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Taking action to fight the coronavirus reaches beyond the workday for ThinkWell’s Philippines team. On the side, they’re volunteering their expertise in these six ways:

  1. Matching health workers to health facilities: When coronavirus cases started spreading through the Philippines, Administrative and Finance Coordinator Susan Rosales stepped in to help. As a volunteer, she provided administrative and financial support to establish the Department of Health Healthcare Warriors Portal, an online recruitment portal that deploys volunteer health workers to health facilities that treat Covid-19 patients.
  2. Distributing PPE to health workers: The shortage of personal protective equipment (PPE) among health workers is a dangerous stumbling block in coronavirus response efforts. Technical Advisor Dr. Lena Alvior has helped provide PPE to health workers in thirty hospitals across the region of Western Visayas. She also helped distribute PPE to the provincial health office of Antique and Guimaras for their contact tracing efforts. During the period of economic turmoil that the coronavirus has left in its wake, the creation of locally made hazmat suits and isolation gowns provide critically needed jobs to Filipino garment makers.
  3. Boosting nutrition for quarantined people: During quarantine, with local markets shuttered and supply chains disrupted, many people have faced challenges gaining access to fresh food items. Dr. Gelo Apostol and Dr. Marife Yap have helped the Philippines’ local governments ensure citizens’ access to healthy food through the provision of nutritious food packages. These are an alternative to food relief packages’ usual menu of processed, unhealthy products (e.g., canned goods and instant noodles). The nutritious food packages also support local farmers who are struggling to stay afloat during the economic downturn. So far, they have helped distribute 4,000 healthy food packages to families as of June 25, 2020.
  4. Risk mapping and monitoring: Data is critical for evidence-driven, efficient responses to coronavirus. Technical Advisor Dr. Gelo Apostol works closely with experts and analysts from top universities in the Philippines to help national, regional, and provincial health authorities assess health system capacities for resilience, monitor vulnerabilities for transmission and mortality across the population, and map the overall risk for health systems to be overwhelmed during the pandemic. The interactive map that Dr. Gelo Apostol and others created can be accessed here.
  5. Assisting health policy and decision makers: Providing advice to national policy and decision-makers on health issues is ThinkWell’s bread and butter. During this pandemic, Senior Technical Advisor Dr. Marife Yap joined the Department of Health’s daily virtual press briefing to discuss and advise on coronavirus testing efforts.
  6. Thanking frontline health workers: Filipino health workers have been giving their all over the past few months. Program Coordinator Jem Sigua and Program Analyst Camille wanted them to know that they are appreciated for courageously saving lives. To express their gratitude, they developed a “thank you” video for the health workers who support coronavirus testing across the country.

 

Covid-19 in the Philippines
PPE-clad health workers, thanks to Technical Advisor Dr. Lena Alvior’s help

 

Covid-19 in the Philippines
Distributing nutritious food packages

 

This blog has been posted with kind permission from Health Policy and Planning Debated

How countries are responding to the COVID-19 pandemic is not only driven by technical and sociopolitical considerations, but also by their recent histories. Uganda is an example of a country whose government’s response has been greatly informed by their recent battles with Ebola. This influence can be tracked through how they have funded and channeled money for their COVID-19 response through their health system.

The Ugandan Government promptly responded to the introduction of COVID-19 by locking down the country and limiting the cases entering. These measures seem to be successful in limiting the introduction and spread of the virus. Still, the Government’s health financing response to COVID-19 presents some risks of not being able to fully adapt and respond to the unique threat this virus presents.

There is growing consensus that it is not just the total funding a country devotes to their response that is important, but where those funds go and how they are managed. In Uganda, external and domestic resources were rapidly mobilized to finance the response.  Yet, out of a request of UGX 464 billion from the Ministry of Health, only UGX 104 billion was allocated to the health sector. This investment focused on strengthening the specialized end of care, rather than testing and tracing through the primary health care (PHC) system; 41% of the overall health allocation was directed to the procurement of medical equipment for intensive care and emergency units, 21% for case management, 15% for health workers and only 6% to surveillance and laboratories.

Given that before the outbreak there were only 55 ICUs in the country, it would be quite difficult for Uganda to increase its ICU capacity effectively within a few weeks. Preliminary evidence seems to indicate that only 20% of COVID patients require oxygen therapy and ventilation. Uganda’s youthful population may further reduce these proportions, even with highly prevalent diseases like HIV/AIDS and malaria. It may also be true that low utilization of routine services, like those related to reproductive, maternal, newborn, and child health (RMNCH), may result in more deaths than from the virus itself. Thus, balancing investments in highly specialized treatment with those that ensure health workers’ safety, improve testing and tracing, and in routine services may prove to save more lives not only now, but in post-COVID Uganda as well.

