Philippine Institute for Development Studies

A Study on Primary Health Care Services in the Philippines

Tessa Tan-Torres
DISCUSSION PAPER SERIES NO. 95-20

The PIDS Discussion Paper Series constitutes studies that are preliminary and subject to further revisions. They are being circulated in a limited number of copies only for purposes of soliciting comments and suggestions for further refinements. The studies under the Series are unedited and unreviewed. The views and opinions expressed are those of the author(s) and do not necessarily reflect those of the Institute. Not for quotation without permission from the author(s) and the Institute.

June 1995
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PART

I. Review Health

of

Research in

on the

the

Cost

of

Providing

Services

Philippines

Tessa

L.

Tan-Tortes, April 30,

M.D., 1995

M.Sc.

2 Abstract :

10-YEAR HEALTH

REVIEW POLICY

OF IN

ECONOMIC THE

EVALUATIONS T the

AND

THEIR

IMPACT

ON

PHILIPPINES. of

Tan-Torres,

Clinical College of

Epidemiology Unit, Medicine Manila.

University

Philippines

OBJECTIVES: the impacb on i. mail country. METHODS: studies, informants. alternatives

To

inventory, policy

critically of and economic manual

appraise

and

describe in the

health

evaluations search for

Electronic survey of

relevant of key more and 2. of of

researchers

and

interview

Inclusion criteria: in terms of from using survey of a September

comparison costs and 1984 to

of two or outcomes March by re: 1994.

completed/published Critical et.al. funding, RESULTS: which health The All unit five in and 2 appraisal 3. mail

guidelines of

published

Drun_ond, source

investigators

dissemination There were were and issues

results total of

and impact on policy. 20 economic evaluations, 14 on cost-effectiveness 60% a perfect were score with 80% All were a on

cost-outcome 4, and the were out from in 60% local

descriptions, analysis. 40% 8 out were of

analysis, median

cost-benefit remaining was score

public of i0.

hospital

concerns. single with

quality

evaluations carrying half appearing

investigator of the sources.

initiated, evaluations. Seven journals. 5 influenced were

received presented policy, policy 2

funding,

published

international Only agenda

scientific the no 8 had

conferences. research impact.

health pre-existing

influenced

5 supported expertise The few good

CONCLUSIONS: There is limited regarding economic evaluations. methodologically had impact sound. Despite

in the country studies done were only 25% in for

dissemination,

on policy. 2. Capacity building Dissemination of value economic 3. of economic for expertise of standards to

RECOMMENDATIONS: i, economic evaluations carrying among More social out and and makers with and

reporting re:

evaluations

enhance 4.

comparability policy

generalizability

Awareness-raising evaluations

interaction sciences

other to

disciplines, enhance impact

including on

economics,

media

policy.

INTRODUCTION: Need Health gross lower the middle increasing Development guarantee manifested requirement, efficiency. possible? Is 5% for Economic Evaluations: constituted of by the by the (i). in shows life level money health that the not more in than 1991. in a 2% of the was and for for World as

care than

expenditures product 3-5% the spent

national

Philippines other There World Health may locally this will

This Asia case the

countries be but not in (2). in in their used in health

recommended Income investments Report a directly by at a 1993 longer whatever

Organization

countries

automatically status The essential care, best (3)?" is ways

proportional

increase expectancy of funding

health the use

'!Are value

limited for

resources achieved

Economic technical economic

evaluations efficiency evaluation measures

have in

been the

used health

as

guide

for

attaining A sound (costs relevant determines in the may

care inputs

sector. and outputs and of

systematically and a values specific (4). both economic The costs from choice of

identifies perspective comparison and

alternatives, and the and

consequences) cost-effective the inclusion define a

alternatives

consequences Other

analysis

full to or

evaluation.

studies

limit themselves (clinical trials) consequences provide characteristics cost-effective Types Full of of a valuable

costs (costing studies) simply describe both program the (see the ability Annex to i). of absence

or consequences the costs and Although any of the the they two more

single

information, precludes option. Evaluations: may

recommend

Economic

economic

evaluat$ons

be

classified

into

four

types:

cost-minimization, benefit analysis inputs but minimization attain justifies simply there be are equal a the few

cost-effectiveness, (5). All of them the outcomes provides evidence or consequences, study. The option. which can scope

cost-utility and costconsider costs in the differently. Costthat the alternatives and In for the in the process, would field, outcomes.

express analysis outcomes pure less

costing

rational

choice medical equal

expensive is limited

interventions

produce

Therefore, analysis.

there

cost-minimization

Cost-effectiveness units like cost/death (process

analysis prevented

expresses (impact As such, relate. the extra is

outcomes measure) this The cost is or the

in

natural

cost/child analysis to costoutcome

immunized

measure).

which clinicians can easily effectiveness ratio describes achieved. of This type which is the both of a of

incremental per extra for

analysis

excellent dominating of

comparison Cost-

interventions analysis where combines incorporates presence

have a unit

a single

effect.

utility analysis years, also The

special of

form outcome, and

cost-effectiveness life measure a weight. QALYs, This as outcome,

quality-adjusted or utility of

morbidity single global

mortality.

patient's

preference

measure programs.

enables Lastly, terms.

comparison

across

different

cost-benefit It is the which e.g. can

analysis only one

expresses outputs among the types deter_ine benefit All the also putting having allows a or the a the that

in of

monetary economic of gives of a

evaluations program, more

explicitly with input a net received. that analysis, terms, when outcomes. disability Evaluations: economic

worth which

a program than the

output

other single

types are

analysis achieving. expressed programs difficulties outcomes Current The

assume in with may like Uses

implicitly monetary different arise or

outcomes

worth measure of to 2).

Cost-benefit

comparison conceptual value Annex

However, monetary (see prevented

a death of

Economic types aid of

different can

evaluations in

provide

useful financing

data which and can 2. 3. 4. 5. 6. 7. 8. system

decision-makers

prioritizing, economic specific care

implementing inform policy of

programs. issues on: specialist technologies payment

Specifically, facilities from public for or

evaluations technologies; institutions

i. planning excluding reforming

reimbursement;

schemes reform for and for audit

health

(especially changing developing

hospitals); budgetary payment medical within health institutions; care professionals; review and the health care schemes; systems

encouraging

utilization users; in

introducing encouraging (6).

co-payment competitive

service

arrangements

5 The (7). Health The Care in 1991 Report to to define everyone Financing approving Oregon 1993 a and Administration coverage Medicaid (2) basic to of Plan used set rank of (8) economic services considers medical and the costWorld

effectiveness

technologies

Development extensively available financing The

evaluations to be made for

medical

interventions

purposes. Pharmaceutical Benefits Advisory Committee has

Australian

required economic for reimbursement maintenance economic Economic

evaluations for _ since January in the

new drugs 1993. United

to be considered Several health also require (from on

organizations data before Assessment

States

putting Nnd

a drug on their New Technologies: at INCLEN meeting in

formulary Focusing Cairo,

Pharmaceuticals; 1993 by H. Glick, : for

presented U. of

January

Pennsylvania,

unpublished).

OBJECTIVES The demand

economic

evaluations

has

led

to

an

increase

in

published studies different of these

economic literature (9,10). However, were carried out in industrialized health studies care also delivery shows that and systems. there that of was there A

most of countries

these with

critical only is fair

appraisal adherence to ensure

to methodological more appropriate

standards use of

a need

methods have

economic been to in

analysis out

(11,12). in the

Economic Philippines. literature locally providing In

evaluations on

also

carried inventory health the

This study seeks economic evaluations appraise for aims the

the body of care available end in view of

and

critically

them future to

with

recommendations this study

s{udies. the research as process from the health

addition, has

examine to

which funding, policy. MATERIALS I.

generated conduct,

economic

evaluations, implementation

dissemination

AND

METHODS:

Search

Strategy: sources of researchers, archivists. studies were investigated the users (Department of The following methods were the Health, used to

Four possible funders, the DOH) and the

6 access them: electronic informant interview. and manual searches, mail survey, key

ElectronicDatabase: Two major electronic databases on health, were searched for economic evaluations in the in Philippines. the National complete MEDLINE Library of The is an MEDLINE and HERDIN, the health sector in database United more searched housed It 3,200

international in the

Medicine to CD-ROM

States. than

includes biomedical citations

references

articles version

from

journals. back to 1982.

includes

HERDIN is the the

(Health local

Research of

and

Development in health.

Information It is

Network) operated Development the DOH and by

database Council there are

studies for

Philippine _and

Health nodes

Research located

and in

(PCHRD)

two

other

the University of databases searched Bibliographic include out local includes search i. in articles reports the from studies over strategy (to

the Philippines Manila. The specific were the Philippine Health Projects The or The in titles Philippine of on over Health studies Database health, 1500 journals. issues.

HERDIN and the Projects carried includes

Database. (published Philippine published 65 journal was: cost, used capture Philippines.

unpublished) Bibliographic international and

publications

including It The

Cost*

costs,

cost-effectiveness,

cost-

benefit, 2. AND

cost-utility) Philippines (for Medline).

Print The

Database: files of of the the DOH Essential containing were National the Health researches searched. Research carried Program out by

(ENHRP) the

different

services

manually

Mail Survey: * Researchers: Names of university-based researchers were obtained from the

Inventory of All entries classification sent entries a

Health Researches, 1990-91 under "traditional were reviewed (annex clearly and 4). their

of PCHRD areas of primary were

(annex 3). concern" were of

authors authors

questionnaire which were

Excluded science in

basic

orientation.

7 * Funders: A list of 5). funding The agencies was obtained was sent from to from the the the ENHRP heads heads for of of of DOH the the

(annex agencies. regional Research

questionnaire was of also the

Information committees and Development.

obtained Philippine

Council

Health

* Librarians: A ifst of the academic College used in of members from the the mail Medicine of the inter-library of the 6). sent A to network of of and copy them in the the to of

health'was Philippines questionnaire

obtained

library survey

University

(annex was

the library of Economics which

the University offers an M.Sc.

of the Philippines Health Economics.

School

Upon sent in were Key The

receipt to people first

of

responses, who were If the

an

additional and

roUnd had not

of

letters

was

recommended a number phone. (annex of were 7): the visited was

been

surveyed

the

round. up on

available,

non-responders

followed Informant different of

Interview services Health to their as in of

vertical and

programs the personnel

in

the were

Department interviewed evaluations University and health College of II.

the possible existence of services. Health economists and the De La Salle Bank

economic from the University and the

the

Philippines

experts in Public Health of

the AsianDevelopment were also interviewed.

Selection

Articles: abstracts defined two the or more were main were reviewed and only as those studies which alternatives, included. focus of present if 1984 peso of in of costs outcomes the The the as based on economic article absolute for abstract). and reported 1994, readily during were the

Of the citations retrieved, full economic evaluations, include both evaluation (operationally: value Or alternatives These the articles Only ten in the past a comparison costs should both being and be of their

outcomes,

quantification and compared reporting are

percentage

were those years,

retrieved, studies September

available or March to

accessible. included

published

inventory.

8 Exclusion i. 2. mean criteria: financial with cost is/are of reports/budgets incidental data not Data discussed on the cost and/or in of data its the health projects to the

standard any that study

(operationalized implications report). Process: as meeting 8) was on

the_

interventions III. Once to * * * * of * press, the Collection the

Research and

article criteria,

was These

retrieved data were

assessed

the sent

inclusion

another

questionnaire reqllested:

(annex the agency) research the research

author.

person/agency personagency person/agency vitae and of if resources the study results academe,

commissioning/conceiving or the funding research the funding

research

(researcher,

decision-maker

performing possible); in of performing funding) presented expended amount the medical

(include (duration

curriculum

study

to DOH,

whom other

(beneficiaries, decision-makers, scientific

community, and

international conference, *

community) letter, etc.) on policy.

how

(briefing,

influence

A hard copy responders, through

of their complete paper was obtained. they were followed up at least calls or visits.

As three

for nontimes

telephone

IV. The guides

Critical manuscripts on

Appraisal: were The (see critically i0 questions 9): perspective being should costs of the evaluation appraised for can be using sound grouped reader's economic into the

methodological (13).

standards Appendix

evaluations following i. and The this research description perspective defines in

parameters question, of of the the

including

alternatives the scope analysis of the

compared; be and the stated societal explicitly to viewpoint, as be consequences

included

analysis.

Ideally,

composed of the in the analysis. choices can in the the address of a

provider, payer The relevant analysis problem. should It

and patient, alternatives include should or if the also this to

should be adopted to be included as alternatives include is an the which current new be

standard program, adequately

medical described

practice (who did

entirely should

"do-nothing"

alternative. what

Alternatives whom, when,

where.and

9 how) to allow readers intervention in their replicate some 2. data costs evidence should the or to decide on own setting Readers have been the feasibility of and if feasible, can missed. also determine the to if

intervention. consequences on effectiveness; are and based for

Economic

evaluations be valid

on

data

on

effectiveness.

The

medical the

interventions, most bias-free and

randomized results. after studies

controlled Prospective provide 3.

trials cohort, in

present

case-control, decreasing measurement order

before of

evidence

rigor. of costs and

identification,

and

valuation

consequences; Once the should be different included indirect psychic and resource reflect, subsidies, allocation the area perspective identified, categories in the (productivity costs and care addition of has been measured costs are losses should rather to the be defined, all and valued. consequences medical gains), Annex to charges motive, i0). input (14). presence and relevant Examples which costs of can be or actual may crossin in

and direct or (see taken than

analysis

non-medical,

intangible In costs measurement of Charges of inaccuracies list prices

consequences

valuation, in

consumption

profit

replacements, expansion, and annuitization and (charging by consensus).

bad debts, the current

4. The being

adjustment for future stream compared enables preference costs is the to

differential timing or discounting; of costs and consequences of the be used discounted in the to the present to

programs This

should costs of the

year.

method time

analysis or enjoy occur

incorporatethe who prefer to

individuals future and may

society benefits for far

postpone Discounting where e.g. 5.

in_ediately. programs the future,

particularly benefits B immunization. analysis; is for very the

important

prevention into

expected

hepatitis incremental

Incremental cost test extra colon needed

analysis to pay

important extra

as

it

gives The

the

extra stool

benefit.

guaiac

for detecting colon cost for a routine cancer as compared

cancer dramatically sixth test to detect to 5 tests is $47

showed that the an extra case of (15).

million

i0 6. In sensitivity economic used the analysis; analysis, may be assumptions imprecise. then are made or some of the or the can the the to

figures varying

Sensitivity and

analysis reassessing study If used, effort has

figures,

reanalyzing

impact of the new numbers on the conclusion of the be used to test the robustness of the conclusion. results analysis be 7. exerted are will to sensitive have obtain on to a change areas estimates. issues to other analysis may its 20 be of concern in where numbers more

delineated precise major

discussion

including to in be the e.g. or 2

generalizability The results of mechanically analysis analysis 20 life life IV. years also years

of findings an economic There limit may be not

settings: are not flaws or

intended

applied. which will does gained

weaknesses _An young

usefulness. address of one

economic

routinely people.

equityissues, person

years

of10

elderly and

Abstracting

Indexing

(annex to

Ii): HERDIN data requirements author's

Papers which were not previously base were abstracted to conform (16) and consent. submitted for indexing

indexed in the its technical with the

primary

ANALYSIS Each * based * study of

: is classified primary as being health follows: studied care) The and The proportion the median research of studies of is hospital or community-

type

intervention

(including of

type

economic each of

evaluation: the are criteria reported.

satisfying criteria qualitatively RESULTS Yield Of the five of 65 :

number process

fulfilled

described.

Search

Strategies (17-21) the

(Table in satisfied Health

I): the the search on MEDLINE, Of the and only 30 72 criteria.

citations

retrieved

articles in

citations citations appendix picked up

Philippine

Projects

Database

in the Bibliographic Database, 14 (17-22, 5) satisfied the criteria. These include in the MEDLINE search.

IA-8A in the five

ii The study i9 had were was a manual (9A). dead study search The or or had knew of the was files sent to to of the 161 ENHRP address. in However, papers (13A) yielded of one whom

survey

researchers,

moved a person only

a different with a study. of these

Response that they could further

rate

49.3%.

Seventeen

responded one

positively

inquiry fulfill

revealed that the criteria.

Of

the

21

representatives nine study (43%)

of responded. Both the were of 21 these

funding

' agencies 52% of

sent the did Search two (IIA two

questionnaires, 23 not of and librarians yield the 12A) a UP The (23,10A).

Similarly, criteria.

responded. fulfilling of which School thesis

searchstrategies library yielded evaluations yielded

inclusion economic key

Economics

undergraduate studies

interview

informants

.......

Thus,

there

were

20

studies

found

(abstracts

in

appendix

12).
Critical Subject Of the i.e., (18), expanded screening respiratory chemotherapy schistosomiasis with pooled blood Appraisal Areas: 20 vitamin canine studies, A rabies (23), WHO ii dealt with public health B immunization breast of management versus (5A), (9A), planning HIV (IIA). concerns, screening (19), cancer acute supplementation eradication on immunization algorithm (3A), for triple (17), hepatitis of the Studies (See Table 2):

through

programme

(21,12A),

infections in pulmonary through (10A),

quadruple control screening of

tuberculosis chemotherapy and family

The

remaining

nine of a

were

hospital-based of center with (20),

studies (22), the of (13A), diagnosis studies modes human

dealing newborns of papilloma in

with (IA),

antibiotic establishment for in pregnant herpes treatment of (4A).There

prophylaxis women (6A), (7A, support four transplant units were

meconium-stained

perinatal infected different patients 8A), (2A)

delivery or

viruses

regimens

immunosuppression diarrhea modes different of

kidney

management

rooming-in and x-ray test

ventilatory

sinusitis

diagnostic

(18i23,4A,10A).

Types

of

Economic

Evaluations:

12 Twelve economic 4A, gA,10A) interventions Only 12A). rabies the to value four Three societal the studies were to undertaken The eight establish an Vitamin and a lead used for the economic A the The the primary studies effectiveness analysis analysis deficiency control human other in as capital study its three on of as purpose (17,18,1Aof the well. of

analysis. sought and studies studies

remaining

included were -and lives used

cost-benefit schistosomiasis saved. process

(17,19,9A, eradication, -adopted approach National outcome. these

elimination, human Day were the

perspective

Immunization Economists cost The benefit rest of at

measure

investigators

analyses. the studies used cost-effectiveness They had analysis doctors economics or as

stopped the thesis main

cost-outcome authors except

descriptions. for one

undergraduate

(IIA) . and Alternatives Considered in the Research

Perspective Question: The costs medical costs. perspective covered and

adopted of the in in

in

these

studieswas or the payer included (6A,

the and only 23),

provider thus, the

of the

services

(Department only

Health) analysis

direct

two

studies,

non-medical

The

studies

which typical

covered of a

the

public vitamin problems

health country, A

area e.g.,

tackled acute The be some

problems respiratory

developing rabies, covered or

infections, studies in developing (16), and of

deficiency. which could but in in of and in in

hospital-based encountered of ill (4A), to the the transplant patients the acute studies,

developed

countries support diagnosis novel country. Outcomes: or used

specifically, (2A)

immunosuppression

kidney

patients alternatives lack

ventilatory were in Choice the of

critically sinusitis response

radiographic considered

resources and of of the the size The

Efficacy The being However, controlled this study significant data

Research on only had

Design

efficacy came ' one to sample a

alternatives predominantly studies efficacy with study on

interventions studies. randomized (IA) to and a show a

considered trial

from generate

local estimates power

inadequate

difference.

radiographic

diagnosis

13 also the The rigor. sample two Three used HIV a from rigorous small study sample design, size. validity This was study, not an but issue also with

suffered

screening. studies of and (17) the used the epidemiological local designs on designs efficacy to on tree local and of had this lower small are A

other

Majority sizes foreign-funded,

limited and on

follow-up. acute

Exceptions studies decision using

community-based respiratory studies employed efficacy,

vitamin (3A) . analysis foreign

deficiency of (18,6A,23) sources of

infections

to determine data.

