Across the world, ThinkWell staff are moving the needle on improving health and well-being around the globe. We wanted to take a moment to introduce you to some of our staff in our offices, starting with conversations with members of our Philippines team.

Maria (Marife) Eufemia Yap, Senior Technical Advisor

Maria (Marife) Yap

What was your life like before ThinkWell and why did you decide to join ThinkWell?

There really isn’t much difference between my life now and before I joined ThinkWell. Professionally, my work concerns have been and continue to be anchored on health systems and development. Undergirding all these is my passion and dedication to teaching and mentoring young professionals to become more responsible and relevant people that can help catalyze changes in the health sector and in the Philippines. I feel very fortunate that working at ThinkWell allows me to carry out what I believe are the important contributions that I can make to young health professionals, to the health sector, and to the Philippines. It is for this reason that I joined ThinkWell.

What do you view as the greatest challenge to improving health and wellbeing in your country?

In my opinion, the problems and challenges we confront as we strive to improve the health and wellbeing of our fellow Filipinos are rooted in leadership and governance in various levels of society. Unfortunately, many of the national and local elected officials operate in a very narrow world that does not have a systematic capture of interconnected concerns and issues that plague the Philippine health system. These mindsets and dispositions are so rooted in historical, cultural, and societal constructs that unfortunately cause much of the fragmentation in the health sector. Thus, it is important to re-shape the way people think, feel, and behave about health and the way health is accessed and delivered.

What makes you hopeful about health progress in your country?

There are many talented, creative, committed, and courageous young professionals who work both in the public and private sectors whose work impacts health. They give me a lot of hope. In addition, there are also many committed and competent public servants who, amidst and despite challenges and difficulties faced, continue to tough it out working in the public health system. All this gives me hope and helps me continue to contribute to helping health progress in the Philippines.

What’s been the most meaningful lesson that you’ve learned during your health career?

I sincerely believe that to be effective in re-shaping the way people think, feel, and behave about health, two ingredients are fundamental: relationships and communication. The health sector is a relational sector; to be effective in implementing prevention and health lifestyle, one must put the person or patient at center stage. This means that one must build a relationship that fosters trust that assures better understanding and compliance. The second factor is communication. In ensuring good health, one must communicate appropriately and effectively to engage the patient and beneficiary to become co-responsible for her/his health. In the final analysis, the person whom we serve must be at the core of all our programs, plans, and activities.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

As a young physician, I was bothered by the information that seven out of ten Filipinos die without seeing a doctor. Even if this fact is not solidly proven by a statistic, I think this reality is still true even up to now. The circumstances may be different now, but I think there are still many Filipinos who die without receiving care from a physician. I always remember this piece of information and use this as a reason for waking up every day and contributing what I can to address this situation. This is a reason why I think this information is important for Filipinos to bear in mind.

Geminn Apostol, Technical Advisor

Gemminn Apostol

What was your life like before ThinkWell and why did you decide to join ThinkWell?

Prior to joining ThinkWell, I was a health systems researcher and an educator, while doing social enterprise work and community organizing on the side. I decided to join ThinkWell to tap into a global resource of opportunities and knowledge that I can hopefully optimize and apply to improve the health and well-being of my fellow Filipinos.

What do you view as the greatest challenge to improving health and wellbeing in your country?

The greatest challenge continues to be the vicious cycle of poverty and inequity that continue to shape and influence how health is accessed, provided to, seen, and acted on by Filipinos. While the health system is paramount, it is these social determinants of health and the environment of volatility, uncertainly, complexity, and ambiguity that we find ourselves in that stand to have a greater impact on the health and wellbeing of people.

What makes you hopeful about health progress in your country?

Apart from the recently enacted Universal Health Care law which opens up significant windows of opportunity for the health sector in the Philippines, what consistently rekindles my hope for the country’s health system is the growing critical mass of young professionals from different disciplines gathering together to move health reform forward.

What’s been the most meaningful lesson that you’ve learned during your health career?

The most meaningful lesson I have learned is that service and excellence should go hand in hand. The greatest service that professionals can do is to excel in their areas of work and impact. Consequently, all excellence is worthless if not offered to greater service for a cause greater than oneself.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

A health statistic I can’t get out of my head is the fact that only 10-15% percent of health outcomes are attributed to healthcare services. The rest lies in efforts aimed at improving “the conditions where people grow, live, learn, play, work, and age in.”

Helena Alvior, Technical Advisor

Helena Alvoir

What was your life like before ThinkWell and why did you decide to join ThinkWell?