Another key challenge was the nature and scope of the Uganda Government’s budgetary allocations. These were formulated using an activity-based approach that was quite prescriptive about the spending modalities. Instead, greater flexibility could have been granted to use these funds in the way that authorities deemed to be best fit to respond to the extremely fluid situation in their jurisdictions caused by COVID-19.

Much of this strategy was from the Ugandan government’s management of the Ebola outbreaks.  However, Ebola presented a very different threat – it spread in a much less dynamic way (e.g. symptomatic transmission, slower proliferation) and demonstrated a much higher case-fatality rate. Hence, it was easier to track down cases and made sense to prioritize treatment. The current, positive response in Uganda could be made even more effective by tailoring to the specific threats COVID-19 presents, while incorporating the key lessons learned from Ebola.

Accordingly, we recommend the following steps the Ugandan Government can take to adapt their response:

  • Adapt funding priorities to the characteristics of COVID-19: increase the investment and operational/technical guidance for community-based testing, tracing, and isolation, as well as health workers’ safety (from community health worker to facility).
  • Find ways to improve utilization of routine health services, like those related to RMNCH, immunizations, and HIV/AIDS. Experimentation with task shifting or telemedicine could be part of the strategy.
  • Make funding and purchasing mechanisms more flexible for local authorities and providers by increasing the non-wage recurrent funding to districts, without developing itemised or activity-based budgets. Concurrently, adapting expenditure tracking mechanisms to ensure a more rapid release of funds (e.g. frontloading funds to regional referral hospitals to ensure liquidity), adjusting expenditure reporting mechanisms (e.g. creating a special code for expenditures related to COVID-19) and introducing proper accountability mechanisms after the allocations have been made.

In this way, the government of Uganda can move to the next stage of its response: from its effective, highly centralized Ebola-based response that prioritized lockdown and treatment to one that meets this virus in the field to control transmission. This means through strengthened investment in PHC systems that test, trace, and isolate cases and that also ensure pro-poor access of essential services like RMNCH and immunizations. By investing more in its PHC systems and addressing the public financial management (PFM) challenges that are constricting the flexibility of their response, the Ugandan government can clamp down on COVID-19, while at the same time, bolstering its health system to be more resilient to future pandemics, beyond both Ebola and COVID-19.

By Federica Margini, Anooj Pattnaik, Angellah Nakyanzi 

This piece originally appeared on P4H

The COVID-19 crisis offers Burkina Faso the chance to land on a more coherent approach to health financing. All sights are trained on the health system right now because of the COVID-19 crisis, and within the COVID-19 response lies Burkina Faso’s best chance at addressing fragmentation in health financing.

In the past few years, the Ministry of Health (MoH) in Burkina Faso has developed a variety of ambitious health financing reforms. Implementation has been difficult, however, and too often these reforms compete for funding and attention, rather than complementing each other as a coherent whole. Burkina Faso’s COVID-19 response offers an opportunity to combine the best from each to build something stronger.

Burkina Faso’s limited capacity to implement reform has been undermined by insecurity and labor unrest.Trans-national security threats have increased in recent years, leading to widespread disruption and more than half a million people were internally displaced by the end of 2019 . In a response to this challenge, Prime Minister Paul Kaba Thieba and his government  resigned in January 2019, signaling a significant realignment of government priorities towards managing the security situation. Labor unrest has further exacerbated challenges to the health sector; a partial public health worker disrupted provision of many non-curative services in public health facilities from May through November 2019.

In the health financing space, a series of reform programs risk being shipwrecked because of competing priorities. A particular area of interest is the way in which the Government allocates pooled funds to providers of health services on behalf of a population, referred to as ‘purchasing’ in health financing circles. Major purchasing reforms currently under way in Burkina Faso include;

  • Gratuité – In 2016, MoH removed user fees for maternal and child health services through the popular ‘gratuité’ program, replacing these fees with payments from the Government. The program worked well until budget cuts at the end of 2018 caused shortfalls in payments, which continue to challenge facility managers and have led to increasing debts to the central medical store.
  • Performance-based financing (PBF) – From mid-2018, with support from the Work Bank, MoH has been working to roll-out a new version of a PBF scheme. In the latest iteration, the scheme will reward facilities for meeting quality standards. However, systematically measuring quality in an objective way is difficult, and progress has been slow.
  • National health insurance – A national health insurance agency, Caisse Nationale d’Assurance Maladie Universelle (CNAMU), was formally established in 2018. CNAMU is mandated to take on the management of several purchasing schemes including gratuité, a plethora of small community-based health insurance or ‘mutuelle’ schemes, and health insurance for the formal sector. CNAMU is building its capacity and is initiating a program to subsidize mutuelle membership for target populations, but transfer of gratuité has yet to happen.