The the i.e., gases

consequences or patients. hepatitis (2A). like and

considered which studies carrier studies planning hydrated. Three B Four family Ag

were directly used state

final showed

outcomes the impact

like on

mortality

infections

intermediate (18), used

outcomes, blood process immunized

arterial fully

(7A, SA, IIA, 12A) acceptors2

measures child Costing: As

% correctly

delimited only resource for Due a

by

the use

perspective medical and market 23) of costs.

taken, prices were

most used

of was in

the

costs on

included actual except used. the was 12A)

direct

Measurement

based valuation

few (17, 2A, to the nature to the rates

where charges were the interventions outcomes, as from no part 2-19%.

exclusively studied and discounting (17,19, of their

short done which

follow-up except for included Discount

determine three used

cost-benefit prevented ranged

analyses

deaths

outcomes. Methods Seven sensitivity of

Economic

Analysis: (17-19,23,4A,5A,9A) and the studies on extensively rabies used

studies analysis

elimination

(15) and chemotherapy of tuberculosis of the Conclusions derived from the in assumptions. analysis Critical based only Only (18,1A, Appraisal: on to a three liberal of the three 13A)

(SA) showed robustness analysis despite changes studies did not employ

incremental Summary An of

appraisal

application was dropped studies)

of gave

the because a

nine of median

methodological applicability

criteria

(discounting

14 score were (67%), of mostly 8 for in the valid studies evidence and (see of table 3). The deficiencies valuation (78%).

efficacy

(67%), analysis 4):

sensitivity of of the

(44%)

incremental Process (Table

Description Development All the of the

Research

Proposal: were funder. investigator-initiated infections (3A) except which for was

studies on by Study: acute the

study

respiratory

commissioned Conduct Eleven the of were studies technical Funding: six studies the of

studies technical University undergraduate

(18,20,22,23,1A,3A-8A) assistance of the of the Philippines theses foreign had

were Clinical

done

by Two

or

with Unit

Epidemiology Manila. (IIA, experts 12A).

studies Four providing

economics

(17,i9,21,IOA) input.

(20,22,4A-7A) Council funded for for by Health foreign (23,

were

locally and

funded Development two (17,8A), one each Bureau (19). time nil to by

by

the while

Philippine eight States were

Research agencies,

i.e.,

United two by by the (3A), funds

Agency

International

Development IA) and

Rockefeller Australian BOSTID on the expended 200,000 (18)

Foundation International and Centers from pesos), of

Development for of 1-12 Disease the and

Assistance Control study, the from

Depending and $150,000-

comprehensiveness varied (1975

months

respectively.

Dissemination Five two other (17,21) were in

Results: in international (22,23) not All in of journals indexed the in in (17-21) MEDLINE. except latter and The two years

published journals

local 13 are were

unpublished. reported

studies the

literature

between 1989 and the most popular conference audienceL Department presented. with

the present. forum for an academic the in

Except for dissemination and/or

one thesis report, was a scientific scientific

international

Twelve of of Health

studies also the audience

had people from the when results were

Influence

on

Policy:

15 There 2A). an Vitamin rabies were Only influence no five on responses of the health on the policy. survey claimed from that These two authors study were (21, had on

authors

their studies

A supplementation control (19), prophylaxis two studies (23) are economic

(17), hepatitis schistosomiasis

B screening (18), control (gA) and (IA). breast and issues studies These acute

antimicrobial An additional cancer definitive raised by screening

in meconium stained babies on tuberculosis (5A) and the research to of Five

influenced now being evaluation. a

agenda answer the

studies the

undertaken

provided were the respiratory unit (22) rooming

data in studies

support of on algorithm

pre-existing policy. for the management of

infections (3A), and of diarrhea of newborn babies

establishment of a perinatal treatment units (7A,8A), and (13A).

in

DISCUSSION: Doctors as Analysts. Most of the studies cost-outcome out by doctors areas reflects than the of clinical topics rather area. were cost-effectiveness which in were economic Therefore, initiated analysis the of the policy choice analysis and in or

descriptions interested expertise. more urgent

carried their of the

the interest need to craft

investigator in a certain

The in

clinical their

bias of

of

the

investigators but also in and

is the

revealed type of

not

only

choice the As analysis because expressed

topics

analysis of costs of the

being

done,

perspective previously done doctors in natural is

adopted the .are

the the

scope main

considered. economic probably outcomes Secondly,

mentioned, more

type with terms.

cost-effectiveness comfortable than is monetary the

analysis

units analysis

cost-effectiveness

natural

choice

for many of policy-making

the problems in the setting frequently

hospital involves

area because the crafting policy involves making for different for on diarrhea transplant technical

for a specific group of patients. It rarely choices between different interventions patients patients ipatients. efficiency ; e.g. versus The rather oral interest than rehydration sion doctors of on the therapy for is

immunosuppres

kidney more

allocative

efficiency.

16

The and to

perspective the the scope direct of of the

adopted costs medical

usually and costs,

is again

the

hospital

or are the

the

payer

effects

considered reflecting

restricted clinical

expertise There is

doctor-analyst. a need to expand choices of types of

however,

analysis, perspectives considerations because in terms of allocation

and costs beyond strictly medical decisions are in actuality being made between programs, even in hospitals. to buy will a the goes not cost the

For example, ventilators affect fourth discussion beyond the the drug

when the decision for the intensive ability for regarding specific of the need the

is being made whether care unit, any purchase hospital to make

available However, rarely and does of

tuberculosis

patients. decision

purchasing for

ventilators

explicitly include a or that which will ventilators.

consideration have to be

of the opportunity waived in place

For

decisions or

involving cost-utility using a

Choices may analysis common of may

between be will unit people. of enrich of

different inadequate have to outcome. societal, This will In be

programs, and This as in costdone to also it turn cases,

cost-effectiveness benefit allow needs involves necessitate interaction comparison a wider different a wider with

analysis

perspective, sectors economists consideration

preferably costs. the

these

analysis.

Adherence The not median adherence all

to to the the

Methodological score of 8 out methodological standards validity be should of a

Criteria: of be a possible may on be equal efficacy 9 in terms of as For in if the not standards assigned evidence minimum misleading weights. used and

example, analysis fulfilled, conclusion build and In on the this

should

requirement

must bring into question of the economic analysis. information credibility will of depend the on eight inventory, derived of the the studies being from

the validity of any Economic evaluations epidemiOlogical coming the insufficient compared. out studies of basis the used. for

numbers of had

analysis efficacy

quality

information

interventions

17 Most of the methodological the standards had There is no industrialized for databases usually variance. of the wide specific with on to costing carry out were de

fulfilled

because

investigators

novo collection of cost data. database on costs unlike in databases However, bits, sample cost the with data of may the one on de reimbursements the big a the novo probably affect paucity would employed collection

easily accessible countries where diseases millions only abound. of a data small of

unlike

includes The analysis. both

imprecision

results of

Because and be

available that find out

data, if

on

efficacy would

costs, extensively

expect to

sensitivity different conclusion. the studies.

analysis This

assumptions technical

or figures will affect tool was not maximized

the final in all of

Finally, in the doing extra analysis

a so,

few

studies to to is

did

not

do the the

incrementa true value at benefit extra

i of

analysis an the margin

and or

failed needed

exploit to pay

economic

which cost

determine for

the

effect.

Lack The state number

of

Technical of

Manpower the 20 studies provides analysis numerous a glimpse The to of the sense the of the large costlist, rather on economic included on locally. references

summary

of literature of citations

effectiveness. this reflects

However, more the

further

examination use of

prevalent

ter_ cost(24)

effective in literature in than a bonanza of economic

a non-technical evaluations.

This the

survey

of

literature growth countries is of an

on (8,9)

economic in has not

evaluations occurred of in

show the

that in local

exponential

economic

evaluations

industrialized setting. the early _ One of of recent 90's the of by will There

absolute

paucity of

studies, analysis future.

although in the

burst possibly main the one be

production heralds for

economic productive is A the major

a. more this

reasons studies academic carried

scarce

availability is that

local

technical

expertise.

finding

majority provided studies undertaken

were done with unit. It is out, with capacity a careful

the technical input clear that if more building plan to has locate to be and

systematically

18 sustain The few foci of technical available in of the expertise have in shown key the geographic applicability and the areas. of

studies

economic settings. areas.

evaluations Consumption In the

public

health are

hospital in both

resources health

considerable although

.public

field, basis number of can

relatively

inexpensive on an based interventions, interventions decision should targeted can we the best

individual the sheer large facing be offered? service?

compared to hospitalof recipients of the resources. is: the to most The what budget, policy extent be how

requires service

outlay How With

frequently for the use

authorities the

affected

available

the

resources?

{n

the

hospital policy different of can the

setting, is more

at

the

individual concerned for of part the

patient about same even budget in of a levels is the present

level, choices a of kidney of an few a

clinical between Because patients hospital. transplant The in

often use major a of

alternatives intensive a

condition.

resources, of the blood waste Because physically cannot and of can to .the frequently

consume For example,

graft

rejection

patient in

because agent the is

inadequate tremendous setting

immunosuppressive question policy of need clinical identified intervention where be is The one

resources. which (an an can patient deny

hospital is

is.more

cost-effective? actually policy (as

assistance person), to a with

clinical patient faceless limited age groups). option.

ethically public

compared

'health

deals to

numbers amounts It

decision to

made or the 20

supply efficient

vaccines only

certain which.

areas

certain

recommend

more

studies an

cover

important

areas

in

public

health

and

hospital-based areas where .useful should

medicine. economic making. out when: of is

However, evaluation In general,

there are is needed economic are at

still many and will be evaluations stake;

in decision becarried sizable

amounts

scarce

resources

responsibility

fragT_ented; the of respective a radically each parties different is are at

* the .variance ,_ there

objectives of or are unclear; exist alternatives

kind; well '.-

i.*. the technology ..understood;

underlying

alternative

19 the impossibly The first results short of time the (25) will of as society with the to the it as ensure doing. adopting is a able whole. where of Health. of rabies that The a carrying second societal determine An of example Agriculture Eradication in humans. out the analysis are not wanted in an

criteria is the an

evaluation emphasizes in is doing or the

worthwhile importance

criteria perspective the of net this of and of

analysis cost to lies with lead

to

benefit animal human dog

rabies rabies rabies will

elimination

program

responsibility

Department

Department eradication

rabies

The versus care the

third might hospital

criteria care easier and vice be

is for for

usually terminally the

illustrated ill but a

by greater criteria

home burden

care to

hospital

patients.

Hospital implies

family The

versa.

fourth

that radically use of resources

different alternatives and costs. The fifth

may entail different criteria will allow a as efficacy alternative. of time, too. data The _

sound economic analysis to be and use of resources are clear final criteria in emphasizes decision-making economic time and

undertaken for each

the and analysis effort

importance at the same be

economic implies out

evaluations that easily a and

well-done requires

cannot and

carried

resources

The

six

criteria that the and the

can last

be

summarized benefits three ensuring

by from

the the that the

first study

three be

ensuring considerable would In the have

potential

would individual

something

worthwhile setting, decisions, of A the

analyzing. economic evaluations on A created adult case an new in should programs, point is reports artificial of is offers be

Philippine before by the of

commissioned are the of made preventive epidemics for

especially Health. have general

Department hepatitis for being are not

nephrology non-selective screening but is

program.

Sensationalized

demand cholesterol

immunization. inadvertently during more necessarily

Efficacy population by heart month. promoted

controversial to do free Preventive

blood

examinations

programs

cost-effective

(_6).

2O In out the hospital of should stick one-time_ be Should the setting, evaluations hepatitis one injury mass carried all entrenched for its screen first out pregnant practices B numerous exist. S the or antigen hospital give opportunities Because carrier for of state carrying the in high our

economic

prevalence country, a or needle do

personnel Should

suffering directly undergoing

immunoglobulin patients tested for the hospital

immunization? for women in and all be

pre-operative diabetes? should be

screening surgery? Many of

re-examined

effectiveness

efficiency.

Generalizability Because of the many with areas, the the

of Studies Done in need to undertake lack of of local studies the done other for countries one study

Other Countries: economic evaluations expertise, in ot.her arises should the same

in

technical done question one country facing

coupled .countries, whether still problem? to other an be

availability industrialized), evaluation in the

(albeit economic replicated Are the countries?

result.s..of_-that

generalizable

When

answering as on

this consisting

question, of two

one data

can sets: of and

picture efficacy efficacy if the is the

an

economic costs. are set of data

analysis Guidelines relatively patients imported, the

and same

generalizability (27,28) used vary and expect

straightforward are one to can will be not

technology that

faithfully of

reasonably

performance

technology

significantly.

However, exchange more have been

cost rate,

data the

will use the to but

depend of

on care

the

country's traded

economy goods, of

and and There

internationally delivery to

importantly, attempts

health

structure. ensure ranking One

standardize primarily also to

methodologies facilitate comparisons.

economic sound of

analysis recommendations interventions

(29,30,31)

and

geographical

approach

which has been parities which countries limited. (3);

tried reflect however,

is to calculate purchasing power the real resources available to experience with this has been very

.If

there

are

gross

differences heart

between transplant

the

alternatives measles

:being
..... ..

compared, then

e.g., minor

versus in

ilimmunization,

differences

methodologies,

21 efficacy or costs will not change basis for the recommendations Report essential heavily (WDR) 1993 services to on the Health conclusions. of the World This is the Development package The WDR (32) of drew which on

(2) on the recommended be offered in countries. Sector Priorities economic diseases. Review

attempted to summarize varied interventions for

existing different

literature

However, beyond the need to decision-makers 1993 (2) and

the essential package, there still remains undertake economic evaluations to guide in other areas. The World Health ENHR this Development Research Report Program plan list

the

Essential

National

of the Department of document, unpublished) cost-effectiveness interventions The The that Research need the for only as

Health (from recognize cost-benefit for Infiuence is or not guide

Program 5 year need as they on

and

analysis

different

priorities and will five

research. on Policy: on the assumption This was of the the

Process economic in

analysis studies could of

premise_ 25%. be

information

decision-makers.

achieved the

Characteristics associated with of

research of of

process influence studies.

probability small number

health

policy

because

An

analysis

with that of

similar method of

objectives

carried

out

in of

Europe funding The funding policy In

suggested and use and purpose of an

dissemination, may and be to results or the public explicit rate. from studies used. able to the important inform by research

source organization government policy research purpose This policy

the

study

determinants.

media,

government objective of with 100%

explicit the for for

favored particular, funding policy demand

adoption government studies a economic

makers. organization of means informing that

achieved

success

a who

evaluations these being were economic

makers

provide the funding for likelihood of the results of their 66 respondents where . not explore regarding an

will More

lead to a importantly, instances would have

high 87% in been

identify

policy-making useful this input(33) study did

evaluations

if

the

researchers results. A

opted

for

an ..

_advocate"

role

their

researcher-

22 advocate policy "i. if it will he/she must have is be better cognizant recognized and impact makers study; be one decision of the makers; various pieces of chances of the that of getting results into have being if the a

following: decision-makers use will in of be resources greater

number of objectives just one of these; 2. the degree decision the of

efficient of are a study involved

relevant

conducting

and/or

commissioning

3. a study will only information available to

4. a study will only have produced before the decision 5. the greater the number are impact aware of the study,

an impact if the results it concerns needs to be of relevant decision-makers the greater the

can be taken; who of

possibility

(33)."

Aside results

from in

close a

contact timely

with fashion,

decision-makers maintaining validity note have analysis of of

and the

producing results,

methodological

standards, improving of policy objectives improve the

increasing:the dissemination, instruments of the relevance of

local and

taking

the

availability the myriad to suggested

while economic

recognizing been (6).

decision-maker

RECOMMENDATIONS: The i. following Develop are and recommended through for action: loci selected of technical geographic

sustain

a network, in

expertise areas in 2.

in economic the country; opportunities

evaluations for

Create

sustained decision-makers on costs

interactionbetween through easy access. decision for areas, by in the the fora,

economists, research, 3. 4. Build Create and

clinicians and policy meetings; an a on-line demand database for

for

economic studies on

evaluations interventions

among

makers

commission

especially Departmen_ 5.

new programs, of Health (e.g., standards and

considered as priority More in '94); and to enhance stages comparability of the

Disseminate

implementation evaluations.

reporting

economic

23 LIMITATIONS: Despite "best. efforts," original copies of two of the evaluations (2A, 13A) were not available for examination. Appraisal was based on the abstracts provided in database. A description of the research process was available for the EPI study (21). The Philippine author retired and could not be reached. the not had

In addition, the author's familiarity with.ll, of the studies may have potentially clouded her critical appraisal skills. However, the complete manuscripts of these studies are available from the author wishing to do an independent and can be appraisal. obtained by anyone

24 Acknowledgments: The author thanks

* this

Health study;

Policy of

Development evaluations

Program which

for

commissioning the base

an for

inventory

economic

became

All

physicians, who authors survey and

academics,

funders, during for hard the

librarians search for the their

and

key

informants * All

participated of studies

materials; research work; research papers, and kept

answering copies Joel the in of

process * Ms.

providing Manalo searched the and and

Marie who in order;

Mr. for people

Merced, relevant the survey

associates, persistently the files

followed-up

the

Philippine this study.

Institute

for

Development

Studies

for

funding

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IA. Gonzales GG. stained Newborns

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TM

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Safety

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Support

3A. the

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T, 1991.

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M.

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Analysis in

of

Respiratory

Infection

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4A Views 5A

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V,

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T.

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the Paranasal T. Regimens

Optimum

Number

of

Radiographic A, of Cabanban

Diagnosis A,

Sinusitis

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Analysis

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Versus Pulmonary

Chemotherapy

Tuberculosis

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T.

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Patients with Herpes Infections: Probable

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7A

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I, Based for

Aplasca Tropical

R,

Tan-Torres of 1991.

T.

Comparing at the

Costs

of

Hospital <..Institute

Treatments Medicine

Diarrhea

Research

8A!: Aplasca _A_alysis of

carlos

C,

Tan-Torres

T.

Cost-effectiveness the Department of

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Diarrhea in

Case Management in the Philippines 1992.

29 9A Basas, Santos J. AT Jr., Model Blas on BL, Velasco P, in Alialy the O, Erce E, of

Expectations Through OT, Paladin

Control

Schistosomiasis 10A Gomes M,

japonica Monzon Human

Chemotherapy FJ,

1987. S. Testing CostUsing

Mitchell Virus

Effectiveness Pooled Sera

of 1990.

