Experiences from the Philippine grassroots: impact of strengthening primary care systems on health worker satisfaction and intention to stay.

BACKGROUND: Inequities in health access and outcomes persist in low- and middle-income countries. While strengthening primary care is integral in improving patient outcomes, primary care networks remain undervalued, underfunded, and underdeveloped in many LMICs such as the Philippines. This paper underscores the value of strengthening primary care system interventions in LMICs by examining their impact on job satisfaction and intention to stay among healthcare workers in the Philippines. METHODS: This study was conducted in urban, rural, and remote settings in the Philippines. A total of 36 urban, 54 rural, and 117 remote healthcare workers participated in the study. Respondents comprised all family physicians, nurses, midwives, community health workers, and staff involved in the delivery of primary care services from the sites. A questionnaire examining job satisfaction (motivators) and dissatisfaction (hygiene) factors was distributed to healthcare workers before and after system interventions were introduced across sites. Interventions included the introduction of performance-based incentives, the adoption of electronic health records, and the enhancement of diagnostic and pharmaceutical capabilities over a 1-year period. A Wilcoxon signed-rank test and a McNemar's chi-square test were then conducted to compare pre- and post-intervention experiences for each setting. RESULTS: Among the factors examined, results revealed a significant improvement in perceived compensation fairness among urban (p = 0.001) and rural (p = 0.016) providers. The rural workforce also reported a significant improvement in medicine access (p = 0.012) post-intervention. Job motivation and turnover intention were sustained in urban and rural settings between periods. Despite the interventions introduced, a decline in perceptions towards supply accessibility, job security, and most items classified as job motivators was reported among remote providers. Paralleling this decline, remote primary care providers with the intent to stay dropped from 93% at baseline to 75% at endline (p < 0.001). CONCLUSION: The impact of strengthening primary care on health workforce satisfaction and turnover intention varied across urban, rural, and remote settings. While select interventions such as improving compensation were promising for better-supported settings, the immediate impact of these interventions was inadequate in offsetting the infrastructural and staffing gaps experienced in disadvantaged areas. Unless these problems are comprehensively addressed, satisfaction will remain low, workforce attrition will persist as a problem, and marginalized communities will be underserved.

Impact of improved primary care on patient satisfaction: Results of a pilot study in the University of the Philippines.

Primary care is generally perceived by the public as an inefficient, low-quality source of health care in the Philippines. Taking a toll on local health policies, the repercussions of these views warrant a more holistic approach in understanding patient experience. This paper evaluates the impact of strengthening primary care services on patient satisfaction at the University of the Philippines Health Service (UPHS). A prevalidated 16-item, 5-scale questionnaire was distributed to 200 eligible patients at the start of the study in 2016 and then again in 2017. A significant increase of highly satisfied patients in 13 of 16 questionnaire items was recorded after primary care services in the facility were strengthened. The highest satisfaction scores were reported for overall wait times, coordination of care, and health advice. Our findings suggest that improvements in primary care services through digitalizing health records, financing laboratory and pharmaceutical services, and retraining staff accounts for significant improvements in patient satisfaction. This ultimately bears potential for better clinical outcomes in form of patient retention and long-term care.

Trade-off between benefit and harm is crucial in health screening recommendations. Part II: evidence summaries.

Evidence on the effectiveness of health screening strategies may be direct (i.e., studies on screening vs. no screening) or indirect (i.e., studies that separately evaluate the screening test[s], the confirmatory test, or the treatment). Critical trade-offs in the balance between harm and benefit for many screening strategies mandate that advocates of health screening adhere to the ethical precepts of nonmaleficence, autonomy, confidentiality, and equity. In our first article, we pointed out five prerequisites to justifying a health screening program: (1) the burden of illness should be high, (2) the screening and confirmatory tests should be accurate, (3) early treatment (or prevention) must be more effective than late treatment, (4) the tests and the treatment(s) must be safe, and (5) the cost of the screening strategy must be commensurate with the potential benefit. As can be gleaned from these criteria, recommendations on screening must be tailored to specific populations. Recommendations in one country, no matter how authoritative, cannot be generalized to apply to all other countries. Although accuracy, effectiveness, and safety data may be global (criteria 2-4), burden of illness and efficiency (criteria 1 and 5) will always vary from country to country. Rather than review various national guidelines, in this last article of our two-part series, we present evidence summaries to illustrate health screening. Our examples were selected to address special issues related to four situations-screening for cancer, risk factors for disease, genetic disorders, and infectious diseases.

