Assessment of the quality of inpatient meals and nutrition and dietetics service processes in select Philippine public hospitals.

AIMS: The nutrition and dietetics service in Philippine public hospitals was implemented by the Department of Health in 2016 to standardise the daily allowance and nutritional content of inpatient meals. Five years later, it is timely for the Department of Health to assess the quality of inpatient meals and mandated nutrition processes in areas such as staffing, food service, and outcomes monitoring. METHODS: A mixed-method sequential explanatory design was employed using (1) quantitative assessment through a facility survey (n = 193 hospitals) and (2) qualitative exploration of quantitative results through 6 focus group discussions (n = 36 hospitals). RESULTS: Philippine public hospitals were unequipped with the inputs necessary to implement processes that produce high-quality meals for patients. The hospitals were unable to comply with the required minimum meal allowance (51%), nutritional content of meals (40%), and food service standards. Moreover, they had insufficient human resources and inefficient food procurement practices. CONCLUSIONS: The quality of nutrition care and inpatient meals in Philippine public hospitals, who serve mostly people on low incomes, is a neglected problem in the Philippines. Moving forward, a systems approach involving the Department of Health, its regional offices, and hospital management is necessary to equip Philippine public hospitals with the inputs and structures necessary to provide high-quality nutrition care and inpatient meals that will facilitate patient recovery and overall patient health.

What explains the large disparity in child stunting in the Philippines? A decomposition analysis.

OBJECTIVE: About one-third of under-five Filipino children are stunted, with significant socio-economic inequality. This study aims to quantify factors that explain the large gap in stunting between poor and non-poor Filipino children. DESIGN: Using the 2015 Philippine National Nutrition Survey, we conducted a linear probability model to examine the determinants of child stunting and then an Oaxaca-Blinder decomposition to explain the factors contributing to the gap in stunting between poor and non-poor children. SETTING: Philippines. PARTICIPANTS: 1881 children aged 6-23 months participated in this study. RESULTS: The overall stunting prevalence was 38·5 % with a significant gap between poor and non-poor (45·0 % v. 32·0 %). Maternal height, education and maternal nutrition status account for 26 %, 18 % and 17 % of stunting inequality, respectively. These are followed by quality of prenatal care (12 %), dietary diversity (12 %) and iron supplementation in children (5 %). CONCLUSIONS: Maternal factors account for more than 50 % of the gap in child stunting in the Philippines. This signifies the critical role of maternal biological and socio-economic circumstances in improving the linear growth of children.

National multisectoral governance challenges of implementing the Philippines' Reproductive Health Law.

In recognition of the role of reproductive health in individual and national development, the Responsible Parenthood and Reproductive Health (RPRH) Law of 2012 was passed in the Philippines after 30 years of opposition and debate. Seven years later, this article examined the cohesiveness of national multi-sectoral governance among state and non-state actors and identified challenges in coordination as part of the first comprehensive evaluation of the landmark policy. Using a qualitative intrinsic case study design and guided by the World Health Organization's systems checklist for governing health equity as our theoretical perspective, we conducted 20 semi-structured interviews with national implementers from health agencies (n = 11), non-health agencies (n = 6) and non-state actors (n = 3) that included civil society organizations (CSOs). Key themes identified through thematic analysis were supported with document reviews of policy issuances, accomplishment reports and meeting transcripts of the RPRH National Implementation Team (NIT). The study found that despite aspirations for vibrant multi-sectoral coordination, the implementation of the RPRH Law in the Philippines was incohesive. National leaders, particularly the health sector, were neither able to rally non-health sector actors around RPRH nor strategically harness the power of CSOs. Local resource limitations associated with decentralization were exacerbated by paternalistic financing, coordination, and monitoring. The absence of multi-agency plans fostered a culture of siloed opportunism, without consideration to integrated implementation. This case study shows that for neutral policies without conflicts in sector objectives, the interest and buy-in of non-health state actors, even with a national law, cannot be assumed. Moreover, possible conflicts in interests and perspectives between state and civil society actors must be managed in national governance bodies. Overall, there is need for participatory policymaking and health-sector advocacy to set health equity as an intersectoral goal, involving subnational leaders in developing concrete action plans, and strengthening NIT's formal accountability systems.