Immunodeficiency

llA Family 12A

Dimalanta Planning Mangahas

PF. Program MAP,

Cost-effectiveness 1993 J. (thesis). A Cost-Benefit Alis the Disease Fabella

Analysis

of

the

Rosete Day:

Analysis 1993

of

the

National 13A.

Immunization Gonzales R.

OPLAN at

(thesis)

Rooming-in

Hospital.

3O

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Methods
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:"

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:....

..,

._.......,

.,. . ..:.. , ....: Numberi::C"::< ...

::

Electronic Medline HERDIN

Search 65 102 5 14

Manual

Search ENHRP Files

Mail

Survey (response Researchers Funders Librarians

rate

of 142 21

50%) 1 0 2

24

interview Key TOTAL Informants 19 2 20*

YIELD

The 5 studies

in the Medline

search also found in the HERDIN

search.

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u_*d _1 p_ Lo_re_L _ data,

_n* I00% vac_n*

d_ rr_d_ _dv_cl, _

_u_ re, our co

r._g,_ m_l

_nd pdce_

8._%

oz_ oi v_ dnolk_r_

nil

b_*_l

_l_n* l_rn,._z a_ _,n

v*ry _p_rn_e pm_fl_'_ OPe/eeo_y ol pm_rom -

_- po_l _c_ur_

e_p_

b_Lg_la_flmp_a_ons

at

_ul d_ Cy_p_dn* 2tCEA Ex_n_d p_gr _n_ _,n DOH I. E_ll_gr_r_ ar L_ed mu_kz Fut_ _n_'_r_ id rJ_Q_trnedc_ _ou_1 e_.p e_dtur_ non* | 0.53 - 5.7_ I F1C _tl_, mare rnuqlln_ond ec_t-e_*c_ven_ h_d I i_l _ f

22 C_:_ au_ eorne

E_t P_hmen_ _

ol p_r_not _ cent et

p_cr

1. H_hrb_ de[v_d

pr _Gn_n_-y _ p_ _

rl_ro_plcH_ c_hc_l

2_doy

n_c_

drel rne d_ v_ h _ v_d_*od

_-tua_ r_sr_re*

.ch_rge_

rm_ dor_

t_bczm poH_nlz _,_h be_r

rfudy donl offi_ e_obl_htnJn_ |

'.."... ::.

_tO.

_OPIC

pR$.=[_C._JV_

ALTFR_ATIVE_

FFICACY RE_F_c.._CM [_ E3]G N

OUTCO_._E3 iDC._T]Pr '

COST_" _EA_ E

OP;COUNTrHG VALUE

SE_Ft_VCPt A _A LYSLT

_CF_Et_ENTAL A _IALYSLS

RESUt]3

COM/_I_

23CEA

Brlc_r co_c ._ s_.6r_P,g

poyor

_. Tm lO+iQ_n_ __ br_o_l LI_ _cu'nno_c_ (SEI

d_ddo_ IT_e _Jn_ mul_p_l _ou__ _f d_o

eo'_ COnC_I _QI _d r,L, r_w r of poriq_nl_ o_vl

dr,_cl / __ecI . rl_dCoi ond no_n_co_

rl1_ce t._e

cl',ar g*s

ss_JHvi_y of cT_T_inl ixoTrln_n

BSEALBXo_d OpBx _Jll1,_ i._l I+] b_f

rot l'rcch l:ToV_d.d

d,dol c_ co_h

i. _$E o_d HP_ _..'_. boEh i_Is I*], I.$E _,_ q._1 + _J1h on_ SSE _-} _'oc.adn,g _ofP-, hladh _'a Y_d,_ _. P-_E _d HPE..#h,_

|I_'_] _ 103,000 sore_n.d. Odn ol '2.1 l_rIy brios_ Co '.I. no

_olh_ heath pL_

pr c_,,_d_-

Z o_en _OlOCy qO1o_]

t.:f IA CEA P_o_hy_ocHc _i_c c_v_ Jot nn_cor'.urn =_d _f_h P._sc,_c_

[+I ;oP_t,0n_led conIToI_ _ _P._'_ p-ev_nl_ct _ _r_l _0 doy_ or I_ ckecl r_cc_ _o_t_

i. F_phybcHc anT_|n cu.K_r_.iwl_dn x 3 doy_ fc_ _cor'c_uPR Itdn_d L_ion_s only, i_ _,h _g_ _d _yrnplo_r_ _r_r_cil_n

;_source u_ _cho1bo_edJ

fo_ ciru_;s ,ind ._crgb_ _or o_h_._

b__il 0c_* bu_ Y._h co_I la_C_g_ ir _il:doMa odrr__,_d or._" I InTar_h v_h fnT* cmor=

_urd_ng oi'a _onG-h.'_

C_

.'4od_ oi ve_on_ _n_n';l ol v [I p_lhml_

_L1_pcrl

paver

1.n'iechor_cc_ v0nH_on f,_ L,_,,Jbar_edpaMonl:[ omb_bog

cohort

art e,rl_ b_od g_ v_l f._n 2_ _ % _fh bQ',_-hrcx.mn,_

di'e _t rne Jca] c,_;

aclu_l r'_o,,zco _e

chcz_ _s

nor _onl;

nol done

ombuba_ Is s_TI. o,_r--0,ffe,c,_lv o

exonlpll o[a I1_ v_-t r._ ,,,..Inov_ be d(:n0 in Indut111ah,_d counld,l_ b,coull ol av11ol_Iky

_.A C E_

.'v_n og ., ',,,,,n of acute n _ r_=_o_o_y _n_.ctlo_ cJ".ldr_

D_pa_t_ _ H_c_h

h Wl_O-A_ algo_t hm _- p_o_de," =rloendon_ dor_dard pcacf.c_

ce_m_,'_-ba_ed co_cTt

A _P rro_ ally

d_e.c_ rne_car c_1"1

_-fu_ r_aurck uTa _mpln_i don_

rr,:_k_t

p'_c_

no_ done

y_l

?_IIO-A Rr o_dthn_ rr<_ r_ ,,rf=c@.'J pk.i._n .,dep,,na'_nl sland_rd

b0ouTi oP t11epenp__vt adopll_ lOON). lh. ThJdy oik to O1_I_C'_ or'_mp_,1ord colt b_JnO 11uct, crt.l. _" BklW_L'_r_ vo_n_ee,r

4A C_._

_oGr _ od'._

_pt/-:: do@_0e,_

pCTle r o

d Tfv_'_r.f _rrib_ rOdOl_<aph_".'hl_ da_,o_e _

o_ Po

_ogn_t

_c _e_l

d<_ I_.

of

ckect cc_h

medcal

alu,._l r_o_ce _e

rn_. _1 pdc_..

_ d_gnocHc _ccuracy

y.s

,*e._or 2 _,t _,_ II rrori o_E-_ff._v.n.u "n. oth_

lhl

dudV

k_oi_n@

'Ll_.,:_y',.-,i!h gId _ ond_d compcr_on

o_',li_lnf,..l_.l f o dognm_ fed _,_

b_

 STUOYNO.

TO_tC

:PI_$_'ECI"_rB

ALtT.RHATrVE3

_FFICACY RrI_R_If DESIGN

L_OLI_CO/uI_ "_

IDENTIFY

COn k_F.A$_JRF ,_

OISCOIJNTING VALLME

IEHSI[JVffY ANALYS_

INCR_NTAI. _HALY$1I L'

RESULTS

COMMEteT$

SACOII" , ndrt_'m_n ona_r_

ChemoItle_y otlubl_c_os_

Depo_n_nt olHeolh

I.l_eed_J_b_fx oI_T$ _lar_dorc_lx] Z Fo_dPJgnbllx oi PT8

erRcocVdola_om RCTttnltee"o. iurl _g_ bo_ &

_cure

dralnr_dcaL o_P_

oc_ud rejoice u_

rroklfpdce_

l_rdLrs_ats _r*_p_erote _0r3ond 4 drug_

4dnJ_ , ch*opet Chon3_n_gn

udngd_olrom_we_ure. do_exfemrvlLJndmv_y a_olfdslhoWn_robml oncX_om

LA Co_t oulon'm dlsoepHon

_,_ogarnenl o_ W*G_on_ po_nh v_lh heep_,s drrpk_2vPu=

p<_o_

1. lcreere',0 m_ddng _L phy_cot

f_ vk_g *xordnolton

d_ddon OnO_*ds u_O vadous _o_zc_ of data #accd poe_gn)

m_ger_d _ ,h_.p* vt_ _tec_lor_

dkecf rn_dc_ ond nonnnedcod cmh

cctuo_ re_urc_ _=e

_orgeL aped mork*f I:dcet

no5 done

no_ done

phydcol eKantno_on ottdm la_e oe_corr_s _d mvM

thh nludy p_o_fdl,s cml do_o $o h_lhr wo_ds _lrme k_luppot OPo cletc_ _:lcy.

i.l_lOl'l ey 7A CE_ " H_N OI-be_B t_eo_nn_nla md ol ocut* do'rh_o Depar_nn_nt or He_lh I. Irlolnne_l h do)'h_o rrcR_omn'eni U_P Z Sl_qd0rcl _:1"o _ I betcce or_ 1_udy Dff_r Focl_ o_4onn_'_ 4,_ orTI '_" ozse=rnent, ccr_c_ dret medcol InCLKIng 0 V4."_ Od o_h acluoJ t_ourcm ,.he m<:_QI pdcms nol _mnD Olv_U_h bltllr 0_10 flrl_ and _e_uted In ,,,.,o'v';nl_ oll_ v.Hch _mld ptoasl rl_lmurel, alu_y I_0_d $0 J_i)_4_k_df_nd _d_ne o_ one cdhln-l,O_Vll v llX,11Ull _olh_

_., C'F_

-:DO-

.'D,::_

-DO.

*DO-

-DO-"

-O'_"

.DO-

-DO-

-00-

IDt, Ll'_,J'lh A bml_ outom_ and L_

Ttudy und J_O_ J_ d_ to _uc:*_ ol TrL_slud_ (7A). K_cou_l or_.se ol prol_ m_. _he du_y v_= ak_ oble to _0 _on,_iSa rl_on'nn_ndar_ on furthl_

_A CaA

Co_ }oporto cherr_

o( 1_ P_o_I_ 4PTOUg_ h,_ c_oy

so<de _y

t, scxeen_g Ixeotn_n_ cosK v_h

and of posh't ve pr a_c_c_t _

b_0T_ ond o_td(d

rldb_on _ _Tevo_.nc4 .

............

.-----no dspdk

_ve_

.................

non_ don_ b_t n_eded Io be done

none

nef _ene_

P_ _n_d L_5y_on

_ol pdn_ v_ffle_ _ C_A, _>oplr not detdlLId eno_ Io olowoffico_ o_e_Brr_rd. modelng _m She oppro(_chto pr_ol_ fuluri o_J_cornem

I0_

C_)_

HW r sT_g 1_o

using pook_d

Fro_eder

I.tcresrb'_ b_=od r0_ Hrv _J_nQ ES]_A ond _adlcle Ogg_on I_

voEd_y zlucty

_H_ _Jcd_<_ly "

dkect medcol o_15 ff_ckJc[n[} e q_onr_ orh_ ov',_r" h_odc_ noF _did

ocquar r_4ource _Le

mod(e_ prlc_

_f

d_nl

Wevo_ncs _al I _ dze

nor dons

po_stzt o[S v_th pCT_ =uggl.dtnoBon _ ,co,.l_' lhon _LL_Aup tO Nrv p_evalen=s o_

oppeon fo be m_e of_ co_-q_t_rrboflg_ ==urdng 100% d_tec_0n ol'_llV oh'w" f*,.11ng_o_,Irr_

_A C _J_

p_

pro0Tom

_ vKt_n"mnl

I, Pond_ T_O_-L_ _ WoO-_'r_ a= F_ocl_l

_ned e1|_ 1 p_o_l_d

# ot ooeeplon coup_ oPylarl y_m/_f effe_, ,pml me.on ..tu_ur* Iddhs -

_61 TTLIO_L oolPi, rnclJdn 0

_ oco_'nh

i_endlr_l of

n<d don_

none

_ol d_,ne

_r_v_d _o_, l Ilec_verPm_l of r_enl yeCTL

e_tAdve V _n_d_ leGO_dcry dolo

Of

i_"_*d_
I_A C_A Nolto_ _=d/_er,_boH on d oy _ole_y HlYclo_e bll-r t.,n_zoH on D c_tone=d acu.m_d e fl_cocy: _o_u_" 50llrlle_toralof ed _t OvIt_g_ _l:t Idng dly_ I du_r _n<k_dmeCk'e .Cf ot'_ PPd_ecl c1f_ . "nnkmOccOunho_ I_O_ exp_ndl_rel 2-1_ non_ nil _5 t1_4 c_ _h N_D _ve_ * oniaPr" an<l_ d_to of

13 A C_

I_ooe-rk_eb_

" '

1o . dtlore

..........................


CLEARLY DEFINED QUESTION r COMPREHENSIVE DESCRI_N OF ALTERNATIVES EFFEC'r'/VENF__; ESTABUSHED

ov s'ruo,Es o,M'r.COOLOQ=
RELEVAv'_I'COSTS IDENTIFIED COSTSAPPRO- COSTSVAJ.UEO PRIATELY MEASU CREDIBLY DISCOUNTING 1NCREMEIqT_d. ANALYS)S SENSIITVffY ANALYSIS OISCUSSK:)NAND RECOMMENDATION TOTAL

t7. ",At.A de_denoy

,"

,"

t'

10

8. He.p_,tll_s :r,_,'em',_g B 19. Rsbles elJmlrm_lon _111 n./tnmunosupl_,'es_on Kidney _lnsp_ml EPI ]22. I_dnata| center 123.Bre_'t Ca

t f I,

t I !

t X X

f I f

," I I

I I I

X ! I

t I X

l I I

8 S 7

I t I

X I I

t X I

I t I

t f l

f X +X

f I I

X X I

I t I

7 S 8

I,.A. Antibiotic prophyhud$ In meconlum-slxlned

IA. Venll[_tory zupporl _ Resi_ltO_

t l

I I

X I

t I

X I

X I

X X

! I

8 8

4A. RacDoI_II_Jc dlagno_s of sJnus_s 5A, Chemo_enzpy In Tuberct,dosJs F_n_',,cy" lnd Herpes Simplex I] virus 7A. Ola.nlhom Management in RrxM BA. [_mraneaManaooment In DOH hospitals Schlsto con's4 I 0._ HN scrnnlng vdthi_eled blood '11,A. Family planr/n o 1 12_ NMIomd Immunization dey

.,'

t I I I

X t X X

X t X X

? t t f _

? ? X X

? ? X X

)(

l X X

X f X X

t I t I

3 iS 3 5

TOTAL.

19 (100%)

15 (7S_)

12 (53%)

18 {S4%)

15 (79%)

12 (f;3%)

15 (78%)

8 (42%)

19 [100%)

$MEDIA_

:_ruDY;-./REsEARC'H_TrrLF.._ NUMBER.. .

RESEARCH INmATOR

SOURCES OF FUNDING

PIEOP[E P_FORMING THE R_;F.A.RCH

R_'_OURCF_ EXPENDED IN THE STUOY

PR_ENTATION TO WHOIV,:

OF Rr_ULT$: HOW:

HEALIH POUCY

INFLUENCE

17

8on eflt-Co_ Analysts lr. the NuM_n Area:, A P_rrotPr_ec/ tn In,=, Philippines

tnvmllgot_

NeD8 - |Pt'_ilppine government ; Come_l Unlvetslly USAID)

Dr. B. PopMn - honored the economic evalua_on Or. F. Solon Or. _. Fernandez _. M. I_thgm Dr. M.A.t.onsa ng'

money' - 4' S !50.000 to S200.00 {19731

gaY% _e,atlh P_Clr personnel DOH Int_nal_l _ennnc ommunlL'y o_mlr_s_rai/ons,,_nde_s

_oecto! tx,_e/Ing$ r.._nte_enca$

YeL l! wOi tel/owed by eglor_ I:x'c_ec_J. I_ for compfex set of loosens Dr. Satan acute exp_ln. tt was utl_n'_alety not made nalk:ea! po,_cy and onty now ts being toveL Imp_emented el 1he na11Qr',ol

18

CEA of Simple Mtctometho(3 for Hepatitis II

Inve_tlgato_

_IOSTID N_tloru:l ACademy of Sciences, LiSA

money. NIL for CEA time - < 6 r'n_nihr,

ao3deme Dept. Of HeoUh Inlm_nallonal _=1on1111 ommunlly mecltcol commvnflyl olhef health peeress* lonols who Implements

_..._rllltIc o_n|mnce puf_icorlons

Yes. Hepall|Lt _ mass lrnmuh_nrlon, which was rno_t cosFeh'ocllve evenfuofly _ptoc; by OOH.

19

_ables Central In the _tep_b_T at the Philippines: Benefits and COSTSO1'I_lrr.lnOllon

tnvesllgarar

personal funds o_" Dr. Dan Rmbeln on_ SOme supp<_1 /_orn lhe COC. Altonlo. GA,

D_'.O. Rshbeln Dr. N. &_'o_o Or. P. Me,F_

mor.ey

1(me

. # 'i0._O0.00 [_988} excluding D. Fl_ll0eln's _'ove110 l?le PhlIs. - 6 monih_ "

oc_=deme ad'mlnlsbcllonttundets benetll(:fles Oepl. of Health Entre'notional tK:lenllflc Io<:;_ rns_lc_ munity/other prototdonol$ lmptement comt._lth who

briefings tartars sctoqrlg onlmence conventions

Yes. lhe on'oils now being I_xed on rabies madk=atlon and COnlTOt a_e p_lty _n response to the dale genmam_ by l_e study.

20

Ketocon_L_Ole In Post*Transpla nt Triple 111_opy: Comparison of CO_IS and Outcomes

Invest:gotoe

PCHRD

D#. I. Gueco Dr. T. Ton-T_'tes .,

money o P _._._(_ * _1990_ lime - 2 months

ocQ(seme Ini_nol_lonol scientific commu_ly meOIcol ommun11yl ott'-,_ health profe_tlonols who Implements oc_cleme Dep't. of Health m_:l]col community/ O_her _ealth p_ofe_ Ionols who _-mpiemonts academe odmln_t, halton/lund_ Oe_D'i. o_' Health. ffCCP lnlemollonol slenlltlo community moo]cot ommunlly/ alh_' heall_ .pi'otesstonai$ who lmplemenll_

sclentflt<: contl, rence

No. Results vet( dlfflcu;t to Implement against standard pracllce.

ol It goe_

22

Clln:_=l Outcomes and Co_ls of HospItollxnilon of Inborn and Ov_'bo_n Intonts In c Pednolar Unlt

tnvesllgator

PCHRID

I_. A_ Sayoo Dr. T, Tan-I'o_'res Or, S. $_'clo

money - ;>15.000 |19_0) lime - 4 rnomh_

s_lenllfl

conl'erence

Ha, li only provided pre-ex_t_ng policy.

suppo_11ng evidence

_f'

:_3

Cold-Eh'1_dlveness as a CA So'een;ng

o_' Bfetosl Exam

Invesilgotot

Rocketollet F_un_otlon

D_. C. Ngel_ng'el

money - @ $$,000 {1989) lime i2 monlhs

tadeilngs convenllons slehlll',(= con fetches publication;

YerL The Phlflpl_ne Cancel Conltol Poragram hal for _tsIb'easl Scteer4ng _'r0gram annual b,east exam by heollh pravtdm and ISS_: C_nenlly we o_e approved and funded 1o do O randomLmd _ I_a_ an P| vs. no o|lv_ screening I.,IMel;ra _on_a to $1ad 1995.