As COVID-19 struck, the Government of Burkina Faso was quick to recognize the need to plan for the health sector response. A critical part of this was figuring out what funds would be needed at front line facilities, how to get those funds there, and how to enable facilities to use and account for the them. Establishing a rational approach was important to counterbalance political interests advocating for funds for their local constituencies.

In the urgency of COVID-19 planning, MoH stepped away from factional interests to identify and combine the strengths of different purchasing schemes. A participatory process led to the agreement of evaluation criteria for options to transfer funds to facilities.  The pros and cons of different schemes were weighed up objectively, setting aside narrow departmental interests. A consensus is emerging that the programme d’appui au développement sanitaire (PADS) system used to transfer PBF funds is the most appropriate to channel additional funds for COVID-19, with its use of commercial bank accounts to move funds quickly and directly to facilities particularly important.

Combining this fund transfer mechanism with strong systems drawn from other purchasing mechanisms has the potential to create a streamlined, integrated approach. For example, policy makers are considering whether to build on the ‘e-gratuité’ information system to support monitoring and reconciliation of COVID-19 funds. Established non-governmental organization subcontracts for gratuité data validation and quality control may also be leveraged.

Maintaining the motivation of frontline health workers is a key consideration and finding the best solutions from across existing systems will again have an important part to play. Recent history in Burkina Faso, and lessons from the Ebola epidemic in neighboring countries, highlight the importance of health worker commitment. Health workers who already feel undervalued may be reluctant to put themselves in harm’s way, should the COVID-19 pandemic explode in Burkina Faso. Giving those we rely on the tools and resources they need to do their jobs safely is a necessary, but perhaps not sufficient, step. Additional incentives, including financial incentives, may be required. Gratuité is recognized as a fair way to decide what funds go to which facility, based on performance, whilst PBF has established tools for sharing incentives between workers at a facility. Again, there is potential to combine the best systems from schemes already in place, and stakeholders should seize this opportunity.

The COVID-19 crisis has forced stakeholders in Burkina Faso’s health sector to think outside of their established silos. This is facilitating the rapid development of integrated systems, in purchasing and elsewhere. Integrated systems, and the partnerships created around them, can stand Burkina Faso in good stead for post-COVID-19 health systems development.

Written by Matt Boxshall (ThinkWell), Pierre-Marie Metangmo (ThinkWell Burkina Faso), Joel Arthur Kiendrébéogo (University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso)

On January 30, the Philippines reported its first coronavirus case. Fast forward 38 days and the government declared a state of emergency on March 9. Soon afterwards, ThinkWell’s Philippines team dove headfirst into tackling the challenges as the pandemic swept through the country.

Scaling-up testing capacity

In January and February, the country had a single lab that could process coronavirus tests. With a population of over 106 million people, there was an urgent need to expand testing capacity.

As a first step to ramp up testing, the Department of Health (DOH) sought out ThinkWell’s assistance to help maximize the testing capacity of existing independent subnational laboratories. To ensure that the quantity of coronavirus testing labs would align with future demand, ThinkWell’s team provided crucial analytics to estimate testing demand and testing centers’ projected capacity.

Since it was clear that additional labs would soon be needed to process tests, ThinkWell developed a strategy for a coronavirus testing certification process for additional labs. Soon, the DOH was met with an onslaught of certification applications from private health facilities.

We knew that the Philippines would need to think big and act quickly when it came to expanding testing, so we assisted with setting up large testing centers and “pop-up” testing labs. The pop-up labs are compliant with coronavirus testing requirements, and built from the ground-up, in partnership with the private sector, within 10-15 days.

Recognizing that this unprecedented crisis called for novel solutions, ThinkWell joined the Expert Panel for Covid-19 Testing as the technical secretariat to discuss innovations and technologies that can further expand the Philippines’ testing capacity.

By June 2, there were 52 testing facilities in the country that could process over 40,000 tests per day. Less than three months since the government declared a state of emergency, the country was meeting its expanded testing capacity goals. The below two maps reflect the increased number of testing facilities between March and June. The maps were developed by G. Apostol and R. Francisco. The interactive maps are available here.

Philippines testing labs Mar 2020
Map of testing facilities in March 2020

 

Philippines testing labs June 2020
Map of testing facilities in June 2020

 

Testing capacity gains in the Philippines
Testing capacity gains between March 31 and June 1, 2020

Developing PhilHealth benefits and policies

During a pandemic, people desperately need health insurance. As part of national efforts to achieve universal health coverage, Filipinos receive health insurance through the government-owned Philippine Health Insurance Corporation (PhilHealth). PhilHealth turned to ThinkWell for support in developing patient benefit policies on coronavirus screening, community isolation, and inpatient care. Applying human-centered design, we developed a Covid-19 patient pathway to guide service delivery methods. PhilHealth is using this pathway to inform the appropriate benefits for Covid-19 patients and to ensure that health facilities are reimbursed for their Covid-19 health services. We also reviewed the implementing rules and regulation for the Bayanihan Act, which mandates that PhilHealth finance various coronavirus-related health services.