I am a public health graduate who proceeded to become a physician. I was a medical clerk when my father was diagnosed with colon cancer. My first-hand experience of it–the clinical and the financial catastrophic burden–solidified the importance of prevention and public health in my mind. I found myself in an NGO working to improve local health systems for five years. I then relocated back to my home region while still maintaining my network as independent consultant. I joined ThinkWell because it gave me an opportunity to continue working in my home region while helping create impact and change in the health systems development arena.

What do you view as the greatest challenge to improving health and wellbeing in your country?

I think most Filipinos are fatalistic and used to the current fragmented health system. It is also very politicized. The challenge is to make more politicians health leaders/champions on behalf of their constituents.

What makes you hopeful about health progress in your country?

The Universal Health Care law of 2019 is an opportunity for the Philippines to boldly reform the fragmented health system. It is a big challenge but also brings great hope.

What’s been the most meaningful lesson that you’ve learned during your health career?

Improving systems is daunting work, requiring much of individual and collective wills. It entails deep awareness of culture and context, practice of dialogue, blending of different expertise, and teamwork. At its heart, it’s working with people, with diverse ambitions, agendas, wants, and needs. It helps when you can dig deep into your core purpose and passion, keep steady, balance, and adapt.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

Fifty-four percent of the total health expenditure in the Philippines is from out-of-pocket. Additionally, around 1.5 million Filipinos are impoverished due to catastrophic health spending. We should endeavor to create and improve systems that offer more prevention and financial protection.

Susan Rosales, Operations Manager

Susan Rosales

What was your life like before ThinkWell and why did you decide to join ThinkWell?

I have worked in global health and development for 19 years as regional program administrator/admin and finance manager/office manager. I decided to join ThinkWell to continue my development work. Since ThinkWell focuses on health, I joined because I have been working with the Philippines Department of Health and Philhealth for so many years and I wanted to continue supporting the improvement of health systems in the Philippines even though I am not a health worker.

What do you view as the greatest challenge to improving health and wellbeing in your country?

From the point of view of non-medical professional, I think that the greatest challenge is how the government can support and provide UHC to every Filipino in terms of funding, improved processes and procedures, improvement of public hospitals infrastructure and medical equipment/supplies and health human resources.

What makes you hopeful about health progress in your country?

With all the technical assistance provided by different donor agencies to the Department of Health and Philhealth, I still believe that all these will bear fruit and hope that someday the health system in the Philippines will be at par with the best countries in the medical field.

In April 2020, COVAX was launched to help ensure that “people in all corners of the world will get access to COVID-19 vaccines once they are available, regardless of their wealth.”

With around 190 participating countries, the COVAX Facility is a global risk-sharing mechanism for pooled procurement and equitable distribution of COVID-19 vaccines. Through the COVAX Advance Market Commitment (AMC), 92 low- and middle-income countries will be able to access subsidized COVID-19 vaccines. This amounts to approximately 1,319 million vaccine doses and will cover about 20% of the countries’ total population.

ThinkWell is a part of a multi-organizational costing working group that estimated the cost of delivering COVID-19 vaccines in these 92 AMC countries.

The model estimated the cost of delivering two doses to health workers through fixed site delivery and to elderly populations through outreach. The model costed incremental financial costs only, assuming that countries will leverage existing health systems (e.g., using existing cold chain equipment).

The total financial delivery costs—including country, regional, and global level costs—amounts to US$2.018 billion, equivalent to US$1.66 per dose supplied and US$3.70 per person vaccinated with two doses (after accounting for vaccine wastage).

Country-level delivery costs amounts to US$1.41 per dose. This includes per diems for health workers, transport, cold chain equipment and running costs, social mobilization, planning, training, personal protective equipment, waste management, pharmacovigilance, and vaccination certificates. It excludes health worker salaries. The cost of implementing an ultra-cold chain was not included, as vaccines that require ultra-cold chain storage will only comprise a small proportion of the overall COVAX facility portfolio of vaccines.

Technical assistance at global, regional, and country level is estimated at US$0.16 per dose delivered. The estimates also include US$77.9 million for five innovations that are being accelerated to advance COVID-19 vaccine delivery: smart vaccination certificates, traceability solution, real-time monitoring, digital micro-planning, and digital tools for safety monitoring. Additionally, the cost of pharmacovigilance and post-introduction evaluations at global and regional level are estimated at US$20.6 million.

COVID-19 vaccine delivery will require adapted delivery methods to reach new target populations. To generate these global level estimates, the team developed scenarios around data from existing immunization studies, including previous Immunization Costing Action Network (ICAN) studies in Indonesia, Tanzania, Sierra Leone, and India, and analysis on the cost of delivering campaigns and outreach during the pandemic. They also relied heavily on unit costs from the Immunization Delivery Cost Catalogue (IDCC), the most comprehensive, current, and standardized global evidence on the cost of delivering vaccines, which ThinkWell built with support from the Bill & Melinda Gates Foundation.