.... ....... ,_.,

"

_RI_ ___.'_OURC:IES'OF.';+'_H:_: _,._'_J'_. PEOPLE PERFORMING _ |N1T_TOR,_FUNDIN G !.'_;:.. _-_._: ":,'T'HE RF_J;EARCH :

RESOURCES EXPENDED iN THE STUDY

- PR_r:NTATION TO WHOM:

OF RESULTS: HOW:.

HEALTH pOt.iCY 11_FI.U_J4CE

Investigator ..='"-.'. ".'._" M,econ_m_'alneo" .... " "_= N_,,.'bom$ Pounoor Unlversl W of _he Phlls. CoJtege of Mecrlclne Commfi'Zee on Research Implementation and Oev_opmenf 3A Cost-Effec.ll'veness Analysis of the Acute Resplralo@' Intectlon Algorhllhm In 8abel Deten'nlnlng the Opl]mum or VI_s tn Radiographic of Poronosol $1nusllls Nvmber Diagnosis commrsfon_l by PJnde AIOAIB . DL T. Ton,-Tones money Itme Oep<_menl o t Health Int_,_nolJ,ono! sclenl111 communlly academe Depatlmenl of Health Inte,rn_.llonol _:.1en1111 community m_lcm commuN;yl other h_l_lth pOfeL _ Ionols who _r-,plemonl$ acetic'no Depa_ment of H_ollh metrical _on'_',unl_yt olhe'r heQ_lh [_'ofel_lonorJ_ who Impter'rmnls PC_RD Dr. R. Monolo$|os Dr. T. Toi_Torrer money - P '_$.000 [t9901 tlme - I montr_ acorns'he meOlcol c_mn',unlly'! O1h_H'h_OIIh p_ofeSP IonoLt who Implemenl$ academe m_1_ol community! othe_ h_o11;I wotas:P lanai| Invesllg0_for Child SL_vlvol P;o_e,c'l. Dr, R. Aplo'_<:;o Deporlmenf of Heolt_ Dt.T. Ton-Tortes Or. C. Co'los . mentor - P8_,1,740 1'_992| tlme - 4 monlhs who tmplerr_nl$ _=lenltflc of Health s_en1111 . cont_ence No. _1only wovlde_ i_r_-e_Istlng policy. |upporflng evidence for _lenr_l'_. ont(l_anoe NO. rc.lenl_.r,c continence Oif_cuIt to _/os 1h15furl pfovl@ol od.dlrk_nol evk_ence In ;ova( ore _'octlce f0 whk:h the_e woI oYeaoy sltong polltlcol wifl. No. t. u . Evans lime - 3 monlh$ olh_r heallh profestP lonols who Implements

4A

_nvestlgot_'

PCHRO

Dr. G. Vlcenle Dr. T. _'on-To_es

money - P iS.000 It990J 11me - 1 month

sclenltl_

conference

5A

Cosl-Mlnlm_a.tlon Anolyd$ at Triple Versus Quod_"uple Regimens In Short Course Chemolhe_'opy _c* _ulmon_y TB

Irnvesflgoto_

I_CHRD

Dr. A. A_efo Or. A. Cobonbon Dr. T. Tor'_-Torres

money - P tS.000 11990] lime - 1 monlr,

_lenlltlC

conference

No I_ul It lnlluenC_:l

1he research

ogenO_z.

_A.

Mangement of Pregnant Pollenls Investigator wllh Hmlp_S $1mpl_X II or Papilloma V'INS In_recJlons: P_oboble Outcomes or'_ Co_ls 1991 COmpod_g Co$1s of Horp;toF BO_l.d T_eotrnent$ at' Dlon'hB-o at 1he Rese._h In$1[tule for Tropical Medldne lnvestlgolor

7A

PCHRD

Dr. L Llnlag _. !'. Tor'_-T_l'es Dr. R. AploIca

money - Pt $.000 119_0) lime - r monlP_

_clenlt_C conference

No. It only wovlOel suppo_ng evidence pOliCy ok'_ody womulgoI:_d bu! n(_KIIng for effective Impl,ementollon.

fo_ a 1pu_l'

8A

CosI-Effe<::tlveness Analysis of Dlorfi_,eo Case.U.onogement Inthe De_0dment of Heall'n Hosplfols

a.odeme _epor)'menl tn1_noflonoi ommunlly..

moOlcq.l cc.m mu nlty/ Othm" heO_:th profe_ Ionol$ who Imple_'_nts World Heollh Qrganlz_i'lor_ g_. Model on _totlons In the, Conh'o_ of Schlsto_.omlosls Japonica Ihough Chemolhe_opy Invesl_,otor GO; > - Deportment or Health $chlstos.omlo_s COfllrot Se_vk_e Or. A. Santos..lit. Or. 8. Bias Of. _'. D_. O. Mf.E. Mr. J. Velo_o Al_ly Etce Bases money - _lh'lcult Io quonitly: oll _'e wo_klng posF$1me Io this study * obo4JI 12 tTton|hs Depo_ment Int_notionol ormlnu.nlly of H_olth sclenllnc . bdeflngs Yek poIl<.'y on cov_'oge. Before POHP II. Coverage: under WB-PDHP, osslstol_.::e - 100_

lime

lJA

A Cost-Effecttvene,'.s Ano;ysl$ at the Fan'Jly Plonntog Program A CosF-Seneflt Anoly_'s of the Notional Immunlzollon Day OPtAN: AIb Disease

Investigator

1ram Invesl_oJor

Ms. P. Otmo_on_o

ltme-

4 n'tonlh$

academe

1beds toper1'

NO.

IZA

Investigator

podn_'s funding

p=_.ono[

Ms. M.A.P. Monoohos _'. J._. Rotete

money time - 3 monlhs

academe vnde,rg_oduote

bdeflngs students

NO. At. of the momenL

13A

Heal_

Economic Studies at the

Invesl_at0

perlon;I

Ck'.R. Gonz_les

_rne - 1 rn,0n_

idm/nmuat_on.ffundera D_pl. _' Healm prm

bneftng_

No.

Dr. Jose FabeLla J_ernodal HospI_I

.1 DisfilJ/_ui,slJiug charadcrislics

uf licalfll care cvaluallofls

Are br,dh +:o.sls(inpuls) and consequences (OUilJUlS) f lhe allemalives o ex,lmirmd ?

Exmvtinesunly

Examines only ' __ -,

I. r;u"Se_L"e"Ce_ / csIs

lmpafison iwo 1 !!here ;_1 ,ernalives? rere

_ d,,._rfil_lul+ ()vdcfml_ _ -__.J. .A 'I'IU/ t'/_I'I.^L Y-E-S-3A ............ PAltlIAL FIfi(;m;y (_r eller;livev_ess evalualion

Cosl descfipliot= EvALUAIIUN 11:1

Cesl-oulcome descfilfliun 2 I'^IIII/_L I'VALUAIIUN

v.................................... FULL ECUNUMIC EVALUAIION EVALUAFION 3B 4 Cusl analysis (;(Jsl-minimitnliun nnalysi.q (,usl-ellm:liv_.nes,_nnalysi9 Cusl_dilily mvaly._i_ Cosl-bervelil ,nalysis

A2. Af, v'.,,vlly 2. IvleasurefilcIIt and cuHse(lueflccs (_lc(JslS ii_ coon(relic ev'_lu_lio,s TYlle of
study

Measulelneni/
v{llHafi(lll El)SIS ()f ill I1()(ll ;diet J),'ltives

ldentificaliun
O/'COIISe(ItICIIC@S

Meastlr(.'lllUil{/
vahl;lli()ll c)(

t)llSeClUCll_t'S

Cust-minimizaliull analysis C'ost-elfectivenuss analysis

l)olhlls I)ullars

Identical il)all relevant respecls Si=lglecried ()f iJlleres(, common to both Idlerl)alive.,_, bul achieved Io differenl degrees

Nul_e Natulal uiiits (e.g., lifeyears gai.ed. disal)ililydays.saved, i)oi.ls ul" blood I)l essure reduction, etc.) I)olhus

Cos.l-I)eaJelil ' allalysis

i)()ll;Jts

Si_Jgleor mulliplc cllccls. not tlecessat ily common Io bt)lh alternatives, a_d 120111111(,111 e/Iccls may be achieved Io different degrees by Ihe altermttives

,.,. ';Cost-ulilily i_.a!lalysis Dollars

5iJ_gle or multiple effecls, not necessalily common to bolh alternatives, mid common effects may be achieved (u different degrees by the alter'natives

Heallhy days or (more o/re.) tlu_!lity adjusted life-years

Annex

3:

LIST PCI-IRD Directory

OF

MAIL

SURVEY: Based Researches UNIVERSITY

- University

i. ABAGUIN, Carmencita M. 2. ACEVEDO, Eustaquia T., M.D. 3. ALBA, Milagros O. 4. ALEILER, Ma. Concepcion, Ph.D. 5. ALMEDA, Leonardo A., M,D. 6. ANASTACIO: Antonio L.., M.D. 7. ANDANAR, Agnes C., M.D. 8. ANGELO, Priscilla Felipe, M.D. 9. ANONUEVO., Susan P. iO. AQUINO._ Rommel M., M.D. il. ARCELLA, Crisostomo A., M.D. 12. AVENTURA, Avenilo P.., M.D. 13. BACLAYON, Melvina T. M.D. 14. BAJA-PANLILIO, Herminia, M.D. 15. BARBA, _ Corazon V.C. i6. BASA, Antonia Cruz, M.D. : 17. BASA, Generoso F., M.D. 18. BAUTISTA, Victoria A.., Ph.D. 19. BEATO: Napoleon Enrico T.., M.D. 20. BERINGUELA_ Adela, Ph.D. 2i. BONGALA. Domingo,Jr. , M.D. 22. BONGGA., ]}emetria C., Ph.D. 23. BUENVIAJE, Mirriam B., M.D. 24. CABUGUIT_Vicente S., M.D. 25. CAJA, Teresita R., M.D. 26. CAMACHO, Angelita .C., M.D. 27. CANELA, Ma. Delta A., M.D. 28. CANTORIA., Magdalena C.._ Ph.D. 29. 30. 31. 32. CARPIO, Ramon E., M.D. CASILLAN-GARCIA, Fe, Rh.D. CATILLO, Amorita V. CASTILLO, Fatima A., Ph.D.

UPM C Nurs PLM CM UPM C Nurs UPD C Pub Adm UERMMMC UERMMMC Chong Hua CM Cebu PLM CM Im con Col Cebu UERMMMC UERMMMC UST STUH CHH Cebu-Pedia UERMMMC UPLB CHE IHNF MCU FDTSM UST Med & Surg UPD Pub Adm UERMMMC UPM CAS UERMMMC UPD C Home Econ UST STUH UERMMMC PLM FEU NRMF UERMMMC UPM Pharm UST Med & Surg UPD.C Ed UPM C Pharm UPM CAS UST Med & SurgDLSU Bio/ Reseach US'T" STUH UPD UERMMMC UF'M C Nuts ._ UPD C Pub Adm PWU UNICOR UST RCNS Biochem UPD Pop'n Inst UERMMMC UF'M C I',lurs. FEU NRMF UDP CSSP Psyc PWU UF'M CAS FEU NRMF OG-Gyn

33. CASTRO, Troadio B., M.D. 34. CLAVERIA, Florencia G. 35. CO, Leortardo L., M.D. 36. CONCEPCION-, Mercedes B., Ph.D. 37. CONSIGNADO , Godiosa 0., M.D. 38. CORCEGA, Thelma F. 39. []ORDERO, Rosa R. 40. CI]YEGKEIgG, Trinidad C., F'h.D. 4i. DE CASTRO-BERNAS, Gloria, Ph.D. .42. DE GUZMAN, Eliseo A. 43. DE GUZMAN, Ludivino 6. , M.D. 44. DE LEON, Agnes Rosario A. :_45. DE L_EON_-F'ORRAS, Elizabeth, M.D. 46. DE LA L_LANA, Ma. Reina Paz A_ '47. DE LA PENA, Marisa Rhodora 0. 148. DE LOS REYES, Josefina O. IA9. DE LOS REYES, Rey H., M.D.

50..DE LOS SANTOS, Maribeth T., M.D. 51. DOMINGO, Lira O. 52. DOMINGO, Ma. Fe A. 5_. DORIA, Alfonso L., M.D. 54. ENRIQUEZ, Ma. Luisa D. " 55. ESTRADA, John Vincent 0., M.D. 56. ESTRADA, Sarah Luisa T.S., M.D. 57. FLORENCIO, Cecilia A., Ph.D. '58. FONTANILLA_ Ma. Alodia, Ph.D. 59. GALVEZ-SANCHEZ, Ma. Fe, D.D.M. 60. GARCIA, Rolando G., Ph.D. 61. GASTARDO-CONACO, Ma. Cecilia, Ph.D. 9 GAVINO, Ma Irma B. 63. GEALOGO, Rufino A. 64. GERVASIO, Natividad C., D.D.M. 65. GONZAGA, Norman Clemente, M.D. 66. 8RECiA, Amelia N., M.D. 67. GUTIERREZ, Evelyn 8.'.. M.D. 68. HERNANDEZ, Cristina B., M'.D. 69. HERNANDEZ, Emilio A. Jr., M.D. 70. HERRIN, Alejandro N., Ph.D. 71. ISAAC, Cynthia V. 72. OOCSON, Raquel C., M.D. 73. 30VES, Policarpio B. Or., M.D. 74. KARGANILLA, Bernard Leo M. 75. KHO, Stanley U.: M.D. 76. KUAN._ Letty G. 77. LACHICA, Robert R., M.D. :78. LAGO, Leonor C., D.D.M. 79. LANFO, Ma. Emma Alesna, M.D. 80. LAO, Luis Mayo, M.D. 81. LAO-NARIO, Ma. Brigette T. 82. LARAYA, Lourna T., M.D. 83. LAURENTE, Cecilia M. 84. LAYO-DANAO, Leda, Ph'.D. 85. LERMA, Norma V. 86. 'LIM, Victoriano Y-, M.D.. B7. LLAMAS, Eusebio E., M.D. 88. LLAMAS, Lourdes, M.D. 89. MAGLAYA, Araceli S. _(!. MAGPILI, _I. MANANS_LA, _2..MASLANG," Policarpia Ma. Elena J. Edith V., Ph.D.

UERMMMC UPD Pop'n Inst UPD CSSP UST STUH DLSU CS UERMMMC UERMMMC UPD DFoodSci&Nuto UPD C Ed "" UPD C Ed UPD CS UPD CSSP Psyc UST C Nurs ' UPD Pop'n fnst UPM C Dent UST Med & Surg . Wt Vis Stt U Ilo PLM C Med Perp Help CM Binan UST STUH Ma'am UPD Econ UPM CAMP PLM FEU NRMF UPM Dept Soc Sci UERMMMC UPM C Nuts UPD Health Service UPM C Dent CHH Cebu UST Med _ Surg UPM C Nuts St. Paul .Col, _Mla UPM C Nur._ UPM C Nuts UST Pharm UST STUH UST Med .& surg UST Med & Surg UPM C Nuts UPM UST UPD UPD UPM FEU FEU UST UPD List UST UST FEU CAMP : Med _& Surg CSWCD C Ed CAMP NRMF NRMF STUH CSSP Med & Surg STUH STUH NRMF STUH

_3.1 MEOILLANO, Evelina A.. _4_."MOOICA, Ma. Georgina D _5. IdONSALI'ID, Ida. Elena M., _6_- MONTE, Rebecca M._ M.D. __:i:::MONZON, Orestes F'_, M.D. _:;NATIVIDAD, Oosefina N. _I_k"NAVAL . Cosine I ldefonso N _,_!NAVARRA, Sandra V., M.D.*' _O_i'.OCONER, Jose T., M.D. _2.0N8. Helen, M.D. _O_I_ORDiNARIO, _Artenmio T.,

M.D.

M.D.

M.D.

UST

As

i04 F'ABLO, Igr,acio S., Sc.D. i05.F'ACIFICO, Jaime I_. IUG.PAHL, George 107.PAJE-VILLAR, Estrella, M.D. I08.PALACIOS, Concordia G., ]}.D.M. I09.F'EREZ, Aurora E.., Ph.D. IIO.PEREZ, Jesus Y.: M.D. Ill.PEREZ, Esmeralda, F'h.D. II2.F'OLLOSO, Tomas M. Or., M.D. II3.PRODIGALIDAO, Abelardo bl., M.D. 114.PLJNZAl-AFI_ Pen(_, I'1.]]. IIS.PURI.IGtSAI',I/_,I'I, llermegenes B., H.D. 116.PAMIREZ, Jos, e S., H.D. 117.F:AHIR[)., /:aurie. S., Ph.I). L18 RAI'II]S H_.iF, el u M. Jr H D. L!9.F_AYI'IIJNI)D,' 'Corazon H., F'II.D. 1.20.RE]q I..I..II)A, Ha. LOurdes L2.[.REGAI-, I_lermo(lelles R., Jr , H.I). I._:..: F;EYES O f_:_lia I_., H.D ,'_1 ,iv L..',',. RII._I:IR, Eustec ta, I'1. II. 1_.4 L[,,JI:t-,A, F.qpPrar_a F. I'I.Do ..... I:'r_liEP[i F:oel A.F' , I,I D, L26.[.;I}I'IO, Ramc,r, t:.dqar-dL_, H. I). .27.RI I-_[[], COl";j:.:(:_['i (._., I'I.D. L28.RIJB1 I'F, f.o._,_r.io l;:., F'h.D _29.SAMOr,ITE, Elena L., Ph.D. L30.SIAI'ISO|,I, Ooseph.i.ne C. ; I'I.D. _-31 _ ..... ohl.lrt]S, Carmen Enverga, M D L32.SEI,IO, Vivie'r} A. ;33.SI, Arlene S. L34.aIASOCO, Ruben E., M D .35.SIBAYAI.I Renato Q., M.D. L36.SOLEVILLA, I_osalinda C., Ph.D. 37.SOLLANO dose D., M.D. L38.SY, Dalisay C..._ Ph.D. _9.SYCIP, Ly, Ph.D. _40.SYLIANCO,Clara Y.L., Ph.D. _4I.TAI'4, Truman N., M.D. i42.TANTEI4GCO, Angelina T., M.D. >43.TAYAG, dosefina G., D.P.A. ;44.TOI4ULTO, Cecilia I)., M.D. ;45. TORRALBA T:kto P., M.D. _.46.TORRES, [_eonardo A. , I'1, D. :_7.TUNGPAt.AN, Luz B., Ph.O. _8.UY,._...... . Karl Fabian L.., M.D. !_.VALDELLOI\I, E-rlinda V M D i_O.:VARELA, Amelia F'., F'h.D. !,I:VEI*ES,do E., M.D. 12:;_VEI,]I"UI_A, Elizabeth R., F'h.D. ..-VICTORIO_ Sandra T.G., M.D.* ,_'4.VIt_LARAZ(-',, Cynthia O. -VIL-L.ARI._gA, Umil, M.D. :I'YAF',Grace V. ,._-ZABIAN, Zelda C. , F'h.D.