The Impact of COVID-19 on Hospital Admissions for Twelve High-Burden Diseases and Five Common Procedures in the Philippines: A National Health Insurance Database Study 2019-2020.

BACKGROUND: The Philippines has the highest cumulative COVID-19 cases and deaths in the Western-Pacific. To explore the broader health impacts of the pandemic, we assessed the magnitude and duration of changes in hospital admissions for 12 high-burden diseases and the utilization of five common procedures by lockdown stringency, hospital level, and equity in patient access. METHODS: Our analysis used Philippine social health insurance data filed by 1,295 hospitals in 2019 and 2020. We calculated three descriptive statistics of percent change comparing 2020 to the same periods in 2019: (1) year-on-year, (2) same-month-prior-year, and (3) lockdown periods. FINDINGS: Disease admissions declined (-54%) while procedures increased (13%) in 2020 versus 2019. The increase in procedures was caused by hemodialysis surpassing its 2019 utilization levels in 2020 by 25%, overshadowing declines for C-section (-5%) and vaginal delivery (-18%). Comparing months in 2020 to the same months in 2019, the declines in admissions and procedures occurred at pandemic onset (March-April 2020), with some recovery starting May, but were generally not reversed by the end of 2020. Non-urgent procedures and respiratory diseases faced the largest declines in April 2020 versus April 2019 (range: -60% to -70%), followed by diseases requiring regular follow-up (-50% to -56%), then urgent conditions (-4% to -40%). During the strictest (April-May 2020) and relaxed (May-December 2020) lockdown periods compared to the same periods in 2019, the declines among the poorest (-21%, -39%) were three-times greater than in direct contributors (-7%, -12%) and two-times more in the south (-16%, -32%) than the richer north (-8%, -10%). Year-on-year admission declines across the 12 diseases and procedures (except for hemodialysis) was highest for level three hospitals. Compared to public hospitals, private hospitals had smaller year-on-year declines for procedures, because of increases in utilization in lower level private hospitals. INTERPRETATION: COVID-19's prolonged impact on the utilization of hospital services in the Philippines suggests a looming public health crisis in countries with frail health systems. Through the periodic waves of COVID-19 and lockdowns, policymakers must employ a whole-of-health strategy considering all conditions, service delivery networks, and access for the most vulnerable. FUNDING: Open Philanthropy.

Cocreation in Health Workforce Planning to Shape the Future of the Health Care System in the Philippines.

BACKGROUND: The Philippines passed landmark legislation in 2019 on universal health coverage, including reforms in the development of its health workforce, an essential building block of responsive health care systems. HEALTH WORKFORCE PLANNING COCREATION PROCESS: We based our planning process on a model of cocreation defined as sharing power and decision making to solve problems collaboratively and build consensus around action. Through cocreation with policy makers, researchers, and other stakeholders, we performed projection studies on 10 selected health professions and estimated the need for primary care at national and subnational levels, which was the most extensive health workforce projection carried out by the Philippine Department of Health to date. We determined health workforce requirements based on target densities recommended by the World Health Organization and a health needs approach that considered epidemiological and sociodemographic factors. In consultation with stakeholders, we interpreted our analysis to guide recommendations to address issues related to health workforce quantity, skill mix, and distribution. These included a broad range of proposals, including task shifting, expanding scholarships and deployment, reforming health professionals' education, and pursuing a whole-of-society approach, which together informed the National Human Resources for Health Master Plan. CONCLUSIONS: Our cocreation model offers lessons for policy makers, program managers, and researchers in low- and middle-income countries who deal with health workforce challenges. Cocreation led to relationship building between policy makers and researchers who jointly performed the research and identified solutions through open communication and agile coordination. To shape future health care systems that are responsive both during normal times and during crises, cocreation would be essential for evidence-informed policy development and policy-relevant research.

Trends in National-Level Governance and Implementation of the Philippines' Responsible Parenthood and Reproductive Health Law from 2014 to 2020.