Crafting policies on telemedicine use

In the era of social distancing and overwhelmed health systems, telemedicine is in the spotlight. The DOH and the National Privacy Commission are harnessing various telemedicine initiatives in the country, and ThinkWell is reviewing DOH guidelines for scaling-up these initiatives. We are also developing a monitoring and evaluation plan of different telemedicine approaches to assess and improve outcomes and impact.

Improving the supply chain for personal protective equipment

There is still a critical shortfall of personal protective equipment (PPE) among health workers in the Philippines. This was initially due to inadequate PPE projections, disrupted supply chains, and a fragmented response. The DOH requested that ThinkWell model and estimate PPE needs, but we didn’t want to rely on traditional forecasting methods to do so—historical methods would severely underestimate PPE needs during an evolving pandemic. Request-driven procurement, on the other hand, is highly subjective and prone to politicization and disproportionate allocation.

Instead, ThinkWell developed an innovative, human-centered approach to estimating PPE needs. Utilizing a patient journey method, we mapped how Covid-19 patients interact with health workers at various settings and times. For each step in the patient journey pathway, we identified health workers’ specific PPE needs. Our analysis is guiding PPE procurement for all health facilities in the Philippines for the coming months.

The Department of Health has also applied ThinkWell’s human-centered approach to estimate the PPE needs of surgeons and dentists as well as the anticipated supply of life-saving antiviral medications for Covid-19 patients. The Department of Environment and Natural Resources has also harnessed our approach to estimate the amount of PPE waste generated during the pandemic.

Strengthening the coronavirus response in region VI

Region 6 is a nondescript name for an area that covers the idyllic islands of Western Visayas. ThinkWell works with various stakeholders (including regional, provincial, and local health authorities as well as local universities and public health organizations) to document the process of coronavirus response planning and implementation, support the development of local coronavirus response policies, and curate key information for internal and external audiences. So far, ThinkWell has co-developed two policy notes in partnership with University of the Philippines-Visayas. The DOH Center for Health and Development in Region 6, as well as partner provincial health offices in the region, have adopted the recommendations.

Many thanks to the ThinkWell team in the Philippines for leading these efforts: Marife Yap (Senior Technical Advisor), Gelo Apostol (Private Sector Specialist), Ian Nuevo (Health Financing Expert), Jem Sigua (Junior Analyst), PeeWee Wee (Senior Policy Advisor), Lena Alvior (Senior Service Delivery Network Specialist), Camille Samson (SDN Specialist), and Susan Rosales (Administrative and Finance Coordinator). 

Five months into the coronavirus crisis, the pandemic has permeated nearly all corners of the globe. Everywhere, Covid-19’s impact is exposing gaps in health systems’ capacity to ensure that people can access high-quality, affordable care. In low and middle-income countries (LMICs) with limited healthcare capacity, crowded living conditions, and inadequate access to sanitation resources, people are particularly vulnerable.

“If you think it is really terrifying to face the prospect of Covid-19 in an advanced industrialized country, if you’re worried about ventilators in New York City, if you’re concerned about the health system in Italy, just imagine what it’s like to face the prospect of a virus where there isn’t running water, where there isn’t a proper health system,” David Miliband, former British foreign secretary and president of the International Rescue Committee, said in an interview with the World Economic Forum.

Many LMICs are racing to respond to the pandemic: Senegal banned public gatherings, Indonesia is repurposing thousands of garment factories to produce PPE, and Peru implemented a strict lockdown. As countries attempt to turn the tide on Covid-19, it’s not enough to simply react to urgent needs. To get ahead of the pandemic’s next wave of disruption, defensive strategies are probably insufficient countries will most likely have to go on the offensive.

To help build a forward-facing strategy, health system experts at ThinkWell, a global development organization, weigh in on six ways that countries can act now to prepare for whatever comes next:

1. Copy and paste solutions won’t do the trick

Covid-19’s impact is starkly different not just across countries, but across communities. New York City, which has more Covid-19 cases than any other city in the world, has had to respond to the pandemic in a much different way than New York’s rural upstate counties, many of which remain largely unscathed. There is no such thing as a one-size-fits all response.