F'WU DLSU EACM Cavite DLSU CS UST Med & Surg CEU Hla C Dent LIF'DPop'n Inst UST bled & Surg UPM CAS CHH Cebu UEr-:IolblHC UERIII'II'IC us r Hed #..: SLtl'g UEH'!!'!I:'I _ IJF'tl C'AS D Soc Sci I IFRI'IHHC UPD F;op'n Inst UF'H CAS USI- STOil l el S IUH IJ:3r STUH HCU Ft)I'SHFIgH L Et;:HHMf_ FEIJ I.II;:MF" biv World Tac UF'I'I CAS BiB UF'D CSSP Psyc UERMHMC US]" Med & Surg Col .[111mConE.Cehu UPM C Pharm UERMMMC UST Med & Surg UST RCNS Med _,. Surg Med & Surg UPD CSSP Psyc NSRI Chem Help MC Binan UPM CAS F'erp Help MC Binan UST Hed & Surg F'LM UPM Registrar MCU FDTM Hosp UERMMMC UPD F'ub Adm Slmn Unv M C Dumag UPD CSSP F'syc UST STUH UF'M Dept Spch Path F'erp Help MC Binan PWU C F'harm UPD F'op'n Inst

PCHRD i. 2. 3. 4.

REGIONAL

OFFICE

Dr.' Charito Awiten RHRDC XI, RHO, Davao City Dr, Conrado Gaslim Or. NLHRDC, RHO, San Fernando, La Union Dr. Oaime Manila RHRDC VI, WVSU, Iloilo City Dr. Jose fina Poblete RHRDF. CIM_ Cebu City

FOLLOW

UP

LETTERS

SUGGESTED

IN SURVEY

l.Dr. Eduardo Gonzalez Policy Research Unit D.A.P. 2.Engr. Elpidio Nerona DOH Field Ut #1, San Fernando, La Union 3.Ms. Trinidad Osteria De La Salle University 4.Mrs. Costancia P. Pitpitan Phil Womens University 5.Dr. Fortunato Sevilla IIl UST Research Center for Natural Sciences 6.Dr. Grace Valerio MCU FDTMF Hospital

... j...................... ]he Pi_iI ippine Irlstitote for Devel opmen La} Studies has commissioned 24 baseline studies to provide information to assist in developing policy on health financing re'form. Among these studies is a re,xiew of researEh on th,._cost of providing health services in the Philippines for the period October 1984 September 93. This review seeks to idelltify, critically appraise and summarize available data on the costs of health interventions done in the country. All reports on the data should have been completed during the period October i, 1984 to September 30, 1993. The inclusion criteria are the -following: I. economic evaluakior, .(cost-minimization: cost-effectiveness., cost-utility or _=ost.-benefit analysi's) a.s a primary focus or as a major" compor,enk o-f a bigger study; OR 2. studies that include collection of costs for a hea IUI int_._r'vr_rltionJ.r_LI_e objectJ.ves and/or methodology o'f collecting" costs is _._xplic.il:ly stated. TI-_e study will e;:clude standard " "financial reports of health projects or studies where the cost data and/or its implications on the intervention are riot discussed at all in the report. Part of l:he process of identifying the studies is a mail survey o{ the res_archers in the field of health who are based in Lul kversi ties. Hay we request you to spef_d a few minutes answer.i.r',g the followJ,lg: I. Have you or ar_,/one you know/heard about carried out any of ithe stud.i_.s whit.h can be included i_n the review (see above !_ir'Jcfusion _ ri teria )? _', ._.YES NO 2. If yes, please write the name of the contact person with his address ,.... and telephone numbers: _AME :

Dear

_.,_.I. No.

Fax

No. A copy of the in the review.

Thank you very much .for your cooperation. _port will be sent to anyone contributing a study _.ease send bac:k this sheet as soon as possible. L_..EU Fax # ( 6.:_ ) F_22-32-35 "" "

_i:iec
I_i_a

tfuiIy yours,
L. Tan-Forres, M.I:). , 1"l.Sc.

Annex

LOCAL

REPRESENTATIVES

i. Mr. Harry Abrillo Meralco Foundation 2. Mr. Thomas World Bank Allen

3. Mr. Hirokazu Arai Embassy of Japan 4. Mr. 3ohan Ballegeer Embassy of Belgium 5. Mr_ William M. Fraser Asian DeveDopment Bank 6. Mr. Harle Freeman Greene Embassy of New Zealand

7. Mr. Christopher Gyellenstierna Embassy of Sweden 8. Mr. Stephen Heeny Canadian Embassy

9. Ms. Jannicke Jaeger Royal Norwegian Embassy lO.Mr. Mogens Jonson Royal Danish Embassy It.Ms. The Nicola Jones Ford Foundation

12.Mr. Angelo King Angelo King Foundation, 13.Mr. Keshhab UNICEF Mathima

Inc.

14.Mr. Alao Montgomery British Embassy 15.Dr. Hans Peterstrauch Embassy of Switzerland 16.Mr. Pedro Picornell Andros Soriano Corporation

A;o

Annex

: LIST OF LIBRAR_WITH Bautista 8 Library LETTER SURVEY

i.

Ms, Loretta G. UERMMMC Medical

2.

Ms. Natividad R. Caballero MCU-Filemon D, Tanchoco Medical Ms. Helen M. West Visayas Canizares State University

Foundation

Library

3.

College

of

Medicine

Library

4.

Ms. Consuelo Cariag_ Mindanao State University Ms. Sylvia M, Catalla Remedios T. Romualdez College O_ Medicine de Jesus of the

Library

5,

Medical Library

Foundation

,.

6.

Ms. Sarah University

East

Library

7.

Ms. Catalina Dela Cebu Institute of Ms. Anabella Cebu Doctors'

Riarte Medicine

Medical

Library

B.

T. Diapera College of

Medicine

Medical

Library

9.

Ms. Nida G. Estrella Fatima College of Medicine Violeta Feliciano Colleges Go Tomas

Library

IO,Ms.

Lyceum-Northwestern if.Ms. : Cecilia of S.

Central

Library

Univesity

Sto.

Medical

Library

12,Ms. Emily S. Gumingan Saint Louis University

College

of

Medicine

Library

i3.Ms. Sarah
_ Xavier Library

Belen

D.

Jacalan Dr. Jose P. Rizal College of Medicine

University

14,Mrs,

Rebecca

M.

Jocson Memorial Library

PLM-Celso

A1Carunungan

15,Mr. Rogelio Malilil Ateneo de Manila Rizal

Library

i&.Ms. Susan C. Munoz Virgen Milagros Educational Institute Institute of Medicine Foundation Library

17.Ms.

Felisa

J.

Padere of Medicine Library

Gullas 18.Ms. UP

College

Rosemarie Dil, Sch of

Rosali Economics

19.Ms. Aurora S. Salvador FEU-Dr. Nicanor Reyes 20.Ms. Imelda B. Sinco College Soriano

3r.

Memorial

Medical

Library

Manila 21.Ms.

Doctors P.

Julieta

Angeles 22.Ms. Susan University

University

Foundation

Health

Sciences

Library

A. Tapulado of San Carlo5

Nursing

Library

23.M_. Emiliana L. Vicente DLSU-EACM Library

PHILIPPINE GENERAL HOSPITAL COLLEGEMEOICINE OF UNIVERSITY OFTHE PHILIPPINES MANILA

Dear The Philippine Institute for Developmental Studies has eommisioned 24 baseline studies to provide information to assist in developing policy on health financing reform. Among these studies is a review of research on the cost of providing health services in th'e Philippines for the period October 1984 September 1993. This review seeks to identify, critically appraise and summarize available data on the costs of health interventions done in the country. Part of the process of identifying the studies is a survey of researchers in the field of health. We came across your study entitled " " In connection with this, may we request you to spend a few minutes answering our questionnaire:

i. Who

thought about doing/initiating the research? investigator (personal interest) commissioned by funder on demand by users Others, please specify was/were the sources of funding of the research?

2. What

3. Who were the (specifically evaluation)

people performing this research? the technical part on costingeconomic (send curriculum vitae if possible)

4.

What

were expended on the study? specify amount in pesos at the time of the study time, specify duration of the study (economic evaluation/costing part) in months

resources money,

5. To whom were the results presented to? (check _s many are applicable) academe administraton/funders. beneficiaries Department Of Health international scientific community medical community/ other l,ealtllprofessio_als who implements press Others, please specify

And

how

was this presented? briefings scientific conference Other_, please specify any

_.

letters conventions

6.

Did

it have YES

influence on health policy? NO If yes, please give details

Please mail back this sheet your study as soon as possible. acknouJ edgement will be done.

together with Rest assured

a hard that

COPY of proper :.-

Thank you. very much. . We hope for your favorable , consideratioll of this request. For Shy questions, please fee,l.... free to conl,aet the undersigned at the numbers listed.

Respectfully

yours,..

1'_:_;r_ I,. ']'a_,.Tc, rre_, Tel. II,,:.;._632)!)85526;

It.D., Fax

I'I.Se. Ho.(632.)522:]235

A_.,.>__'_

1,7,- .'_._x,_ ASSESSING

a A SUGGESTED CHECKLIST ECONOMIC EVALUATIONS

FOR

I. Was a weU-defined question posed in answerable form?

$

I. 1 Did the studyexaminebothcosts andeffects theservice(s) of or pro_s)? 1.2 Did thestudyrevolvea comparison alternative.s? of 1.3 Was a viewpoint for the analysis stated and was the study placedin any particular dccislon-maging context? 2. Was a comprehensive description of the competing alternatives given? (i.e., can you tell who? did what? to wh6m? where? and how often?) 2,1 Wereany importantalternatives omitted? 2.2 Was(Should)a do-nothhtg alternative (be)considered? 3..Was there evidence that the programmes' effectiYenesshad been , established? 3.1 Has this been done through a randomized, controlled clinical trial? If not, how strong was the evidence of effectiveness? 4. Were all the important and relevant costs and consequences for each alternative identified? 4, I Was the rmtge w_dcenough for the research question at band? 4,2 Did it cover all relevant viewpoints? (Possible viewpoints include the community or social viewpoint, and those of patients and third party payers. Other viewpoints may also be relevantdepending upon the particularanalysis.) 4.3 Were capital costs, as well as operating costs, included? 5. Were costs and consequences measured accurately in appropriate physical units? (e.g., hours of nursing time, number of physician visits, lost workdays, gained life-years} 5.1 Were any of the identified items omitted from measurement? If so, does this mean that they carried no weight in the subsequent analysis? 5.2 Were there any special circumstances (e.g..joint use of resources) that made measurement difficult? Were these circumstances handled appropriately'.) 6. Were costs and consequences valued credibly? 6,1 Were the sources of all values clearly identified? (Possible sources include market values,patient or client preferences " and views, policy-makers' vi.cwsand health professionals' judgements.) 6.2 Were market values employed forchanges involvingresources gained or depleted? 6.3 Where market values were absent (e.g., volunteer labour),or

o d

market values did not reflect actual values, (such as clinic space donated at a reduced rate), were adjustments made to approximate market values? 6.4 Was the valuation of consequences appropriate for the question posed? (i,e., Has the appropriate type or types of analysis--cost-effectiveness, c0st-benefit, cost-utilitybeen selected?) 7. Were costs and consequences adjusted for differential timing? 7.1 Were costs and consequences which occur in the future 'discounted' to their present values? 7.2 Was any justificat.ion given for the discount rate used? 8. Was an incremental analysis of costs and consequences or alternatives performed? 8_I Writethe additi6nal (incremental) Costs generated by ohe alternative over attother compared to the additional effects, benefits or utilities generated? 9. Was a sensitivity analysis performed? 9.1 Was justification provided for the ranges of values (for key study parameters) employed in the sensitivity analysis? 9.2 Were study results sensitive to changes in the values (v.Sthin the assumed range)? 10. Did the presentation and discussion of study results include all issues of concern to users? I0.1 Were the conclusions of the analysis based on some overall index or ratio of costs to consequences (e.g.,cost-effectiveness ratio)? If so, was the index interpreted intelligentlyor in a mechanistic fashion? 10.2 Were the results compared with those of others who have investigated the same question? 1I.I.3 Did the study discuss the generalizability of ihe results to other settings and patient/client groups? 10.4 Did the study allude to, or take account of, other important factors in the choice or decision under consideration (e.g., distribution of costs and consequences, or relevant ethical issues)? 10.5 Did the study discuss tssues of implementation, such as the feasibility of adopting the 'preferred' programme given existing financial or other constraints, and whether any freed resources could be redeployed to other worthwhile pro_mu'n_?

COSTS I. Orgamz_ng and operating costs within the healtll sector (e.g. health professronals' time. supplies, equipment,

CONSEQUEN I. Changes _n physical, emot:onal funct:oning

CES soc:al, and (effects)

power-..cap_tal

costs)

Direct costs [1. Changes in resource use (benefits)of IIl. Changes _n the quality life of patients and their families (utility)

t[. Costs borne by patients and their families - out-of-pocket expenses - patient and family input into treatment _ - time lost from work } Indirect costs - psych:c costs J

a. for organizing and operating services within the health sector - for the original condition - for unrelated conditions Direct benefits

I1[. Costs borne externally to the health sector, patIents, and their fatalises

b.

relating to activities of patients and their families - savings in expenditure or le:sure time input - savings in lost work 1 j Direct benefits

/_p_t,_],,_-

time

}Indirect

benefits

.. _._

Types

of costs

and

consequences

of

health

services

and

programmes.

_iiiiii!_ iii ili_i_ie_iii_i_s_i_i ! !i i _

Part I1. Development of a Self-Instructional Manual on Cost-Effectiveness Analysis for Local Health Center Physicians.

Prepared by: Tessa L. Tan-Torres, M.D., M.Sc. Aloril 30, 1995

2 ABSTRACT: DEVELOPMENT OF A SELF-INSTRUCTIONAL MANUAL T the ON COST-

EFFECTIVENESS FOR HEALTH CENTER PHYSICIANS. Clinical Epidemiology Unit, University of College of Medicine JUSTIFICATION: The passage of the Local

Tan-Torres, Philippines

Government

Code

of

1990 required devolved local government units to plan, monitor and evaluate services, including health care. For decisionmakers, an assessment of the safety, effectiveness and in addition, efficiency of services to be provided is essential. Expertise the needed in carrying information. out economic evaluations will provide

OBJECTIVE: To develop a self-instructional manual (SIM) on cost-effectiveness analysis for health center physicians METHODS: i. Review and critique of existing manuals on economic evaluations; 2. Development of an SIM; 3. Review of SIM by different experts; health 3. pre-test of SIM on 3 health programs in centers with process documentation; 4.

Revision of SIM based on comments from the experts, feedback from physicians who participated in the pre-test, process documentation report, critical appraisal of the costeffectiveness analysis completed in the pre-test. RESULTS: A total of 8 different manuals on cost-effectiveness analysis perceived were published in the past l0 years. Based on the needs of the target learners, a new manual for selfdeveloped. This was pre-tested by health on 3 different programs: expanded programme family planning and national _tuberculosis

instruction was center physicians on immunization,

control. The cost -effectiveness analyses were completed within 18-28 working man-hours. In terms of quality, the analyses were graded 6-7 out of a possible perfect grade of 9 points. The manual was subsequently revised. RECOMMENDATIONS: The self-instructional manual on costeffectiveness analysis, as pre-tested in urban health centers, was comprehensible and enabled the physicians to undertake analysis on their own. The SIM. must also be pre-tested in the rural areas where the information needed may be difficult to obtain. More importantly, incentives and support must be given for health center physicians to undertake costeffectiveness analysis which will allow for more informe_ decision-making.

3 INTRODUCTION: Assessment The Local of Learning Government Needs: Code of 1990 devolved government

services, including health, to the local government units. With decentralization came an influx of new opportunities together with new responsibilitiesand roles. Among these are the planning, monitoring and evaluation of health services to be provided locally and the allocation of funds in budgets to cover these services. A prerequisite skill to planning and decision-making able to assess the cost-effectiveness of the is being different

services being provided and those being planned on being provided. Since cost-effectiveness data are best generated locally, the physicians will have to learn to carry out economic evaluations to generate data themselves. Criteria for Evaluation of Learning Materials on Economic Evaluations: There are several references available on the methods of economic evaluations. local health center should be: However, physicians. not all may Preferably, be of help for the references

1. readable (visually attractive and utilize non-technical language); 2. self-instructional (for user's independent study done at his or her own pace with built-in feedback to assess progress); 3. adapted and to enable maximum use of of locally costs available and data; of

4. generic to different health Survey of Evaluations: A survey economic published

allow comparison programs. Available

effects

Locally

Learning

Materials

on

Economic

of locally available evaluations revealed in the last i0 years.

references on methods of eight different manuals

The World Health Organization manual on control of diarrheal disease and the Panel of Experts on Enviromental Management for Vector Control manual are specific to programs on control

4 of their laid out target diseases (1,2). Although these manuals are in a self-instructional format, they modify formulae,

offer examples and discuss issues specific to the disease and its interventions. This exclusive focus on the disease implies that the reader will have extrapolate the techniques to other Two its others data are and to take areas. an extra step to

geared more for the academe, very rigorous in analytic requirements and are probably not These are Methods

designed the Data for the

for use at the health center level (3,4). for Decision Making Manual and Drummond's Evaluation. by the Primary the Asia-Near Aid (5,6). for The

Economic manuals

Cost analysis is the main focus of Health CareManagement Advancement East The Bureau of US Agency for PHCMAP manual is designed

Program and Internatonal primarily available.

administrators and where computers are ANEB of USAID is a very detailed presentation of Both manuals, effectiveness. however, do not Although cost

of costing methodology. discuss choice of measures

analysis per se can be used to improve planning and management (7,8) at the health center level, theevaluation function inherent in cost-effectiveness analysis is not emphasized. The WHO and PRICOR have each produced two comprehensive

manuals (9,10) on economic evaluations. These are generic, self-instructional, non-technical in language and intended for use in the health center level. However, because of an attempt to cover extensively the many different programs, the manuals are thick (138 and 94 pages, respectively) and may daunt a beginning reader. There is a need to develop an introductory text for beginners. The PRICOR and WHO manuals may serve as references, when needed. OBJECTIVE OF THE STUDY:

This project was conceived to prepare an introductory text on cost-effectiveness analysis in a self-instructional format for local health center physicians. The focus of the project is on the acquisition data. of skills rather than the actual generation of

5 Assumptions of the Study: The following are assumptions i. There is a need skills in undertaking 2. The economic made in this study: to acquire out an

for health center physicians economic evaluations.

health center physician is capable of carrying evaluation, using a self-instructional manual.