In 2012, the Philippines passed the Responsible Parenthood and Family Planning Law, a landmark legislation billed as a multisectoral and rights-based approach to further sustainable human development. This article is part of the first comprehensive evaluation of the implementation of the law by national-level actors. This evaluation is intended to assess the progress of implementers in the conduct of mandates, roles, and responsibilities described in the law and its implementing guidelines. Interviews with key national government officials and data from official documents and literature revealed 3 major trends in governance and implementation from 2014 to 2020. First, despite being a multisectoral policy, performance was siloed within individual units of implementing agencies, with limited interagency coordination. Second, although the law explicitly called for interventions to invest in human capital and address socioeconomic disparities for sustainable human development, performance focused on biomedical and health interventions, particularly in the area of family planning. Third, national-level governance for reproductive health interventions concentrated on programmatic and operational concerns. Overall, this case in the Philippines illustrates that fragmented implementation has contributed to the slow improvement of reproductive health outcomes. This study highlights the challenges of governance and multisectoral coordination to implement multidimensional interventions in a low- and middle-income country, and it provides potential areas for political and administrative reform in reproductive health governance in the Philippines. By creating a common narrative and onboarding multiple sectors, officials can better identify and address structural determinants with holistic policy solutions to improve reproductive health outcomes.

Cost-utility analysis of heart surgeries for young adults with severe rheumatic mitral valve disease in India.

BACKGROUND: Rheumatic mitral valve disease (RMVD) is a major cause of acquired valvular disease in India. We compared the cost-effectiveness of surgical treatment strategies for young adults with severe RMVD from an Indian public payer perspective. METHODS: We developed a Markov model to reflect the burden of RMVD among a hypothetical cohort of 20-year-olds in India and to estimate quality-adjusted life years (QALYs) and lifetime costs associated with three strategies: (1) Repair; (2) Mechanical valve replacement (MVR-M); and (3) Bioprosthetic valve replacement (MVR-B), compared to a baseline strategy involving a mix of surgeries approximating the standard of care in India (32% Repair, 33% MVR-M, 35% MVR-B). Data on disease burden, intervention effects, and direct medical costs (2018 US$) were obtained from the literature. Deterministic and probabilistic sensitivity analyses were conducted to assess model uncertainty. RESULTS: Repair ($2530, 9.7 QALYs) was less costly and more effective than the standard of care ($2990, 8.7 QALYs) and MVR-M ($3220, 6.2 QALYs). The incremental cost-effective ratio for MVR-B ($3190, 10.1 QALYs) compared to Repair was $1590 per QALY, which may be cost-effective at a threshold of India's per-capita gross domestic product (GDP: $2005). The optimal choice between Repair or MVR-B was sensitive to variations in surgery costs, background mortality, and risks for reoperation. CONCLUSIONS: Our model-based analysis suggests that Repair is the optimal strategy and MVR-M should not be recommended for this subpopulation. MVR-B may be cost-effective in contexts where quality of Repair is not assured, newer generation bioprostheses are used, or the costs of the bioprosthetic valve decrease.