COVAX stakeholders use these cost estimates for planning, budgeting, and fundraising for COVID-19 vaccine delivery at the global level. At the country level, governments and partners can utilize the COVID-19 vaccine introduction and deployment costing tool (CVIC), which has been developed for detailed planning and budgeting of COVID-19 vaccine delivery strategies.

To further explore the costs of delivering COVID-19 vaccines in 92 AMC countries, you can read the full report or have a look at the summary slide deck. More information about the research is also on here.

ThinkWell is continuing to support countries to cost their COVID-19 vaccine roll out strategies.

What’s one of the greatest public health investments but is often underfunded? Immunization.

“[Immunization] programs are a victim of their own success. The expanded program for immunization started in the 1970s around the world…and today, in most parts of the world, a lot of diseases [such as diphtheria, pertussis, tetanus, poliomyelitis, measles, and tuberculosis] aren’t a major part of our lives anymore…so [immunization] is not front of mind,” ThinkWell Program Manager Martha Coe said at the “Prevention and Vaccines in the Covid-19 Era: Bold Choices for Financing Immunization Systems” webinar hosted by MSD Brussel’s Policy Centre on January 27, 2021.

The Covid-19 pandemic has underscored how critical vaccines and prevention services are for resilient health systems. But beyond the massive undertaking of developing new vaccines and distributing them, financing systems to efficiently deliver these products is no easy task. And when a health crisis hits and vaccines are critically needed, health budgets are often under strain and their systems are unprepared to absorb new funding or vaccines effectively.

Even though preventative services can reduce healthcare costs over time, they’re often deprioritized as an investment area due to the lag in tangible benefits. In a study of Europe prior to the pandemic, less than 3% of the total health care spending was allocated to prevention and less than 0.5% was allocated to vaccination on average across countries.

Since 2016, ThinkWell has consulted for Merck/MSD on sustainable immunization financing. We’ve looked at health systems across Latin America, Asia, and Europe to understand how immunization is financed, what challenges countries face, and how external stakeholders can engage with challenges and support governments to strengthen immunization programs.

In 2019, we started studying what drives decisions around how funds for immunization are mobilized and used in the European Union (including the UK). Of course, each EU member state has its own economic, political, and social contexts as well as unique immunization systems and funding scenarios. Still, we identified four key themes that drive immunization financing across the region.

  1. Political prioritization drives funding: All countries prioritize their health sectors, but funding for preventative services including immunization is not always a political priority. This has led to coverage gaps, among other challenges.
  2. Financing is focused on performance improvement: Instead of investing in ways to build their immunization budgets, most countries focus on using available funds to improve vaccination coverage rates.
  3. Public systems engage new actors in immunization financing: As immunization programs grow, governments often appoint more actors to finance and deliver services. This creates complex systems that are not always accountable, cohesive, or well-coordinated.
  4. Limited guidance provided from the regional level: Even though EU member states experience common challenges with immunization financing, the EU’s governing body doesn’t provide much overarching guidance or learning platforms for countries to share their experiences.

With the momentum behind immunization ballooning as coronavirus vaccines are rolled-out, we hope that Europe will invest in prevention for the long-term. Governments can start by understanding and leveraging key immunization financing drivers. We have an opportunity to get bolder when it comes to confronting these drivers in policy design and innovating new approaches to financing immunization systems.

As a first step, “we would love to see the EU establish a platform where immunization and prevention can be discussed beyond Covid,” Martha Coe said.

And what can external stakeholders do to seize and maintain the momentum around prioritizing immunization? In addition to immunization advocacy, “we can provide more resources and capacity to increase knowledge and support [governments with limited capacity to find] solutions that move the needs towards sustainable immunization financing,” Coe concluded.

When governments embrace smart investments in immunization, we’ll begin to fully realize the potential of immunization programs both during and beyond the Covid-19 crisis.

If you want to learn more about our research on sustainable immunization financing in Europe, you can read this brief and view this presentation. In addition, you can explore our other work for Merck/MSD here.

You can watch the full webinar recording here:

Written by Leah Breen with Martha Coe

This piece originally appeared on Health Systems Governance Collaborative here

Written by Bernardo II Cielo (De La Salle University), Pura Angela Wee-Co (Strategic Purchasing for Primary Health Care, ThinkWell), Aliyah Evangelista (Knowledge Management and Information Technology Service, Department of Health Philippines), Maria Eufemia Yap (Strategic Purchasing for Primary Health Care, ThinkWell), and Matt Boxshall (Strategic Purchasing for Primary Health Care, ThinkWell)

Telemedicine solutions have the potential to help address geographic and socio-economic inequities in accessing health care in the Philippines, but they have remained in the periphery of public health policy over the last 10 years. Outside the emergence of the pandemic, there already were significant cost barriers to accessing health care, particularly for low-income populations and populations living in remote areas. Adopting telemedicine solutions can reduce inequities as it allows for people to avail of health services otherwise inaccessible through conventional means of health service delivery. Local technologies that increase access to health services synchronously,  through telephony or video-consultations, or asynchronously, through tele referrals via  text messaging, have been implemented in different capacities over the years and have provided insight into how telemedicine can be mainstreamed in the country.