3. The results of a cost-effectiveness analysis useful in deciding which recommendations to make in Ehe efficiencyof a program. 4. The health skills learned future. METHODOLOGY : center physician in this project

will be improving the the

will be able to apply to other programs in

The self-instructional manual (SIM) was developed stages. First, a review of the references on the

in several methods of

economic evaluations in the Primary health care setting was carried out. The first draft of the SIM was produced, attempting to incorporate the strong points and address the weak points uncovered in the review (ii). The SIM was critiqued by a content expert from the University of the Philippines School of Economics and a faculty member on development of self-instructional manuals from the National Teacher Training Center for the Health of the Philippines Manila. Professions, University

Three local health centers were selected to pilot test the SIMs on different programs. These were the Expanded Program on Immunization, the National Tuberculosis Control Program and the Family Planning Program. A questionnaire (Annex I) was provided to the local health center physicians to assess their extent of participation in decision-making and their need for learning about undertaking economic evaluations. With the self-instructional manual (Annex 2), the local health center physician carried out an economic evaluation with minimum of supervision from the project research associate. During the process, they were observed by the research associate who noted any questions they asked and who then provided answers/technical assistance as needed. A written report health on the cost-effectiveness center physicians. They analysis also gave was submitted by feedback on the the

6 process out(see and their plans annex 3) . regarding the study they made carried

The accuracy of the data was verified by the research associate. The submissions were then evaluated using the criteria of Drummond (Axunex 4). The SIM was subsequently revised based on the following: i. comments from the economist and the SIM expert; i. feedback from the health center physicians; 2. process documentation report of the research associate 3. accuracy of the completed reports on cost-effectiveness analysis of the health programs. RESULTS: Pre-SIM Survey: The participating physicians are medical officers IV who come from the Tatalon, Old Balara and Commonwealth health centers. The initial survey showed that the local government code has not radically affected their day-to-day functioning. The physicians expect decisions and policies to emanate from a higher authority and view themselves more as implementors. Current scope of the decisions they make is limited to division of labor, facilitating patient flow, use of CHWs and other similar "small" decisions. They realize the importance of considering costs in making decisions and view many decisions as requiring additional logistic support which, at present, is difficult to obtain (Annex 5). Post-SIM Survey

The physicians carried out the evaluations in 12-20 working man-hours each. This estimate covers only the work done in the health center and excludes the time spent by the project research associate who collected data from the city health department and provided the data (Annex 6) upon request (another 6-8 hours). They were reasonably confident (78-90%) of the accuracy of their results and intended to apply the results in their health centers. The part the physicians found easy to understand was that on the decision whether to carry out a cost-effectiveness analysis. The step-by-step approach also was cited as helpful. What they considered difficult was the technical discussion on costing and they suggested making it simpler, outlining it and providing more examples of the computations.

Brief reviews (annex 7).

or

summaries

in

the

text

were

also

suggested

Observations of the The physicians knew of the problems was and data routinely also what they chose the alternatives to Selection of the

Project Research Associate: the .community very well. Identification easy due to the availability of statistics collected by the health center. This is as the outcome or measure of success for be considered. to be considered wasdifficult.

alternatives

They understood what efficacious, acceptable and feasible meant but the actual search for alternatives to be included in the cost-effectiveness analysis took time. Most of the time was.spent on costing_Although recurrent costs were easy to obtain, considerable amount of time had to be spent on treatment of capital costs, allocation of joint costs (e.g., personnel time) and discounting. The final analysis or putting the costs and effects together in an incremental costeffectiveness ratio was accomplished with ease (Annex 8). Comments from The economist the Experts: suggested that:

I. the different levels of decision-making, e.g. day-to-day, annual and long-term, be detailed so that the contribution of economic evaluations in each level can be clearly delineated; 2. efficiency be added as another criterion in making decisions versus and not simply effectiveness (technical) as the main criterion; 3. a precautionary statement be made that the limitation of the analysis to the perspective of the Department of Health will make it unable to identify phenomenon like shifting of costs when shortening clinic hours; 4. a discussion on the typology of health center activities be included. The SIM expert suggested that: i. more exercises be provided made available for feedback; 2. 3. 4. 5. stated objectives match with some of the annex/tables more examples be given; a few editorial changes with the correct answers being

the content; in the text proper;

be included be made.

8 Critical Appraisal of Cost-EffectivenessAnalysis: The physicians' objective was to improve performance of their respective programs by increasing coverage. Thus, for the two programs on family planning and tuberculosis control, a number of community health volunteers would be trained to substitute for the standard personnel in the health center. For the immunization program, the question was whether to increase from two to three outreach activities in a week. Efficacy was assumed based on current experience; substitution of personnel meant that the quality of work be the same and a week would childrenactivity Costing programs ...... the cost was that addition of one more outreach be able to catch the same as before. on current experience. Thus, i.e. would in of

activity number

based

for

the

two

where CHVs would substitute for of sup@r_is_o n was not identified

standard personnel, and costed. In one CHVs which might Purchase prices

of them, no incentives were provided to the jeopardize the sustainability of the program. were used to value the inputs. Incremental cost-effectiveness analysis was three projects but only one did sensitivity rate varied by 5%). As assumptions were efficacy rates, sensitivity analysis should The incremental acceptor, extra cost-effectiveness P886.50/extra TB ratios patient

carried out by all analysis (efficacy the basis for the have been done.

were extra 12/extra completed treatment

and P486/extra fully immunized child. A major part of the extra costs in the tuberculosis and immunization programmes is due to the additional cost of drugs and vaccines consumed. Not one of the papers did a full discussion of results. It is only in the post SIM interview where the physicians state that they will implement the alternatives, implying that they found the alternatives to be cost-effective or worth paying for to get the extra outcome.

The are

scores based on the application of methodological criteria 6-7 out of a possible score of 9. See tables 1 and 2 for and annexes 9-11 for the full reports of the

summaries projects.

9 DISCUSSION AND RECOMMENDATIONS:

Considering the amount of time spent on conducting the costeffectiveness analysis and the absence of previous experience in conducting these studies, the physicians were able to produce reports which, though simple, are accurate and useful to them. With modification, the self-instructi0nal manual may be improved to enable the learner to acquire the skills by himself. The revised SIM must-be tested on a wider scale, particularly with. the participation may not have as easy access to data compared to the urban doctors. In this project, the physicians of rural physicians who and technical assistance

completed

the projects

because

of externally imposed deadlines and thepersistent follow-up of a research associate. Outside the research setting, it is important to create incentives for the health center physicians to start undertaking these types of studies so that they will fulfil their potential as direct planners for the health of their con_unities. Incentives may include freeing engage in these types of up time efforts, for the physicians to providing technical

assistance as needed, delegating authority and responsibility to make decisions, and disseminating results to other center physicians through newsletters/ communications. Unless these are done, physicians in the health centers will continue relying on national directives to provide guidance for new activities. The ultimate test of success of the SIM is whether new decisions strategies

are being made to offer new services based on cost-effectiveness analysis.

or apply

i0 Acknowledgments The author thanks to :

* the Quezon City Health Department for consenting participate in the study and to provide information; * Drs. Alagano, Castillo, effectiveness analyses; Borreo who conducted the

cost-

* Dr. Arnold Agapito, research site technical assistance;

associate,

for

providing

on-

* Mr. Mario Taguiwalo of the UP School of Economics and Prof. TKP Gailan of UPM National Teachers' Training Center for the Health Professions for reviewing the self-instructional manual; and * the Philippine funding the study. ns51nune _or DeveLopment . Studies for

ii

References:
i. Phillips Costs M, Shepard D, Lerman S and Cash R. Estimating

for Cost-Effectiveness Analysis: Guidelines for Managers of Diarrheal Disease Control Programmes. Geneva, World Health Organization, 1985. 2. Phillips M, Mills A and Dye C. Guidelines for Cost Effectiveness Analysis of Vector Control. Geneva. WHO PEEM Secretariat, 1993. 3. Brenzel L and the Data for Decision Making Project Harvard School of Public Health. Application of Cost-effectiveness Analysis to Decision-Making in the Health Sector of Developing Countries. Draft, January, 1993. 4. Drummond M, Stoddart G and Torrance G. Methods for the Economic Evaluation of Hea_th Care Programs. Oxford. Oxford Medical Publications, 1986. 5. Reynolds J. Cost Analysis (module 8, user's guide), The Primary Health Care Management Advancement Programme Series. Washington DC. The Aga Kahn Foundation. 1993. 6. Asia Near East Bureau USAID. ANE Bureau Guidance for Costing of Health Service Delivery Projects 1990. 7. Berman P. Cost Analysis as a Management Tool For Improving The Efficiency of Primary Care: Some Examples from Java. International Journal of Health Planning and Management 1986;1:275-288. 8. Thomason J. Use of Cost Analysis to Improve Health Planning and Managment in Papua New Guinea. pp. 119-126. 9. Reynolds J and Gaspari KC. Operations Research Methods:Cost-Effectiveness Analysis (Pricor Monograph Series No.2). Maryland USA. Primary Health Care Operations Research. 1985. i0. Creese A and Parker D (ed.) (1990) Cost Analysis in Primary Health Care: A Training Manual for Programme Managers. Unpublished document WHO/SHS/NHP/90.5. ii. Gailan TKP. How to Write Self-Instructional Materials. Manila. National Professions 1989. Teacher Training Center for the Health

17_ _'i_,_ _.. Descripl_onf Cost-Effectiveness o Analyses FamilyPlanning Perspective Altematfves DOH 1. 6 community health volunteerso be trained t as POPCOM-FP coordinator 2x/wk 2. Standard'. idwife m as POPCOM-FP coordinator x/wk 2 Tuberculosis DOH 1. communityealth h volunteers tomonitor patientsat 1:8 CHV:patlent ratio 2. standard: defaulters visited homebyreed at tachsandlabaides Immunization DoH 1. 3x/week outzeachctivity a 2. 2xlweek out_'each activity

ResearchDesign Outcomes " Ide.ntJ.lyosts c " MeasureCosts ...:.

assumed 25% acceptance assumed 100%efficacy assumed1 FiC per rate for.bothaitema_es 100ImmunlzzCions # newacceptors patients whocomplete treatment. basedonresource use andexpertopinion basedonresource use andexpertopinion purchase price

fullyimmunized child.

based on resource use and expertoplnlo n basedon resource use andexpertopinion purchase price

basedon resource u., andexpert opinion basedonresource us andexpertopinion purchase price

ValueCosts

DiscounUng

none

none

none

_ensltivtty Analysis IncrementalAnalysis Results

none yes ExbaP12/exbaacceptor

on efficacyrate yes ExtraP886.50/exba patientcompleted treatment

,none yes ExtraP4861extra FIC

13

"-k_._ "7.-, SUMMARYOF STUDIES BASEDON METHODOLOGICSTANDARDS l FamilyPlanning. Tuberculosis ontrol C Expanded Progran onImmunization

CLEARLY DEFINED QUESTION COMPREHENSIVE DESCRIPTION OF ALTERNATIVES EFFECTIVENESS ESTABLISHED RELEVANTCOSTS IDENTIFIED COSTS APPRO"PR_TELY MEASURED COSTS VALUED CREDIBLY DISCOUNTING INCREMENTAL ANALYSIS SENSITMTY ANALYSIS DISCUSSIONAND " RECOMMENDATION

..X

TOTAL

6.

SIM Project Annex Center Physicians

l: Start

of Project

Questionnaire

for Health

i. Under the local government differences in the way the health do you expect any difference?

code, do you observe any center operates? If none,

2. Let's look specifically the health center level. A What examples

at planning

and decision-making do you do?

at Give

types of decision-making as needed.

or planning

B If there are changes that you wish to institute in the services being provided by the local health center, at what level are these changes decided - health center or city health department or central Department of health level?

C. What kind of information to the decision-maker?

do you

need

to study

and present

D.

What

do you

know

about

cost-effectiveness

analysis?

E. Do you anticipate any economic evaluation with manual? If yes, please

difficulties if you carried out an the aid of a self-instructional the anticipated difficulties.

list

Thank

you

very

much.

Name/Date

i#

AN_ 5 End of Project i. and Overall, analyzing

Questionnaire how the much data, time doing

for did

Health you

Center in

Physicians carrying out the

spend the

economic

evaluation

(including

reading the

manual,

collecting

write-up)?

2.

From

a scale of your

of

0-100%,

how

confident

do

you

feel

about

the

accuracy

economic

evaluation?

3.

What

do

you

intend

to

do

with

your

coSt-effectiveness

analysis?

4. SIM?

What

part/s

did

you

find

difficult

to

understand

in

the

5.

What

part/s

did

you

find

easy

to

understand

in

the

SIM?

6.

How

can

we

revise

the

SIM

to

be

better

able

to

serve

you?

Name/Date

/_tA/kX,/-/

.q

A SUGGESTED CHECKLIST A3SESSING ECONOMIC EVALUATIONS

FOR

1, Was a well-defined question posed in answerable form?

| .

1.I Did the study examine both costs and effects of tile service(s) or programme(s)? i .2 Did the study involve a comparison of alternatives? 1.3 Was a viewpoint for the analysis stated and was the study placed in any particular decision-making context? 2. Was a comprehensive description of the competing alternatives given? (i,e., can you tell who? did what? to whdm?where? and how often?) 2. I Were any important alternatives omitted? 2.2 Was (Should) a do-nothhlg alternative (be) considered? 3, Was there evidence that tile programmes' effectiveness had been established? 3.1 Has this been done through a randomized,controlled clinical trial? If not, how strong was the evidence ol'effectiveness? 4. Were all the important and relevant costs and co,?scquencesfor each alternative identified? 4.1 Was the range wide enough for the research question at h,md? 4.2 Did it cover all relevant viewpoints? (Possible viev.polnts include the community or social viewpoim, and those of patients and third party payers. Other viewpoints may also be relevant depending upon the p_rticular analysis.) 4.3 Were capital costs, as well as operating costs, included? 5. Were costs and coasequences measured accm-Jtelyin appropriate physical units? (e.g., hours of nursing time, number of physic|an visits, lost workdays, gained life-years} 5. I Were any of the identified items omitted from me:,sureme,t? If.so, does this mean that they carried m) wcightin the subsequent,'malysi._? 5.2 Were there any special circumstances(e.g.,j,i.t u_e ,f resources) that made measurement difficult? Were these circumstances handled appropriately? 6. Were costs attd consequences valued credibly? 6.1 Were the sources of all values clearly idcntilicd? (Possible sources include market values, palicnl or client preferences and views, policy-makers' vi.ewsand heahh professionals" judgements.) 6.2 Were market values employed h_roh;ragesinvolvingrcst_ulccs gained ,r depleted? 6.3 Where market values were absent (e.g..vohmtecr lalx,lj 1,ot

\_t

HF

,X-_.,c. ,_,,xz,,,_ _

E_

e_,.,.,_-,__.,, 0 _,._.r._ 6 _,.,,<.p,_c_.,z_.. I

IT.

market values did not renct actual v',ducs,(such as clinic space donated at a reduced rate), were adjuslmcrusmade to _rpproxintate market values? 6.4 Was tile v._luation of consequences appropriate for dee question posed? (i.e,. Has the appropriate type or types of analysis--cost-effectiveness, cost-benefit, cost-utilitybeen selected?) 7. Were costs and consequences adjusted for differential tinting? 7.1 Were costs and consequences which occur in the future 'discounted' to their present values? 7.2 Was any justification given for die discount rate used? 8. Was an incremental analysis of cos(s and consequences natives performed? of alter-

8.1 Were the additional (incl:emcntal) costs generated b)' one alternative over another compared to the additiona} clfccts, benefits or utilities generated? : 9. Was a sensitivity attalysis performed?

9.1 Was justification provided for the ranges of values (for key study parameters) employed in the sensitivity analysis? 9.2 Were study results sensitive to changes in the values (within the assumed range)? 10. Did tire presentation and discussion issues uf concern to users? of sludy results include all

1O.I Were the conclusions tff the analysis based rm some overall index or ratio of costs to consequences (e.g., cost-effectiveness ratio)'? If so, was the index interpreted intelligently or in a mechanistic fashion7 I(I.2 Were the results compared with those of others who have investigated the same question? 10.3 Did the study discuss the gcneralizability of the results to other settings and patient/client groups? 10.4 Did the study allude to, or take account of, other important factors in the choice or decision under consideration (e.g., distribution ethical i "]es)? of costs and consequences, or relevant

10.5 Did tire study discuss issues of implementation, such as the feasibility of adopting the 'preferred' programme given existing financial or olher constraints, and whether any freed resources could be redeployed 'to other worthwhile programmes?

12

Anne>,' 5 :

PRE-SIM

SURVEY

FOR

LOCAL

HEALTH

CENTER

PHYSICIANS

i.

Under the Local Government difference/s in the way the dQ you expect any difference? RESPONSE A :

Code, do health center

you observe operates? If

an nonc_

So far, only "perceived" changes are felt., though as -former MHI] under DOH (National) to OCHI) then under MMC_ observed a great difference in the implementation of services e.g. training for new programs takes almost two years or as mucl as four year s (from DOH to MMC to OCHD to NC) to take effects-a. programs and training have-to pass througl_ others (for training_ too) before they can come down to us. Thus., provinces are. fat ._ore advanced in implemenlation than cities are. I perceived the same thing happening as all program_ have to pass the local gov' t. from which has no previous background in Health and Health Care Delivery. They will have tc _rakn first. Allocation of funds may be a subject of dispute. Non-political alignment between mayors and CHO's may become a problem. Add to thi_, "political appointees" who are non-civil services. And consequently delivery o services may be affected RESPONSE B : There were rio differences in the programs and of course, we have achieved gains most especially in EPI, NTP, and leprosy. The only difference now is in logistics since funding is devolved now to local government. Health workers, most especially in the rural areas, don't receive their stipends on time and some of their compensation have not been given yet. RESPONSE C : I am not in a good position to answer this. as I joined the Health Department after passage of the devolution _ law. My team mates, however, agree that there hardly has been any change. Maybe An the "future, there will be differences An the way health centers operate, depending on the policies and priorities of the local government.

2.

Let's look specifically the health center level.

at

planning

and

decision-making

at

a.

What type of decision-making/planning [ Please give eramples. ' A :

do

you

do?

RESPONSE

Center (short-term) Action Accomplishments for each no say as to how-much, as Decision-making at the l,ealth work due to so center many

Health

planning is confined to a one-year Plan fop Targets and Expected year based on population. Persdnnel has percentages are: already dictated. is confined to "small decisions" made patients, compartmentalizing is not done in other health of as dai!y these

e.g. flow of patients (vJhich

centers), use of Community _.Jorl(l'oads etc., etc. No

health volunteers and sharing shattering, landmark, decisions

are '_'pre,made" from up to down, though V Je can only recommend after stating problems of importance. Whether these affects final decisions Xrom up., is rarely 'felt. Strategies may, of course, be purely our owr_j as iar as proper implementation F_EsF'ONSE B : may go.