To factor regional differences into countries’ preparedness plans, Pierre-Marie Metangmo, MD, a ThinkWell senior policy advisor in Burkina Faso, recommends that countries conduct a baseline assessment for their health systems. This type of assessment gives policymakers and planners, “a clear sense of where their strengths and weaknesses lie across all health system levels and geographic regions.” With that data in hand, policymakers and planners have a better understanding of their country’s varying health needs and capabilities. And they can thereby target their investments to equitably build their capacity to respond to the pandemic’s ebbs and flows.

coronavirus

2. Pop stars can make good role models

With the world in unchartered waters, people are looking to others for how they should act in this new coronavirus era. Should they wear a facemask outside? Let their children play at the neighbor’s? Changing ingrained behavior is hard—and we know that information and knowledge doesn’t always lead to better habits. People don’t like being told what to do, but they do often respond when they observe others modeling behavior. Leaders in Hong Kong and Taiwan have set an example by wearing facemasks. Musicians in countries like Vietnam, Uganda, and Panama are creating viral songs and music videos to promote coronavirus prevention strategies in a way that aligns with local culture. Puerto Rican artist Bad Bunny’s Spanish lyrics for his song “At Home” include, “I wanted to see you/but that won’t be possible/I have to stay home.”

“Coronavirus response plans need to have a community dimension,” said Dr. Metangmo. “You need to communicate in the cultural context.” If countries have plans in place to equip local leaders and influencers with the tools to spark behavior change, through their own actions and modeling, a community will be in a better position to slow a pandemic.

Benter Owino, a ThinkWell senior technical advisor based in Kenya, recommends that governments harness mobile technology to deliver pandemic prevention and treatment messages. “Culturally appropriate communication in people’s local language, through popular mobile apps and platforms, can go a long way toward reaching people in a compelling way,” she says.

3. Trust: a health system’s secret weapon

West Africa and the Democratic Republic of Congo’s Ebola outbreaks have taught us that when people don’t trust their health care systems, pandemics thrive. In the Congo, a survey by Harvard Medical School found that 45 percent of respondents thought Ebola did not exist or was a political conspiracy.

While citizens’ trust in state institutions is critical to managing a pandemic, trust within the healthcare system is also paramount. “A crisis shows the broken pieces of a healthcare system,” says Dr. Metangmo. “When there’s little trust and poor communication between health leaders and personnel, you lose time addressing irrelevant issues instead of mobilizing people and resources to solve the crisis’ problems.”

Dr. Metangmo recommends that governments invest in strengthening collaboration and communication between community health workers, health facility managers, and all the way up to the ministry of health and executive office. That way, when a health crisis hits, the system has a united front of health experts who are prepared to fight together.

4. Start saving

During “normal” times, when a pandemic has ebbed, “financing for pandemic preparedness falls through the cracks,” says Angellah Nakyanzi, a private sector specialist at ThinkWell in Uganda. “That means we end up dealing with each health emergency as it comes. Health must be treated with the same priority as infrastructure development and national security.”

While many external financing mechanisms exist for responding to a pandemic, historically there have been fewer financing options for preventing a pandemic. The funding that does exist is fragmented, complicated to disburse, and doesn’t always align with existing domestic-health funding flows. “Uganda needs a deliberate mechanism for financing pandemic preparedness and response,” Angellah Nakyanzi argues. Supplementary budgets, passed during the heat of a crisis, are insufficient. Uganda and other countries might be better served if they maintain a continuous financing strategy for future epidemics and pandemics.coronavirus

5. Remember not to let a pandemic’s shadow leave other health needs and workers in the dark

Pandemics tend to eclipse other healthcare needs. But chronic issues like diabetes or ER visits due to accidents don’t just disappear. “One of the most important things governments can do is determine how to keep essential services running during a pandemic,” says Dr. Metangmo. “You can’t lose sight of other health needs.” Dr. Metangmo suggests that LMICs plan for how clinics and hospitals can di

vide treatment wards for both pandemic patients and those battling other afflictions.

At the same time, it’s not always possible for organizations to continue providing all health services during a pandemic. Nonessential medical care and elective surgeries may need to be postponed. “You can’t do business as usual during a pandemic,” Dr. Metangmo says. Governments might prepare concrete plans for maintaining “must-have” care during a crisis while suspending “nice-to-have” services. They can also create strategies that enable health care workers to rapidly transition from providing nonessential care to urgent care. Without a flexible plan for health care workers to nimbly shift roles, skilled workers may find themselves needlessly out-of-work.

6. PPE can’t wear itself

“In Kenya, the rush to procure medical commodities for coronavirus overshadowed discussions around health worker needs,” Benter Owino shares. “When cases first appeared in Kenya, there were lots of political conversations about how to get more PPE and ventilators, but rarely did the government address the availability of health workers to fight on the frontlines.” If there’s no one to operate those ventilators, they’re obviously worthless.

With coronavirus infecting health workers at an alarming rate, there’s an even greater need for a robust force of trained medical personnel. India only has 0.8 physicians per 1,000 people (compared to 4.2 in Germany) and Ecuador has 12 nurses per 1,000 people (compared to 17.3 in Switzerland). There simply aren’t enough health personnel to adequately fight a pandemic in most low and middle-income countries. When this first tsunami of global Covid-19 cases has passed, countries would be wise to address their gaps in health worker capacity and build up their workforce, to prepare for the next wave, whenever it might come.