The Comparative Effectiveness of Autologous Blood-derived Products Versus Steroid Injections in Plantar Fasciitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: Plantar fasciitis is one of the most common musculoskeletal diseases, and nearly 90% of patients can be successfully treated by nonsurgical options. However, it is yet to be determined which nonsurgical treatment has the best efficacy. The present study investigated differences between autologous blood-derived products and corticosteroid injections in the treatment of plantar fasciitis. TYPE: Systematic Review and Meta-analysis. LITERATURE SURVEY: PubMed, EMBASE, CINAHL, and Web of Science were searched for relevant articles up to November 2019. There was no language restriction, and unpublished trials were excluded. This systematic review included only randomized controlled trials. METHODOLOGY: The primary outcomes were Visual Analog Scale and American Orthopedic Foot and Ankle Score (AOFAS). The follow-up times were divided into short term (3-6 weeks), intermediate term (3 months or 12 weeks), and long term (6 months or 24 weeks). The random-effects model was utilized, and weighted mean difference was calculated as the pool estimates. SYNTHESIS: Thirteen randomized controlled trials and 640 patients were included. No significant difference in Visual Analog Scale reduction was observed between autologous blood-derived product and corticosteroid injections in the short term (weighted mean difference [WMD] = -0.84; 95% confidence interval [CI], -1.71 to 0.03; P = .057), intermediate term (WMD = -0.24; 95% CI, -0.90 to 0.42; P = .475), and long term (WMD = 0.47; 95% CI, -0.72 to 1.65; P = .44). No significant difference in AOFAS was observed between autologous blood-derived products and corticosteroids in the short term (WMD = -0.65; 95% CI, -5.40 to 4.10; P = .79), intermediate term (WMD = 0.17; 95% CI, -8.07 to 8.41; P = .97), and long term (WMD = 1.16; 95% CI, -4.54 to 6.86; P = .69). CONCLUSIONS: This systematic review and meta-analysis of autologous blood-derived products versus corticosteroids for plantar fasciitis is the first that includes only randomized controlled trials. The meta-analysis found no significant difference between autologous blood-derived products and corticosteroids, as measured by Visual Analog Scale or AOFAS. These findings applied whether followed up in short, intermediate, or long term. These results differ from previous studies that showed superior efficacy of autologous blood-derived products compared with corticosteroids in the long term.

Previous and active tuberculosis increases risk of death and prolongs recovery in patients with COVID-19.

BACKGROUND: There is a growing literature on the association of SARS-CoV-2 and other chronic conditions, such as noncommunicable diseases. However, little is known about the impact of coinfection with tuberculosis. We aimed to compare the risk of death and recovery, as well as time-to-death and time-to-recovery, in COVID-19 patients with and without tuberculosis. METHODS: We created a 4:1 propensity score matched sample of COVID-19 patients without and with tuberculosis, using COVID-19 surveillance data in the Philippines. We conducted a longitudinal cohort analysis of matched COVID-19 patients as of May 17, 2020, following them until June 15, 2020. The primary analysis estimated the risk ratios of death and recovery in patients with and without tuberculosis. Kaplan-Meier curves described time-to-death and time-to-recovery stratified by tuberculosis status, and differences in survival were assessed using the Wilcoxon test. RESULTS: The risk of death in COVID-19 patients with tuberculosis was 2.17 times higher than in those without (95% CI: 1.40-3.37). The risk of recovery in COVID-19 patients with tuberculosis was 25% lower than in those without (RR = 0.75,05% CI 0.63-0.91). Similarly, time-to-death was significantly shorter (p = .0031) and time-to-recovery significantly longer in patients with tuberculosis (p = .0046). CONCLUSIONS: Our findings show that coinfection with tuberculosis increased morbidity and mortality in COVID-19 patients. Our findings highlight the need to prioritize routine and testing services for tuberculosis, although health systems are disrupted by the heavy burden of the SARS-CoV-2 pandemic.

Association of SHI coverage and level of healthcare utilization and costs in the Philippines: a 10-year pooled analysis.

BACKGROUND: The Philippine Health Insurance Corporation (PhilHealth), which manages the Philippine national health insurance program, is a critical actor in the country's strategy for universal health coverage. Over the past decade, PhilHealth has passed significant coverage, benefits and payment reforms to contain costs and improve the affordability care for high-cost diseases, inpatient care and select outpatient services. METHODS: We studied the association of PhilHealth with health care utilization and health care costs using three rounds of the Philippine Demographic and Health Survey with data on individual outpatient and inpatient visits from 2008 to 2017. RESULTS: PhilHealth membership was associated with 42% greater odds of outpatient utilization and 47-100% greater odds inpatient utilization depending on survey year. Depending on facility type, use of PhilHealth to pay for care was associated with higher average health care costs of 244-865% for outpatient care and 135-206% for inpatient care. CONCLUSIONS: PhilHealth has likely decreased barriers to health care utilization but may have inadvertently driven up health care costs in the country. Results align with past studies that suggest that reforms in the prior decade have done little to contain health care costs for Filipinos.

