols and the expansion of access to essential medicines through the national pharmaceutical supply network.

In January 2024, the Presidency of the Dominican Republic formally recognized the HEARTS strategy as the foundation for strengthening primary health care under the national initiative “Más Salud y Esperanza de Vida.

This transformation has also been supported by a broader institutional partnership. In September 2024, the Dominican Republic became the first country to formalize the Primary Health Care Alliance, bringing together the Ministry of Public Health (MISPAS), the National Health Service (SNS), the Pan American Health Organization (PAHO), the World Bank, and the Inter‑American Development Bank. This alliance aligns investments in infrastructure, digital health systems, workforce development, and prevention of noncommunicable diseases, positioning HEARTS as a central platform for strengthening primary health care and improving population health outcomes.

Digital Backbone: National Health Information Systems

To ensure consistent monitoring, the Ministry of Public Health strengthened national digital platforms to support the reporting and analysis of HEARTS indicators.

These systems support:

• Real‑time reporting of hypertension diagnosis and control rates
• Facility‑level performance dashboards
• Regional comparisons and trend analysis
• Structured quality improvement cycles

Facilities implementing HEARTS report standardized indicators that allow the health system to monitor blood pressure control rates, treatment adherence, and service delivery performance.

In January 2024,

the Presidency of the Dominican Republic formally recognized the HEARTS strategy as the foundation for strengthening primary health care under the national initiative “Más Salud y Esperanza de Vida.”

This digital architecture is reinforced through improvements in the Primary Health Care Information System (SIPNA), where HEARTS indicators have been integrated into routine monitoring processes, allowing managers and policymakers to track performance across the national network of primary health care facilities.

From Measurement to Improvement

Data collection alone does not drive change. The Dominican Republic institutionalized performance review mechanisms at multiple levels of the health system:

• Facility‑level team reviews
• Regional oversight through the nine Regional Health Services
• National aggregation of indicators for policy decision‑making

Quality improvement processes have been strengthened through the implementation of the HEARTS Maturity and Performance Index, which provides a standardized framework for supervision, performance feedback, and identification of implementation gaps.

Training programs for health workers and health managers have also been expanded to support these processes, including training on HEARTS quality improvement methodologies and facility self‑assessment tools designed to support continuous improvement in service delivery.

Recognition of Excellence

In recognition of its structured implementation and measurable gains, the Dominican Republic received the World Hypertension League Organizational Excellence Award (2025).

The award, accepted by Minister of Health Víctor Atallah, highlighted:

• National scale‑up of the HEARTS strategy across the primary health care network
• Large‑scale workforce training in hypertension management and cardiovascular risk assessment
• Expansion of free access to hypertension and diabetes medications through the national network of Farmacias del Pueblo
• Institutionalization of monitoring systems and quality improvement processes

By December 2025: HEARTS expanded to 87.7% of primary health care centers nationwide (1,214 of 1,384 facilities)
316,741 people diagnosed and receiving follow‑up under HEARTS protocols
63.8% of patients achieved blood pressure control (<140/90 mmHg)

These results reflect the progressive consolidation of standardized care pathways, medication access, and system‑wide monitoring mechanisms.

Why the Digital Layer Matters

For many Caribbean health systems, hypertension control falters not because protocols are unavailable, but because performance is invisible.

The Dominican Republic demonstrates that:

• Standardized treatment protocols improve consistency
• Free medication improves access
• Digital monitoring ensures accountability

By integrating HEARTS indicators into national digital systems, the country created a sustainable architecture capable of:

• Tracking progress toward population hypertension control
• Supporting Universal Health Coverage goals
• Generating evidence for policy refinement

When protocol, medication access, workforce training, and digital monitoring align — measurable improvement becomes possible.

A Model for the Region

The Dominican Republic’s experience illustrates a critical insight for Caribbean health leaders:

Clinical reform without data is fragile.
Data without governance is ineffective.
But when protocol, medication access, workforce training, and digital monitoring align — measurable improvement becomes possible.

Through the integration of HEARTS into primary health care reform and national digital monitoring systems, the Dominican Republic has positioned itself not merely as a program implementer, but as a regional leader in performance‑driven primary health care transformation.