Note: This is an update of a post that was published on the 15th of May. This update reflects newly published guidance from WHO on the implementation of campaigns in the context of COVID-19.

Many immunization campaigns have been suspended to prevent increased COVID-19 transmission, but some campaigns will nevertheless need to go ahead, with additional precautionary measures in place to ensure the safety of health workers and the community.

With support from the Bill & Melinda Gates Foundation, ThinkWell has estimated the added cost per dose of several potential precautionary measures: personal protective equipment (PPE) for vaccination teams, additional infection prevention and control (IPC) measures at immunization sites, extra staff and supplies to ensure physical distancing and triaging at campaign sites, additional per diems due to potential changes in delivery strategies, and estimates of an increase of other operational cost components (such as additional social mobilization and training). The analysis uses data from 10 studies on the cost of conducting an immunization campaign to model each scenario at a low, medium and high intensity level, as well as the combined effect on the cost per dose.

The results of this analysis of the additional delivery cost of conducting campaigns during COVID-19 show that:

  • The cost per dose could increase by 5% when placing hand washing stations at campaign sites and 9-20% when adding PPE for health workers.
  • Adding crowd controllers to vaccination teams to manage physical distancing and screening at campaign sites could imply a 10-26% increase in the operational cost per dose.
  • Per diems associated with a longer campaign duration could result in a 8-32% increase.
  • An increase in other operational aspects of the campaign, such as social mobilization and transport, could increase the operational cost of a campaign by 10-40%.
  • All protective measures and operational changes combined could increase the operational cost of a campaign by 49% in the low scenario up to 154% in the high scenario.

This rapid analysis is meant to illustrate a range of potential cost implications to provide general guidance for the direction of policies and potential cost expectations that would require the mobilization of additional resources.

To read the full report, click here.

Follow-up analyses conducted by ThinkWell and the Harvard T.H. Chan School of Public Health will assess the cost implications for routine and routine outreach immunization service delivery.

In these last few months, two dangerous illnesses have taken center stage in our lives. The first sickness, COVID-19, has radically changed the way we live. The second, an ever-present disease, has stepped back into the spotlight – the sickness of racism.

Most of us who have entered the field of global public health have done so partly from outrage with the disparities we see around the world. Access to health care should not be based on race, gender, sexual orientation, or socioeconomic status. We believe that access to healthcare is a fundamental human right of every person on this planet. Underlying this belief is our fundamental conviction that all people are created equal, and must be treated so.

We stand here today outraged by the senseless, almost normalized, killings of African Americans. We are angered by the systematic discrimination that people of color face. We are infuriated that our health system has not delivered for African American and Latino populations, resulting in dramatically disproportionate COVID-19 infection and death rates in those populations. We are incensed for that young child, bullied and teased for her race, who will grow up believing that no matter how hard she tries, she will never be the ‘same’ as everyone else. We are appalled that, 150 years after the end of slavery, we still face an endless stream of racist killings that is ravaging our African American communities. We believe that the persistence of these injustices represents a vicious attack on America’s core values, and we demand empathetic leadership to defend the free society that we so cherish.

ThinkWell has and always will fight for the dignity, justice and equal treatment for all. We will continue to advocate for systems that are just and inclusive. We will continue to support the countries we work in to implement policies that eliminate disparities. And we pledge to stand with those who are on the frontlines of the battle against bigotry and discrimination.

This post was originally published in BMJ Global Health

Four months since the first confirmed case of COVID-19 in the Philippines, the number of cases has risen into the thousands. Testing capacity has expanded rapidly, but testing continues to limit the Philippines response.

The Philippines has adopted a “whole of government, whole of society” approach to address this global pandemic, grouped around four main components – Detect, Isolate, Treat, and Reintegrate. Detection is the critical first step in managing and controlling the spread of COVID-19 and can determine consequent strategies. However, at the onset of the pandemic, the country had very limited testing capacity. The Department of Health (DOH) formulated and adopted four key strategies to address this: (1) maximize capacity of existing laboratories, (2) certify more laboratories, (3) establish “big testing centres” or pop-up laboratories in strategic areas, and (4) explore other testing approaches. On April 24, the National Task Force on COVID-19 set a target of 30,000 tests per day by May 30.

Increasing the Philippines’ testing capacity

In March, the Research Institute for Tropical Medicine (RITM) was the only laboratory in the Philippines with the capacity to conduct the World Health Organization-recommended RT-qPCR testing for COVID-19. Since then, RITM has tirelessly supported public and private testing facilities to develop COVID-19 testing capacity. As of May 25, 34 RT-qPCR facilities have been certified across the Philippines, with 40 more in process. Eight laboratories with automated GeneXpert® COVID-19 systems  have also been certified, and at least 20 more are awaiting certification. As of time of writing, these efforts have led to a rated daily testing capacity of 31,528 (Figure 1) – surpassing the government’s target.