Preliminary validation of the PRImary care facility Management Evaluation tool (PRIME-Tool), a national facility management survey implemented in Ghana.

BACKGROUND: The management quality of healthcare facilities has consistently been linked to facility performance, but available tools to measure management are costly to implement, often hospital-specific, not designed for low- and middle-income countries (LMICs), nor widely deployed. We addressed this gap by developing the PRImary care facility Management Evaluation Tool (PRIME-Tool), a primary health care facility management survey for integration into routine national surveys in LMICs. We present an analysis of the tool's psychometric properties and suggest directions for future improvements. METHODS: The PRIME-Tool assesses performance in five core management domains: Target setting, Operations, Human resources, Monitoring, and Community engagement. We evaluated two versions of the PRIME-Tool. We surveyed 142 primary health care (PHC) facilities in Ghana in 2016 using the first version (27 items) and 148 facilities in 2017 using the second version (34 items). We calculated floor and ceiling effects for each item and conducted exploratory factor analyses to examine the factor structure for each year and version of the tool. We developed a revised management framework and PRIME-tool as informed by these exploratory results, further review of management theory literature, and co-author consensus. RESULTS: The majority (17 items in 2016, 23 items in 2017) of PRIME-Tool items exhibited ceiling effects, but only three (2 items in 2016, 3 items in 2017) showed floor effects. Solutions suggested by factor analyses did not fully fit our initial hypothesized management domains. We found five groupings of items that consistently loaded together across each analysis and named these revised domains as Supportive supervision and target setting, Active monitoring and review, Community engagement, Client feedback for improvement, and Operations and financing. CONCLUSION: The revised version of the PRIME-Tool captures a range of important and actionable information on the management of PHC facilities in LMIC contexts. We recommend its use by other investigators and practitioners to further validate its utility in PHC settings. We will continue to refine the PRIME-Tool to arrive at a parsimonious tool for tracking PHC facility management quality. Better understanding the functional components of PHC facility management can help policymakers and frontline managers drive evidence-based improvements in performance.

Reflections on the use of the World Health Organization's (WHO) OneHealth Tool: Implications for health planning in low and middle income countries (LMICs).

The World Health Organization (WHO) launched the OneHealth Tool (OHT) to help low and middle income countries to develop their capacities for sector-wide priority setting. In 2016, we sought to use the OHT to aid the Philippine Health Insurance Corporation (PHIC), the national health insurer of the Philippines, in decisions to expand benefit packages using cost-effectiveness analyses. With technical support from the WHO, we convened health planning officers from the Philippine Department of Health (DOH) and the Philippine Health Insurance Corporation (PHIC) conduct generalized cost-effective analyses (GCEA) of selected un-financed noncommunicable disease interventions using OHT. We collected epidemiological and cost data through health facility surveys, review of literature such as cost libraries and clinical practice guidelines, and expert consultations. Although we were unable to use GCEA results directly to set policy, we learnt important policy lessons which we outline here that might help inform other countries looking to inform service coverage decisions. Additionally, the entire process and GCEA visualizations helped high-level policymakers in the health sector, who have traditionally relied on ad hoc decision making, to realize the need for a systematic and transparent priority-setting process that can continuously provide the evidence needed to inform service coverage decisions.

Soil-Transmitted Helminthiasis and Schistosomiasis in Children of Poor Families in Leyte, Philippines: Lessons for Disease Prevention and Control.

Objective: Neglected tropical diseases (NTDs) continue to be a public health problem in the Philippines. We assessed the association of soil-transmitted helminthiasis (STH) and schistosomiasis with selected health-related and socioeconomic variables in four villages in Leyte, Philippines. Methods: Stool specimens from 418 adults and 533 of their children from 209 families were examined through the Kato-Katz technique. Results: STH and schistosomiasis were present in 64.6% and 12.5%, respectively, of study participants. Analysis through the generalized linear mixed model revealed a number of associations between infection in parents and their children. Findings indicate that years of disease prevention and control efforts in these areas have been unable to bring down prevalence in children and their parents. Eliminating NTDs as public health problems will require a systems thinking approach beyond implementation of vertical control programs alone.