Uncertain government regulation of telemedicine has constrained its development in the Philippines. Donor-funded public sector initiatives were often small scale and were primarily treated as tangential services in support of the standard face-to-face consultation. Private sector interest has also waxed and waned over time and never really scaled as well. With telemedicine technology advancing at a rate which is difficult to keep up with, regulators feel that they lack the capability, capacity, and confidence to create and enforce policies. This delegitimizes the technology, which in turn creates discomfort in the consumer market. The lack of effective political prioritization, as manifested by poor public information, inadequate communications technology (ICT) infrastructure, and inequitable regulatory and financing levers, led to the slow development of telemedicine practice.

COVID-19 has further emphasized the need for effective telemedicine.  Following the decision of the Philippine government to implement lockdowns in response to the increasing spread of COVID-19 in early March, seeking health care services became increasingly difficult. At the same time, the fear of catching the virus from these health facilities altered health seeking behaviour. Health facilities, who were already operating at full or over capacity as health care resources, were reallocated to concentrate on responding to the growing pandemic.

The Department of Health (DOH) responded to this challenge by establishing a telemedicine ‘sandbox.’ Together with the National Privacy Commission (NPC), two policies were issued which enabled a no-cost partnership arrangement with telemedicine providers to offer free COVID and non-COVID related consultations during the pandemic in Metro Manila. The engagement was treated like a regulatory sandbox, where the DOH was able to closely monitor and learn from the implementation to strengthen its regulation. For telemedicine providers to be engaged, they had to secure certification from NPC and DOH that they are compliant with current privacy and quality standards. Engaged telemedicine partners were advertised to the public through an official COVID hotline, and in return providers were required to submit their utilization data to DOH for the duration of the engagement. At the onset, two providers participated in the sandbox, and another three providers joined in succeeding months.

The pilot implementation so far illustrates the potential strengths and limitations of how telemedicine can expand the accessibility and efficiency of health service delivery, even in a post COVID-19 world. The first two telemedicine companies who participated in the sandbox reported operating at full capacity and provided approximately 50,000 consultations over a three-month period, mostly through telephony. Some of these even came from outside Metro Manila and only around 10% were eventually referred for face to face consult. This signified high demand and acceptance for the service but – compared to the size of the Metro Manila population – capacity to provide the service was still not enough. Further scaling up the service entails cost in terms of training capable physicians and ensuring enough equipment.

To further improve access to telemedicine, DOH needs to establish a conducive regulatory environment through responsive policy-making and active engagement of these providers. DOH has facilitated multi-agency policy formulation for the sandbox, developed assessment mechanism to check on privacy as well as safety concerns of new health ICT, and engaged different telemedicine providers including the private sector. The DOH has also started to involve other agencies, like the Department of Interior and Local Government (DILG), in designing future enhancements as they continue to discuss the program to improve its implementation, especially in terms of adapting it to a devolved setting.

The sandbox approach has generated useful insights into the continuing and often unforeseen risks of telemedicine practice. Enabling policies to ensure patient safety and quality of service through teleconsultations comparable to that of face-to-face consults have yet to be fully developed. Another risk observed was the continued practice of offshore data processing and its implications on security and patient privacy. Ensuring access to technology in resource poor areas in the Philippines remains a concern.  Ultimately, the inadequate capacity of the government to regulate telemedicine, whether in terms of its legal framework, the skill of its regulators, or its resources to assess and engage providers, will serve as  a constant barrier if appropriate investments are not made.

The sandbox approach will help set a course for a stronger health system incorporating telemedicine in the post COVID world.  Gaining insight into the broader health policy environment within these controlled set-ups allows for the development of more dynamic and responsive policies that better fit the contexts unique to the country and the technology being regulated. With the continuing development in terms of access of the majority of the population to technology, the country can consider a phased approach to ensure that quality and equitable access is reached.

Authors: Bernardo II Cielo 12, Pura Angela Wee-Co 2, Aliyah Evangelista 3, Maria Eufemia Yap 2, and Matt Boxshall 2

1 De La Salle University

2 Strategic Purchasing for Primary Health Care (SP4PHC), ThinkWell

3 Knowledge Management and Information Technology Service, Department of Health Philippines

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