Usually because the indicator that proved they worked belonged to the donor and not to the country. In epidemiological week 23 of 2025, the Dominican Republic measured 2,986 facilities and published coverage and timeliness for each of its 40 provincial directorates. A pilot outside that measurement cannot outlive its funding.
There is a scene that repeats across health cooperation: a primary care pilot works, publishes good results, the funding ends, and it disappears. Not because it failed. Because nobody planned what came next.
The usual explanation is money. It is true and it is incomplete.
What exactly is lost when a pilot ends?
Three things, and only the first is budget. The funding goes, the team that ran it goes, and the way of knowing whether it still works goes with them.
The first two get discussed at length. The third almost never does, and it is the one that decides. A program without funding can come back if someone demonstrates it was worth having. A program whose evidence lived inside a donor report can demonstrate nothing once that report stops being written.
Why does measurement decide survival?
Because absorbing a pilot into the national budget is a decision somebody has to defend, and decisions are defended with numbers the institution recognizes as its own.
An indicator designed for a project logframe answers the project question: how many people were reached, in what time, at what cost. That is a legitimate question and it is not the ministry question. The ministry asks something else: what changed in this territory, compared with the other territories, and did it hold.
When the pilot ends, the second question goes unanswered, because it was never being answered.
What does the country already have to measure with?
More than tends to be assumed, and that is worth saying before proposing anything new.
The National Epidemiological Surveillance System publishes operational indicators every week, with names and numbers. In epidemiological week 23 of 2025:
- 2,986 facilities at the first, second and third level of care were required to report.
- 2,652 reported, meaning 89% coverage, and of those 87% did so on time.
- All 40 provincial and area health directorates appear compared against one another, week by week.
That is a national measurement apparatus, with a historical series, territorial comparison and regular publication. No project built it, and it leaves with none of them.
Is there a case where absorption actually worked?
Yes, and it is Dominican. The national HIV response is moving from international to domestic financing, with a mechanism and with dates.
The State already covers one hundred percent of antiretrovirals, and a National Fund for the Sustainability of Care and Treatment was created, expected to contribute between 4 and 5 million dollars a year from 2027 for HIV and tuberculosis medicines and supplies. The Global Fund contribution is estimated to end between 2028 and 2030.
What distinguishes that case is not more willingness. It is that there is a mechanism with a name, a figure and a calendar, rather than an intention. That is precisely what a primary care pilot is rarely asked for.
What would a pilot designed to survive do differently?
Three things, and none of them costs money at the outset:
- Choose, before starting, an indicator the national system already collects or could collect. If the pilot needs its own form to prove it works, it was born depending on itself.
- Publish its results in the same territorial unit the country compares by: the provincial directorate. A result that cannot be set beside the other 39 enters no budget conversation.
- Fix at design time who keeps measuring once the project ends, naming the institution. That is not paperwork: it is the difference between evidence that continues and evidence that expires.
What this analysis does not claim
It does not claim pilots are unnecessary. Many have tested things the country would not have tested alone, and that function is real.
It does not claim measurement is sufficient. A pilot can be measured impeccably and still not be absorbed, because the final decision is political and budgetary.
And it evaluates no particular project and no agency. The observation is about how evidence is designed, not about who funds it.
Sources
Weekly epidemiological bulletin of the Dirección General de Epidemiología, week 23 of 2025, the source of the 2,986 facilities, the 89% coverage, the 87% timeliness and the 40 provincial directorates. General Health Law 42-01 and Law 87-01 creating the Dominican Social Security System, both of 2001. On the HIV transition: official communications from the Ministry of Public Health and the Presidency regarding the National Fund for the Sustainability of Care and Treatment and the Global Fund timetable.
- Epidemiological surveillance
- Policy and regulation
- District-level reporting