Figure 1. Milestones in expanding testing capacity for COVID-19 in the Philippines
Figure 1. Milestones in expanding testing capacity for COVID-19 in the Philippines

Towards the end of April, the Task Force T3 (Test, Trace, and Treat) initiative was officially formed. This public-private coalition is currently prioritizing testing. T3 has mobilized the private sector to construct 15 standards-compliant pop-up turnkey laboratories in priority areas, and these new pop-up labs will contribute at least 9,000 more tests per day. The group also provides support in supplies mobilization, IT-based inventory system development, as well as donation of automated testing platforms.

30,000 tests per day – a practical possibility?

When the rubber hits the road, a whole new set of challenges emerge. The highest actual yield of tests officially reported to date is 11,254 (on May 14), only 35.99% of the rated testing capacity (Figure 2). Testing facility production averages only 29.30% of rated capacity. Performance is undermined by tedious procurement processes and lack of inventory management system, resulting in the slow replenishment of supplies. Some facilities also need more trained personnel, and deployment of volunteers can be hampered by lockdown restrictions. Specimen collection is uneven across the country, with some local government units aggressively setting up swabbing sites, leading to the overloading of some testing facilities whilst others are underused.

Figure 2. COVID-19 testing outputs and efficiency rate in the Philippines
Figure 2. COVID-19 testing outputs and efficiency rate in the Philippines

Lessons learned

Public outcry for immediate mass testing pushes the government to rapidly scale up, but strategy execution must stay true to the science of testing. This has been achieved by upholding facility standards that ensure integrity and accuracy of testing, and carefully evaluating new innovations brought to the table. The government, with technical support from ThinkWell Philippines, regularly convenes an expert panel composed of public health practitioners, scientists, and laboratory experts to ensure that strategies undertaken to increase testing capacity are efficient without compromising quality. As part of the government’s efforts to build public confidence on the status and results of these strategies, information is released to the public daily through virtual press conferences, situationers, and an online COVID-19 dashboard and data warehouse.

Whilst rapidly scaling up capacity is necessary; it is not sufficient. Equal attention needs to be given to maximizing productivity. This is being supported by developing an IT-based inventory monitoring platform, continuously engaging the private sector to enhance supply mobilization, and developing zoning strategies to systematically match local areas and swabbing sites to current and potential testing facilities.

The challenges of this pandemic demand the engagement of diverse stakeholders. Collaborative work between the public and private sectors and constant communication with local government units produce palpable results in expediting testing capacity. A centralized approach to coordination and planning continues to prove useful in rallying stakeholders and streamlining all efforts into one coherent strategy.

Written by Christian Edward Nuevo, 1 Jemar Anne Sigua,1 Matt Boxshall,2 Pura Angela Wee Co,1 and Maria Eufemia Yap 1

  1. Strategic Purchasing for Primary Health Care (SP4PHC), ThinkWell Philippines
  2. ThinkWell United States of America

“The coronavirus spreads like wildfire, and thanks to us, it’s spreading now to other regions [of Indonesia]. Social distancing acts like the fire extinguisher, but it must be readily implemented in affected areas. It is the responsibility of regional government to provide the fire extinguisher for places in need. Question is: is government financially ready to provide it?” asked Hasbullah Thabrany, Chief of Party for USAID Health Financing Activity (HFA) led by ThinkWell.

Indonesia is currently battling high numbers of confirmed COVID-19 cases. As of June 1, there are 26,940 confirmed cases, with 1,641 deaths. Numbers are expected to continue increasing. Worldwide, experts agree that social distancing could help to stem the tide, but there have been barriers to adoption of these strategies in Indonesia.

Major challenges in Indonesia, including mobilizing resources and communicating about the outbreak, are rooted in decentralization of the health system, and much of the execution of preparedness efforts is being done at the regional and local level. Messages delivered to local communities about the pandemic and effectiveness of social distancing are disorganized and unclear, posing risks to gaining public trust.

“To avoid the spread of wildfire, it is imperative that local government take measures needed to allocate fund. This needs advocacy especially, even at the district level, if needed – to educate and raise awareness of local leaders of the urgency of the matter, and to act quickly,” Dr. Thabrany added.

In every part of the world, this is a litmus test for health systems capacity. There is a lack of capacity to prevent and detect COVID-19 cases early enough for intervention in Indonesia, while providers are bearing the impact of supply-side limitations. It is an unmerciful exposure of long-standing neglect to the health systems backbone of the country.