For e;:ample_ I just encountered a diarrhea outbreak in my area. I went to verify the presence of epidemic, diagnose the health of the community and give health ectucation. I reported to the OC Health Department and the epidemiologist came in to help
LIS.

F_ESPONSE 1. 2. 3.

: barangay officials. to UHNP personnel. among personnel.

'Coordination with Giving assignments Division of labor

0

b. If there are changes that you wish to institute in the services being provided by the health center, how are these changes decided health center or city health office or central DOH level? RESPONSE center A : it : I am only one month old in the City Health I'm in the process Of adjustments - I have not. on the services we rendered. But as I observe in I would' like that the nutrition program . be l.y the food supply and I saw a second degree malnourished. There was the micronutrients malnourished child nogain of weight can't just be made outright _oncerns policies_ rules and at the health regulations.

Changes, level when RESPONSE B

Since Department and made any changes the community

prioritized especial that we are giving. become third degree inspire of feeding.

RESPONSE Health

: decided at the city health can Only propose changes. office'level.

Changes are center personnel

c. What. kind Of information make these decisions? RESPONSE great! from UP A :

do

you

need

to

studyTpresent

to

"Great changes" can only be proposed UP. If accepted, But when it will become "final" is thequestion. Policies center maybe based on our experiences and findings. B : thru

RESPONSE It's

papers

after

establishing

the'facts.

RESPONSE C : Basically, we need to look alternatives, benefits and advantages

at the eTf'ect of vs. disadvantages.

diTTerent

d.

What

about

costs?

Do If yes,

you how

need do

to know you go

ho_J about

much

the_

changes _.Jill cost? the (:osts? RESPONSE A About of everythingwould like to equipments : costing, from have, paper like

getting

yes,

we

are

interested

to

know

the'cost we of

to medicines, to whatever changes additional personnel, modernization _rom materials in

etc., can In costing,

the gov't. "afford them? _Je get the smallest detail cotton buds is used per day, per month,

to personnel, (ho_J many and then summarize cost, RESPONSE money, logistic B :

per patient total/year.

EPI)

Any program you would like to implement may involve and we have to determine needs and requirements for support and present this to the national level.

RESPONSE It

C : is also

important

to

consider

the

costs

of

the

proposed _l_anges/projec_ts be apprc, ved due to es_imat._,._d by canvassing needed

since even excellent projects may not budget I imitations. Costs are usual Iy and summing up _he costs of all resour(__es

e.

What

difTiculties A :

do

you

anticipate?

RESPONSE get them,

No funds available, or when prices are already B :

it takes higher.

several

years

before

we

RESPONSE priority and

First, financial - programs like these would require allocations of budgeting resources. Second, manpower - we need adequate manpower in health health-related sectors in order to implement this program. RESPONSE C : items may may not be be hard readily to cost. available. Information on prices

of

Some commodities

2_

Annex

6:

QUEZON

CITY

HEALTH

DEPARTMENT

COSTS

Number of District 1 2 2a 3 4 Total

Health

Districts # of

in Quezon City: health centers 13 8 Ii 9 i0

health

centers

51

Number Type Doctors Nurses Midwives Dentists Nursing Dental Utility Med

of

Personnel # 92 66 98 52

in

QCHD:

# Personnel/health Type Doctor Nurse Midwife Dentist Nursing Dental Utility Med Aide Aide Aide 1 (i) (i) (i) # 1 1

center

Salarymonth* P7 308 P6 P5 P6 P3 P3 P3 P6 024 0"20 275 263 263 012 024

Aide Aide Aide

9 25 54

Technologist

Technologist(l)

Data

Sources:

Dr.

Domingo,

Chief

for

Field

Operations for Administrative

Atty.AlexAbila, Department.

Chief

* Excluding Carta.

13

month

pay,

additional

benefits

under

Magna

Training: for QCHD, almost all Rent training for other seminars venue is are held at Bernardo Health Center. P400-500/day.

Expenditures: P120 P 80 P200 Data - food (lunch, 2 snacks) registration per trainee Training per day QCHD

- materials, - total Source:

expenses Dr.

Novera,

Officer,

Supplies: Expanded Vaccines BCG DPT OPV Measles Hep B Tetanus

Programme on Immunization Cost/vial Doses/vial P172.80 20 P 28.50 i0 P 17.20 10 P 56.20 i0 P432.00 Toxoid P552.00 I0 20

Cost/Dose P8.64 P2.85 PI.72 P5.62 P43.20 P27.60

Family Planning Condoms - P61.44/box

of i00 = P0.60/condom

Oral Contraceptive Pills - P6.84/cycle Intra-uterine Device - P48.38/IUD Tuberculosis Medicine INH 300 mg Rifampicin Ethambutol Control Cost/tab P3.24 450 mg P44.00 300 mg P2900 400 mg P38.70 by DOH

Pyrazinamide not provided SCC Kit - P39.00 Other Item Supplies:

P Cost/Unit of 72 of i0 23.72/glove 3.12/slide 33.10/bot 233.28/tube 0.40/pledger 100.80/tin 1029.60/gai 82.36/roi1 4.75/gauze pad 63.35/unit 108/piece 172/bot 230.40/gai

Gloves at P284/doz Glass slides at P224/box Vaginal antiseptic Lubricants Cotton Pledgers Fixatives Povidone Iodine Cotton roll

at P331.20/box

at P39.60/box

of i0

Gauze pads at P237.60/box of 50 Pregnancy test kit at P633.60/box of I0 Basal Body Temperature thermometer Albothyl Rubbing alcohol Data Source: Dr. Domingo, QCHD Field

Operations

Infrastructure: Cost of ii,000. Construction per m2 of a health center is PI0,000-

Health Center Balara Tatalon Commonwealth Data Source: Section, QC Hall

Area (m2) i18.32 140 48 (housed within-the Engr. Corpuz, Engineering

barangay Dept.,

center) Planning

Anne::_.. Physicians

End

of

Project

questionnaire

for

Health

Center b

I. Overall, how much time did economic evaluation( including

i

you spend in carrying out the reading the manual, collecting write-up?

and

analyzing BALARA: C'WEAL]H: TATALON:

the 20

data,

doing

the

HOURS 2 of hours 14 daily for more than i week

about Total

hours

2. From accuracy BALARA: C' WEALTH: TATALON:

a scale of your 90% 78% 85%

of 0-100% economic

how confident evaluation?

do

you

feel

about

the

3. What analysis? BALARA: witl_ the C'WEALTH: TATALON:

do

you

intend

to

do

with

your

cost-effectiveness

We will community We Apply can it

use it health test in it the

in our communEty. I have already volunteers to discuss my proposal. in our barangay. center-.

met

health

4.

What

parts

did

you of once

find

difficult

to

understand

in

the

SIM?

BALARA: The details but wher_ tried even C'WEALTH: TATALON: The costing

the costing were hard to grasp at were reasonably easy to understand. _as most of difficult. the alternatives

first

part

Determine

the

effects

5.

What

parts

did

you

find

easy

to Dr

understand
,.

in

the

SIM?

BALARA: analysis; C'WEALTH: easy.

Deciding whether to do choosing alternative._, The other steps aside

not to do a cost effectiveness the step-by-step approach the costing were relatively

from

TA]ALON: Decision be underLiaken. 6. HOw can we revise

whether

a cost

effectiveness

analysis

should

the

SIM

to

able

to serve

you?

.BALARA: outlined summaries

I'f yoLt can simplify it further; m.aybe by making it more and by giving e:,,amples of the computations, reviews or in the text. Include some appendices in text. {or it the as a

C'WEALTH: Honestly., I did nok, spend much quality time SIM. I don't thi_,k l'min a good position to ev'aluate _J Ie. ho TATALON: blore e>'amples may help special]y in the

romputations,

AN_.OBSERVATIONS BY HEALTH

ON THE PERFORMANCE CENTER PERSONNEL

OF

AND

ON

THE

ANALYSES

DONE

Step

l."Decide whether be undertaken. This aware

or "

not

a cost-effective

analysis

should

step was easy for all of problems in their

3 respondents health Centers

as they were which need

much attention. Efficiency (less input, more output) was always considered; hence, this portion seemed to have aroused interest in the manual among the respondents. Step 2. "Determine alternatives ..."

Understanding the guidelines for choosing alternative w_s e_Lsy for the respondents. The words efficacious, feasible, and acceptable are very popular among public health care deliverer-s. The difficulty is in their actual search for alternatives _Jhici_ would fit these descriptions and for combinations of alternatives which _,Jou]d need/ fit a cost-effectiveness analysis. Much tme was spent on this step. One respondent initially had alternatives which seemed efficacious but were very expensive to be feasible nor acceptable to higher _fficials. Another respondent had alternatives which would fi_ a cost minimization study (same effects but c_ne obviously needed more input). Step 3."Determine the main outcome ..."

No problem was encountered in this step as it was clear to all respondents which statistics need improvement. Alternatives offered by each respondent had a Common and easily measurable outcome sought. Step 4."Identify, measure and value inputs."

This is probably the most difficult portion as most time was spent on this. Detailed identification o_ inputs itself is time-consuming and requires one to be meticulous, imaginative and thorough. All respondents initially were at a loss on how and where to start identification approach in of steps on of inputs alone. The step-by-step this portion and the example iden_ificatlon _age i2 helped them get going.

Determining the costs of inputs was more difficult for everybody. Recurrent inputs were easy to cost (except personnel). Costing capital inputs was quite a puzzle for- all. One respondent did not attempt to read.the portion more than once and instead opted to wait for his appointment with the oberver whom he asked for

explanations

ano

examples.

Hnnualization

and

discounting were initially vague but were easily understood with examples. Personnel costing w_also a common waterloo; e.g. costs were not in proportion to the time spent by health persondel for a certain activity. At least 2 respondents also asked for differentiation between building and building operating cost and the like. Step 5.'Data analysis" SignifiCance was analysis" needed eaily understood. minimal clarification.

ICER and its "Sensitivity

As a whole, the respondents' pre-occupation with other concerns probably also affected their performances. One respondent was almost always unavailable and hence ran out of time to complete the analysis unhurriedly. All three concentrated on the main text only and admittedly did not bother to read meticulously the several pages of appendices. The respondents also felt they needed more time to come up with better quality analyses.

ARNOLD V. Research

AGAPITO, M.D. Assistant

Project

Title:

"ALI'ERNATIVE'PERSONNEL

FOR

FAMILY

PLANNING

COUNSELLING"

PROPONENT

Old Balara Health Center, Tandang Diliman, Quezon City clo Josephine N. Borreo, M.D. Medical Officer IV - PIC

Sora,

OBJECTIVE system by supervision.

To complement developing health

existing family workers through

planning training

delivery and proper

.PROBLEMS

IDENTIFIED : i.

: Very low family planning acceptors. (Only 8 for first 6 months of 1994) mostly results of oneon-one counselling vs. mass edutation. Poor "family planninq counsellor ratio to potential targetted users. ( Only 1 POPCOM personnel for 38,000people of which 15% are women in the reproductive age.) Poor recording system for evaluation acceptors (new and continuing) both at health center and outreach outlets. t workers which of the

GENERAL

'_

3.

PARTICULAR

SUB-PROBLEMS : . i. Lack of FP room or space for POPCOM the health center or in sub-station conducive 2. Lack other to counselling for sessions. keeping

in are

of record books information.

.statistics

and

3.

Lack of volunteers

incentives _or BSPOS/community to sustain their interest.

Not

health even

a _ack of rice on Christma_ , nor transportation allowance for better mobility. Lack of uniforms, even just a t-shirt or blazer to identify themselves in the community for recognition and respect by their neighbors.

3o

ALTERNATIVES

OFF_RED

I. Recruit 6 community health volunteers (CHV's) who will undergo a FP seminar workshop. Each CHV will act as the POPCOM-FP personnel/coordinator in each of the 6 areas of Old Balara. This will result in a ratio of i CHV: 950 women in child-bearing age. If each CHV is able to counsel to 8 clients per day and uses 2 days of the week for FP alone, the 6 FP's will be able to counsel to 4,6U8 clients or 8i%of the 5,700 target clients in i year. Advantage Disadvantage : _ more personnel/counselors little training, for 6 people

: cost of trainidg, needs incentives/al iowances already in the areas 1 midwife activities

conduct of Old

2. Employ FP outreach Balara. Advantage

who will help in the FP program and 2 i.: _eekly in the different areas

1o_er training

personnel (i f any)

cost, in FP

needs

little

Disadvar,l-age

: less number of f cached; mid_Jife_ {: ommur_ i ty

target populati,:_n not a resident of the

EX[:'ECTE))

E"FFEf]TS >

OF

;'FIE AI_.TEI'_I"IATIVES:

In, teased FP Acc.eptors --> high p_.rcentage or continuing In the past 3 years, an average _:liec_ts c.ounselled (one-on-one) to become cnr,tir,,_ir, users, g very few target clients educa t.i.or_ campaigns were mohivated to p Iann ing. } Assuming c:an Be reached 25% E_ficacy CHV's will Rate become i.,150 of acceptors.

users of about 35% of acceptor-s and who attend mass" practice family

the

4_600

that

by

> Our POPCOM personnel counsel ls to an average of 12 clients per" day for the past 3 years. If she uses a total of 2 days of the week for FP., she will counsell to 1,150 in a year., 288 of whom will probably be acceptors. NOTE : Outreach activities are usually done _or i/2 day at a time.

31
INPUTS : For CHV's., steps are : QCHD has prepared

j.. Preparation o_ lesson plan (Note: lesson plans For different ropiest) 2. 3. Preparation of visual aids.

Training of CHV's includes, different kinds of advantages and disadvantages proper ways psychology, bel-iefs and recording of of

FP

methods.,

their

of counselling: includes a touch respect on individual religions., preferences reporting materi_Is counselling materials ": I year and actual

of

and

,l. Production 5. 6. Delivery Pr-ovi_ions

teaching FP

actual

"for recording

7. For

Moni_oring- POPCOM outreach steps ar'e :

midwife

i. f:'lanr_inc]and c_fficials. 2. F,rotnot.ior_of

schedulir,tl

act.ivi.ty _aitl_ barangay

activity

.:._,. OuLr'each 4. Recording

act:ivLy and moni'Loring the results.

STEPS

FOR PHASE

CHV's I.

DIRECT

COSTS/INPLITS

l.Preparation of lesson and visual aids/tieaching materials,

plan

Trainer 'Teaching materials manila paper hand-outs pentel pens 6 ballpens noteboDks

2. Intensive workshop for

training 6 CHV's

seminar

Trainer and trainees: honoraria projector rent for venue x 2 days snacks and lunch certificates (6) blazers and t-shirts

PHASE

I I. record visual books aids

i. Provision of teaching materials and recording materials. 2. Actual FP counselling

trained CHV's; al lop,antes/incentives

STEPS

FORPOPCOM

OUTREACH

I.

Planning

and

scheduling

FP personnel transportation and allowances (very minimal., if any) teaching materials leaflets and posters

2. 3.

Promotion Outreach

of

activity

activity

FP personnel visual aids FP materials record books

4.. Recording

3_
PHASE INF'UTS : Recurrents Personnel : CHV" s training/meals P200 x 6 = PI.,2c)O. O0 honoraria PlOOlday >, 2 days ,,' = PI,2(!O.O0 6 trainers honoraria PSOO/day >; 2 days ;: 2 -- P2,000.00 driver P100 x 2 = P200.00 I. TRAINING COST :

Supplies

notebooks, pente ! pens whiteboard 2 red, ball point

P6.25 P40.50 2 pens black 6 P2.55

>' 6 = P37.50 x 4 = P162.00

pens,

x 6 = P15,30

bond papers i r im ye i low pad i pad manila stapler staple paste, paper: _i wires 2 tubes 20 i0

P 53.00

PI6.50 P2.25 P36.75 P4.25 P2.00 P120.00 x i0 = P22.50

ce_tificates: Equipment cost Building cos t Vehicle cost operating

operating

venue

rental

P400

_' 2 'days = P800.00 _or 2" days

operating

fuel vehic

o'I'rented le

PI00.00

Capital : Building Vehicle Eq u i pmen t PHASE Personnel If. FP

_ all rented "

,.

I
PI.,O00.00 x 6 x 12 mos = P72,C)00 since only 2 days in a week are for FP and the rest for other activities P28,800 6 x P25 = PISO 6 xPi6.75=Pi00.50 12 xP2.25 = P27 P200 >'6 =.PI200 .... P50 x 6 = 300

COUNSELLING CHV's Allowances

Supplies Pentel Pens Record Books Manila Paper Blazers,6 (sleeveless) T-Shirts (6) (6) (12)

Building cost vehicle cost equipmen costs capital

operating operating L operating costs Total Cost P36.,547

F'OF'COM OUTREACI-I FF' Counsel I ing Midwife & F'opcom salary of PSO2U >: 12 = P6_].,240 since only a total of _ days used for FP promotion P24 ._ 90 0 uniform allowance P I., 000 Supplies Manila Pentel Record Paper --: 2 Pens ;,' 2 Books ;' 6 P4.50 F'50.00 PIOU.50

F'ersonnel

S
Building cost Vehicle cost Equipment cost CAP ITAL : Building Equipmen Vehicle TOTAL t operating

operating

tricycle fare D__

transport

P200.O(i

operating

---OF TRAINING ALTERNATIVE

P25,451 CHV'S VS. by MIDWIFE ALONE They are

ADVANTAGES I.

always 2. congress

Better one-on-one counselling ratio in contact with their neighbors/targets. Salaries enact a not subject law similar

CHV's.

to increases within to that of "housemaid later act "as train their

5 years law".

unless

3. Those trained intensively can "Re-echo" seminars or can informally companions 4. Unit. P36,547 1152 Data ICER Analysis: = P36,547 1152 - 25.,541 = - 228 924 in the cost community. CHV's vs.

trainors in "alalays"

or

unit

cost of P25,451 2BB

Popcorn =

alone

= P32

per. acceptor w_n

P88 per acceptOr

II_096 = PI2 extra cost paid to achieve el.: tra effect

Intangibles : Reverberation to own home area will be FP arid t_erP, for-e train

the communities - CHB's working .in their indirectly influencing their neighbors on r_w community FP counsellors.

3_

A_W_ Ib Tatalon Health Dr. Castillo. Medical Officer-in-

Center Charge

Problem

Identified:

Low percent treatment.

of

patients

who

complete

anti-TB

1993

data:

Total enrolled to total wllo completed "Drop-out rate

SCC course treatment

133 = 81 = 52

(61%) (39%) and education physical exam

on

Problem imp6rtance

is probably dLie to lack of of completion of treatment,

motivation periodic

and sputum exam. Poverty hence be Iost to follow-up. their medicines to be able family. Supply of medicines Objective:

also causes some to be dislocated, Others are forced to sell some of to buy food and other needs for the are also sometimes delayed. of patients who

To increase the number and percentage would complete treatment course

Main

Outcome:

LO_b,J_

_l.Ll._

_-X_.,_

Alternatives: i. Home visits by med. techs and lab aides. This has done for one year now. REcords are checked and defaulters are visited by health personnel. Disadvantage: Some patientsbecome depend more on home lazier visits. and been

2.