Trade-off between benefit and harm is crucial in health screening recommendations. Part I: general principles.

Health screening is defined as the use of a test or a series of tests to detect unrecognized health risks or preclinical disease in apparently healthy populations to permit prevention and timely intervention. A health screening strategy consists of the sequence of a screening test, confirmatory test(s), and finally, treatment(s) for the condition detected. The potential benefits of health screening are easy to understand, but the huge potential for physical and psychological harm is less well recognized. Thus, health screening should only be recommended when five criteria are satisfied: (1) the burden of illness should be high, (2) the tests for screening and confirmation should be accurate, (3) early treatment (or prevention) must be more effective than late treatment, (4) the test(s) and treatment(s) must be safe, and (5) the cost of the screening strategy must be commensurate with potential benefit. Direct evidence from screening trials is subject to less bias. In some instances, indirect evidence may be acceptable, e.g., when the condition screened for is a risk factor for a disease rather than the disease itself.

Zinc supplementation reduced cost and duration of acute diarrhea in children.

OBJECTIVE: To determine whether zinc with oral rehydration solution (ORS) is more cost effective than ORS alone in the treatment of acute diarrhea. STUDY DESIGN AND SETTING: Cost-effectiveness analysis among patients consulting the emergency room of a government institution. METHOD: Cost of treatment and outcome of participants of a randomized trial of zinc+ORS vs. ORS alone for acute diarrhea were investigated. Included were subjects 2-59 months with diarrhea <7 days and no dehydration. The direct medical, nonmedical and indirect costs were obtained, using the societal perspective. The incremental cost-effectiveness ratio (ICER) was calculated. RESULTS: Sixty patients were given zinc+ORS and 57 were given ORS alone. Mean duration of diarrhea was 17 hours shorter and mean total cost of treatment was 5% cheaper in the zinc than ORS group . The ICER showed that with use of zinc, the society saves $ 2.4 per day of diarrhea <4 days and spends $ 0.03 per case of diarrhea averted <4 days from consult, although the confidence interval included the null value of zero. CONCLUSION: Use of zinc with ORS reduced the total cost and duration of acute diarrhea. The ICER suggests cost effectiveness of zinc supplementation but there is a need to further assess the role of zinc supplementation in a larger population.

Cost-benefit analysis of newborn screening for galactosemia in the Philippines.

To determine the incidence of galactosemia (GAL) in the Philippines and to determine whether newborn screening for GAL is cost-beneficial from a societal perspective, cost-benefit analysis was performed. Newborn screening for GAL was done after the 24th hour of life using the Beutler test. Patients screened positive were recalled for confirmatory testing. Using incidence rates obtained from the different participating hospitals of the Philippine Newborn Screening Program (PNSP), the costs for the detection and treatment of GAL were compared to the expected benefits by preventing mental retardation, cataracts and other physical disabilities caused by the disorder that would lead to a loss of productivity for the individual. Sensitivity analyses for incidence and discount rates were also included. Of the 157,186 newborns screened by the PNSP since its inception in 1996, 8 screened positive results. Confirmatory testing of these patients showed that 2 had galactosemia. The incidence of galactosemia in this population therefore, is 1 in 106,006 (95% CI= 1:44,218 - 1:266,796). Projecting the figures to the actual birth rate (1.5M newborns/year), the total costs of the screening program amounted to $1.1M, while the total benefits amounted only to $0.2M, yielding net cost of $0.9M. A cost-benefit analysis of the screening program for galactosemia using the incidence 1 in 106,006 demonstrated that the costs of the program outweigh the benefits. The true incidence of galactosemia in the Philippine population may yield an incidence rate that will result in greater net benefits for the program.