ThinkWell is committed to providing support for reliable measures for health financing in relation to COVID-19, especially financing care for patients. USAID HFA, with ThinkWell, is seeking ways to illuminate the cost associated with of COVID-19, by looking at costs associated with the infection beyond clinical care. We also plan to collect additional data from National COVID-19 Task Force officials to provide COVID-19 case estimation and projections in country. The study aims to provide better evidence for claim reimbursement of COVID-19 cases, as well as provide input to the budget scheme related to the pandemic. The study is in partnership with the Center of Health Financing and Insurance of the MOH (CHFI/PPJK MOH GOI) and the National Institute for Health Research and Development (NIHRD MOH GOI).

Dr. Thabrany presented during a webinar in April 2020, a collaboration between the Indonesian Association of District Indonesian Association of District Health Office and USAID HFA. Speakers included Dr Edhie Rahmat, MSc, USAID Office for Health; Dr. Bayu Teja Mulyawan, Apt., M. Pharm, MM, The Head of the Bureau of Planning of the Ministry of Health; Purwanto, SE, MSc, Director, the Budget of the Human Development and and Culture, Ministry of Finance; Hasbullah Thabrany, MPH, DrPH, ThinkWell. Participants included directors of primary health care services and district health official staff all over the region.

Recognizing the critical yet untapped potential of the private sector in ensuring the health of Filipinos, the ThinkWell Philippines team helped to facilitate a session in the Private Sector in Public Health (PSPH) Monthly Series. The Series convenes stakeholders from the private sector to converse about pressing health system issues, explore innovative solutions, and influence policy discourses. The Asian Institute of Management (AIM) of Stephen Zuellig Graduate School of Development Management and the ISPOR Philippines Chapter also helped to facilitate the event.

The event was titled, “Our Common Ground: Towards a shared understanding of the UHC Law and its opportunities and challenges for the private sector in the Philippines.” The session aimed to uncover opportunities that the country’s Universal Health Coverage (UHC) Law provides for the private sector. The discussion was attended by twenty-five stakeholders representing fourteen private sector organizations. Representatives from the Department of Health (DOH) and PhilHealth also participated in the discussion that Dr. Marife Yap and Dr. Gelo Apostol of ThinkWell Philippines led.

ThinkWell initiated the discussion with the question: Does the Philippine private sector have a strategic role in implementing the UHC Law? Everyone agreed that the private sector does have a role, but the more important question is what is that role? Participants shared confusion about little guidance on the role from the DOH and PhilHealth, as well as about the law’s implementation schedule. Ultimately, the private sector recognizes the importance of the UHC Law in democratizing health care and strengthening public health. They are willing to assist in addressing health system gaps, but they need to have a clear understanding of what the government expects from them, especially when it comes to interfacing with local governments that will handle the management and financing of province or city-wide health systems and health care provider networks (HCPNs).

The following main topics were discussed during the session:

  • The roles of and expectations from the private sector are not laid out in the Implementing Rules and Regulations (IRR) of the UHC Law
  • The government’s priority initially is to organize public facilities into networks, but it does not prevent private facilities from participating as well. There is confusion as to how private facilities can be part of a network.
  • The important role of local government units (LGUs) as managers of HCPNs was recognized, but issues on financing and extent of coordination with LGUs were raised

Participants also discussed the extent to which private facilities would have to coordinate with local governments:

  • Private institutions can offer the latest primary care benefit package, Konsulta, as long as they reach the indicated requirements. However, there was a concern that the private sector has not yet been fully engaged in the development of the new primary care benefit package. There was also confusion as to whether Filipinos will have the freedom to choose a primary care provider or they will be assigned.
  • Considering that the private education sector contributes significantly to the production of the human resources for health in the country, the government needs to engage with them more.
  • How can providers work with the government on initiatives on development of software applications?

The DOH and PhilHealth recognize the important contributions of the private sector to implement the UHC Law, especially when it comes to service provision. The government aims to address the mistrust coming from the private sector and also develop a comprehensive strategy on how the private sector can be more actively included. It was also noted that all sectors and stakeholders should be actively involved in consultations to ensure that all voices are heard and included. Ultimately, the government wants to ensure that the public and private sectors will have equal footing, especially when it comes to the delivery of quality services.

The private sector’s role in public health service requires a few critical principles: building trust, creating a dynamic relationship, and holding a shared value of better health services. There is an expectation that transactions and policy be made with less ambiguity. The group asks for clarity with the current UHC law’s Implementing Rules and Regulations on government reforms to deliver UHC services. This clarity is necessary to enable the private sector to meaningfully participate.

Written by Geminn (Gelo) Louis Apostol, MD, MBA, Private Sector Specialist, ThinkWell Philippines and Kenneth Hartigan-Go, MD, Associate Professor, Department of Strategic Management Head, Stephen Zuellig School of Development Management, Asian Institute of Management, Makati City, Philippines

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