Sixteen (16) CHVs to monitor patients personally and ensure compliance. Target enrollees for 1994 is 128. Each CHV would have 8 patients to monitor in a year, until their completion of treatment and conversion of sputum exam to negative.

Steps Home visit by Health i. Review of 2. Home Center records persoonel per week >: 4 = 60 monthly (same patients); 120 patients yeaKly

visits -i5

3. CHV Home i. 2. 3.

Monitoring Visit Training of CHVs on TB education and Assignment of patients to CHVs Actual home visitation and monitoring - B clients per CHV per year monitoring

3_

INPUTS Health Center Personne ! Personnel

_ : _
!

F Records

U :

0
I

N :

S Monitorinc.

Visits

',

Med.

]ech

', ', ', :

!

Med.

Tech.

',Lab.Aide _ Med. ', ' I ', ',12 hours ', ,

, --I

and Tech

Supplies book EquiP. O.C.

Drugs

Record

,
', ; _ _
i __ !

Building O.C. of health center Vehicle Building O.C. T r a n

clse

s p o
!

i I o w a n'c

e use

',

',12 hours

of
heal th center

:
',
| I

',
',
! I

Vehicle Equipment

,,
',
I I

....:_.
',
u! i

COST Personnel Supplies Equipment Vehicle Building Eq u i pmen t Building Vehicle Total Cost 116,502 O.C. O.C. O.C. F'

BREAKDOWN

FOR

HOME

VISITS

2,_27 .60 . 112,336.00 c

i,152.00 84.25

702.12

INPUTS CHVs Personnel

_ Training CHVs

S Monitoring CHVs Med. Tech.

Visits CHVs

Honoraria

Supplies

Training terials O.C. D.C. O'.C. T r a

Ma-

Drug

ReCord book 'Notebooks

Equip. Building Vehicle Building

Electricity n s p o _ A I i o w a n c e _ Health Center

COST Personnel

BREAKDOWN

FOR

CHVs P i, 600.00 5 L_0.0 u g 5'.2. _._._ 150.0_] L19,808.00 1"76.00

CHVs S p e a ke r Med, _ec [_. Iraining 0rugs Record books/ notebooks

Supplies

Equipment Vehic le

O.C. 0 -C. 0.C. 384. _:;0 56.00

Building Equipment Bui Iding Vehicle"

468. O0

l-__ob. Cost aI

123,594.

Incremental

Cost

Effective

Ratio

(ICER)

123_594 128

116,502 = P 886.50/extra 120 patient treatment completed

3ensitivity

Analysis Assuming P only 123_594 122 95% efficacy P of alternative A

i16_502 = 120 P 3_546

lost

per

completely A. B.

treated P P

patient / 120 / 128 = = P 971 P 966

i16.,502 i23,594

A_klex Brgy.

rl Quezon Charge City

Commonwealth, Dr. Ruth Alagano Officer-in-

Medical

Problem i. 2.

Identified EPI Fully Defaulters: per year Immunized child (FIC) of about 94% of drop-outs of about 6% on an average Over the past 3 years. target of i36

Commonwealth is a relativ'ly large barangay subdivided into areas. There is only one health center serving it, and this health center is considered inaccessible by several inhabitants or at least hardly accessible.

Objective: Main Outcome:

Toe increase FICs

the

FICs

in

a year

AIternatives: I. Additional outreach activities - increasing the hum'bet of outreach activities from 2 to 3 per week to be able to immunize more clients and hopefully include potential defaulters. Fifty clients per day (average) would result in 2400 immunizations pedr year and approximately 240 more FICs for the year (usual ratio of i FIC per i0 immunizations done). Advantage: Disadvantage: Higher absolute no. of E,xpensive_ does not rate FICs address

drop-out

2.

Stick to the usual 2 outreach activities per week. Five CHVs can take care of the job of following up drop out. Some i40 drop-outs per year (actual rate 236) is equivalent t'o Ii-12 per month. Records can be chec.ked and meetings can be held monthly with the 5 CHVs, each of whom can visit 2-3 drop outs monthly and inform them of immunization schedules (homebase and outr'each). Advantage: Disadvantage Inexpensive; addresses - Lower absolute no. drop-outs of FICs gained

Steps Out reach 1.. Coordinatinn with bar.angay officials leaders regarding additional outreach (Done during the usual 2 outreaches.) Coordination with QCHD for additional (vaccines, etc.) Promotion of additional outreach Actual outreach Recordin, g and monitoring results and area schedule supplies

2. 3. 4. 5. CHV

Follow-up i. 2. 3. Monthly meeting with Home visits conducted Monitoring of results CHVs by CHVs,

INPUTS OUTREACH

:
P !

F
, I

N
_l I

T Promo

I
I !

N
I |

',
; ! t

Brgy.

QCHD I g_ee-_n -', m %i

i

I OutreachlMonitoring i ' 'I I MD I Nurse I '; Nrs m Aide' ; ' Midwife_ !

I _

personnel

_ '! l , I
l ! a ,

MD

MD

I Health 'Personnell t ' | ' ,

l __

Nurse

Supplies

: , m
I

,
l l ! !

' 3 'A ! ' 2 '' I

p

Manilal Paper Pentel Pens

Vaccinesl Alcohol Syringesl Cotton

Ice

N'book I I
' |

Equip. ting Vehicle

operacost D.C.

: 1
| I

1 1
I

Electri=: city Transpo. fare

I l t ., I
I

: 1

Transpo fare

I :
1

Building Building Vehicle Equipment

O.C.

1 |
;

:
! i

:
! t

' I ' ' ; '

, I,

Icebox regrige-' I tor :

I . .

' 1 ' '

Cost

Breakdown

for

Outreach

Personne

MD Nurse N.Ade Midwi_ e

8,770 7_229 (4 .3,916 b ._ 024

P 25,939 personnel x i year)

Supplies

BCG

DTP OPV Hepa B Measles Syringes Alcohol Cottonba I is Ic e Manila paper F'entel pen

2:073.60 2,325.60 I ;403.50 II,404.80 . i_48o-70 5,760.00 i15.00 73;6.00 48.00 6.75 50.1)_._ P 25,406.95

Vehicle

O.C

Transpo fare = 4 personnel ': P 4 (4 weeks >, 12 manths)

768.00

Building Bui Iding Equ i pmen t Vehicle

8.C.

Ic e bo:'

60. O0

P 52,174.00 Cost per- FIC: P ,,_.174 S_, / ._4c = P 271 39

43
INPUTS CHVs Personne I : : : ,, F Meeting Nurse CHVs ', ', ', ', : " of 24 (use U N : C Home CHVs T I Visits 0 | N S Monitoring Nurse

Supplies

: 5 notebooks : 5 pens ...... ., O.C. O.C. : ', Total ,, ', _

Record .
!

book

Equip. Building

'

hours meeting and record reviews of Health Center facilities) A I 1 o _ a n c e '0 C e n t e r

Vehicle Building

O.C.

T r a n s p o '0 H e a I t h

COST Personnel Supp Iies Equipment Vehicle Building Equipment Bui Iding Vehicle Total Cost .Cost per FIC 1597.56 = 481 45 O.C. O.C. O,C, 960.00 5,81 F' 75.30 75.00 (nurse

BREAKDOWN only)

FOR

CHVs

p 1597..56/.136

=.P

11.75

Incremental

Cost

Effective p

Ratio

(ICER) = P 486

52_174 240

- P 1597,56 - 136

__i_ii _ iIIi_i_i_ ..... _i_ i__ _iiiiii/I/!!i ii_i I _i _/i;//_ _.............. I ii i _ _i_ii ii iiiii_i i i !ii _ii_ _ ..... __ii_iiiI 2_i_

Part and

III. Efficiency

Comparison of the in

of Health

the

Effectiveness Center and the Care

Referral Services

Hospital

Delivering

Primary

Tessa

L.

Tan-Tortes, April 30,

M.D., 1995

M.Sc.

2 ABSTRACT :

QUALITY AND COST OF PRIMARY CARE SERVICES IN THE HEALTH CENTER AND THE HOSPITAL. T Tan-Tortes, Clinical Epidemiology Unit, University of the Philippines College of Medicine, Manila OBJECTIVE: To compare the quality and costs of primary care services delivered at the health center and hospital SAMPLE: consecutive patient-practitioner encounters under the following programs: Expanded Programme on Immunization (EPI), National Tuberculosis Control Program (NTP), Family Planning (FP) Program at the health centers and referral hospitals in an urban area METHODS: For Quality of care: 1.0bservation of 100 patientpractitioner encounters/ program/level 2. Patient feedback through in-depth interviews of 30 patientsprogram level and focus group discussions of 4 groups /program/level. For Cost: i. health center annual expenditures of the program including overhead and operating costs 2. hospital provision by a clinican of estimates of units and costs of resources consumed by the programs. RESULTS: Median score of 7 out of a possible 9 indicators observed for EPI. Median score of less than 50% attained in the FP and NTP programs. Patient satisfaction was high in all three programs. There was no difference in quality of care between the health center and the hospital based on the indicators observed and patient feedback. Costs in the health center and the hospital were P273 and P1689 / fully immunized child, Pi,588 and P1890 / patient completed TB treatment and P135 and P772 per family planning acceptor respectively. CONCLUSIONS: Based on the indicators observed, the quality of care was excellent in the EPI but needs improvement in the FP and NTP programs. However, patient satisfaction is uniformly high in the three programs. There is no difference in the quality of care delivered at the health center and hospital levels. The average cost per outcome in the 3 programs is lower in the health center than in the hospital. RECOMMENDATIONS: i. Specific feedback to be provided to the study sites 2. Training and supervision be in accordance with the quality of care indicators 3. Encourage delivery of services of the three programs at the health center 4. Require a referral letter or impose a user's fee in the absence of a referral letter for patients demanding primary" care services from the hospital.

3 INTRODUCTION: The Philippines was one of the first countries to adopt the philosophy of primary health care. Primary health care is defined as "essential health care based on practical, scientifically sound, and socially acceptable methods and technology, made universally available to individuals and families in the community, through their full participation, and at a cost that the community and the country can afford and maintain at every stage of their development in the spirit of self-reliance and self-determination (i)." Primary health care is expected to be provided at the first level of contact, where the people live and work. In the Philippines, the first level of contact is at the health center where services, including medical care and patient education,are provided. 0ut-patient departments of secondary and tertiary care level facilities (hospitals) also provide the same services, intended specifically to address the needs of the people living in the hospital's immediate catchment area. At present, there is no attempt to restrict access to higher level facilities by requiring either a referral letter from a lower level facility or payment of user's fees. The patientclient may choose to go to any facility providing the services and he/she can expect to receive some form of care. However, for the service provider and financier, it will be more efficient if the same service was availed of at a lower level facility. In developed countries, there have been a few experiments to lower costs of the health care system by strengthening the primary health care units to attract patients and draw them away from hospitals. A successful example recently reported in scientific literature was the experiment in Almere, Netherlands which resulted in lower referral rates to medical specialists and national average The initial influenced reputation, lower prescription rates (2). rates compared to the

choice of facility by the patient-client may be by several factors including accessibilityi" etc. However, the most important factor

4 influencing satisfaction Quality of continued patronage of a faci!ity is the of the patient with the care beinH received. care provided at t|ie health center level can be a technica ! perspective, practitioner'spoint of e.g., ..standards of view or using the of patient studies done with limited

assessed using care from the

patient's' perspective I, (subjective assessment satisfaction). Most of the:' 'quality assurance locally have remained '.as circulation in the Department A systems analysis of Quezon carried out in history-taking, sputum internal reports of Health.

the Luberculosis control 1990 bY Va!eza, et.al., Collection. and analysis,

program in showed that and patient

counselling'to promote c0mpliance could be improved. Drug and laboratory supplies were Snadequate(3). In 1991, Solter, et. al., assessed the quality'of care in family planning in four regions in the country,...Th@ s_udy showed that if basic equipment, current IEC materials and contraceptives are in short supply, it is.'_ifficu_t to provide a full range of services. Other areas needing improvement were supervision, recording, steriliiation pr6cedures, follow-up and provision of other reproductive healt_ 'services(4). A systems analysis on" services related to child survival carried out by PRICOR in B_lacan in 1988. Results of studies on the expandedPr09ram:on in_unization _showed the service except for immunizations supplies. facilities delivery_ co_pDnent re-use' of. syringes provided. This was the that

was relatively trouble-free and/or needles in 7% of was attributed .to lack of and needles, 20% of the at some point in the

Aside from-_ackof, reported .vacciDe

syringes shortages

previous year. Inyen_ory '_QSs'Were present and updated only in a third of the centers- vlsited. Active supervision .by the public health nurs_ during' i_nunizabion activities was rarely observed (5) . OBJECTIVES: This study compared three public health programs delivered different levels of care in ._n vrban area based on: a. effectiveness as patient feedback;and b. efficieh_y..as: ratios. ' '' "' ..... _easuWed 'measured by by " quality average assurance scores at and

cost-effectiveness'.

5 METHODOLOGY: Choice of Programs: Three programs of the Department of Health were chosen based on the different types of clientele being serviced. The three programs chosen were the expanded program on immunization (EPI), servicing infants and children; the family planning program (FP), servicing mostly women in the reproductive age; and the National Tuberculosis Control Program (NTP) , serving adults, majority of whom are men. Choice of Facilities: Three levels of care

were

chosen

to be

studied

in

the

Quezon Quezon Avenue to'the

City area. These levels were: health center (primary), City General Hospital (district or city) and the East Medical Center or EAMC (referral). A letter addressed

Quezon city Health Department asked for the participation of three health centers, namely Tatalon, Balara and Commonwealth. These were purposively sampled because they were large and had a big enough clientele to allow fast recruitment of patients. In the hospitals Recruitment addition, inviting of sample: consecutive patients availing observed in the designated letters were sent them to participate to the directors in the study. of

During the recruitment period, of the services chosen were centershospitals. Quality Assurance * Observation: Indicators:

The PRICOR thesaurus (6) was the source of checklists for the quality assurance evaluation of the three programs selected. The relevant checklists were provided to the heads of the different services to get their input in terms of local standards of care expected of Department of Health personnel. The checklists (annex I) were subsequently revised based on the feedback received. Through role-playing, research assistants were trained on the

details to be observed. After training, one research assistant per program was assigned to each health center (total of nine observers). They were assigned to observe i00 patient-practitioner interactions per program per level.

Interview:

Immediately after availing of the service, a third of the patients (n=first 30/program/level) were interviewed to obtain their subjective assessment of the quality of care received. They were asked to provide grades for specific parameters (e.g. length of time given by the practitioner, clarity of explanations, etc.) and to provide a global satisfaction score. A questionnaire (annex 2) was used to elicit the patients' feedback.

* Focus Group Discussion: The research assistants practised as facilitators and rapporteurs for focus group discussions after reading an instructional manual on focus group discussions (7). Four focus groups of 3-5 individuals were constituted to discuss their perception of the quality of service received for the disease per level (see annex 3). A fan was given as an incentive for discussions. Collection the patients to participate in the focus group

of costs: manual developed in another details on collection of cost hospital was

Refer to the self-instructional part of the study which gave data in obtained Revision

the health center. Average cost in the from estimates provided by a clinician. of Protocol:

After one week of observation at the Quezon City General Hospital, recruitment was terminated because there were too few consultations. For the same reason, patients in the family planning clinic of the Philippine General Hospital (PGH) were observed instead of those in (EAMC). These revisions in health center ANALYSIS: Descriptive statistics were used to describe Results were reported collection method. using means, medians and proportions each task observed in the facility. by program, by facility and by data . protocol resulted in and referral hospital, only two levels of care, available for comparison.

7 Reliability or internal consistency of patientclient's feedback was checked using the Spearman rank correlation. The sum of the grades given by a patient/client for each individual task was correlated with his global satisfaction rating expressed in percentage. To check validity, the patient's global satisfaction rating was also correlated with a figure [(number of tasks correctly accomplished/ number of tasks to be correctly accomplished) x I00] summarizing the technical assessment by the research assistant of the observed patient-practitioner An average cost immunized child, completing RESULTS : TB encounter. (1993 peso) per service provided per family planning acceptor and was obtained at each level (per fully per patient of care.

treatment)

The number of practitioner-patient interactions observed per level of care is shown in Table i. For EPI, all interactions at the health center level consisted of actual immunization sessions. At EAMC, 38 observations of practitioner-patient interactions were censored because in_nunization could not be accomplished due to lack of vaccines.

For NTP and FP, majority of the interactions observed were of the "case-holding type," i.e., patients come to the health facility primarily for replenishment of their stock of medications or supplies. Table their 2 shows the number of patients interviewed assessment of the service that they received There were tuberculosis regarding from the

center or hospital. for EPI, seven for planning.

eight focus group discussions control and five for family

Reliability and Validity of Measures: Patients' satisfaction ratings were inversely their global scores (r=0.33, and a higher rating are perceptions consistency _atisfaction. of in good the

correlated

with

p=0_002). A lower global score both indicators of patients' Thus, there is internal expressed statements of

service. patients'

8 For validity, patients' significantly correlate with research assistant. Expanded Programme The EPI performed satisfaction the technical rating did not assessments of the

on Immunization: very well in almost

all

observed

indicators

of quality assurance. However, approximately less than 50% of the practitioners took time to explain to the caregiver about the possibility of side-effects and what to do in case these occur. About 20-30% of the interactions observed did not satisfy the indicator for informing the caregiver about what vaccine had been given. This was true in all the facilities observed except for the Tatalon Health Center which performed well on this indicator. There was no difference between centers or between levels in terms of quality of performance (table 3) except that the EAMC, during the period of observation, ran out of BCG vaccines. During the in-depth interview, caregivers gave the service an average global rating of at least 85%. Only 0-2 caregivers per center gave a failing score for a specific parameter, e.g. time given by the doctor, clarity of explanation, bedside manners, etc. Again, no difference in quality was seen between centers and between levels (table 4). In the focus group discussion, the most common complaint was

the long waiting period. Some more doctors and enforcing a policy. The was 5). cost P273 The lack of vaccines

suggestions included _first come, first was mentioned

adding served"

in EAMC

(table 5).

per fully immunized child in the health center level (annex 4) while in the hospital, it was PI,689 (annex

National Tuberculosis Control In the health centers, 0-30%

Program: of patients

observed

werenewly

diagnosed cases of tuberculosis while in the EAMC, over 70% were newly diagnosed. At the health center level, low scores of 50% or less were obtained for history-taking. Less than 10% underwent an adequate physical examination. In both areas, physicians performed better at the hospital level.

9 For sputum AFB examination, the health center physician performed better (but still with low scores) in counselling on the importance and method of production of sputum sample than his hospital counterpart. At EAMC, sputum samples were not taken. The to diagnose physicians relied on chest tuberculosis (table 6). examination and x-rays

Follow-up patients came to the health center to be given their medications except for EAMC where they were issued prescriptions. In general, over 50% of the physicians emphasized the importance of maintaining contact and verifying that the patient knew his appointments. No one at the health center and a low 10% at EAMC inquired about adverse effects(table 7).

The in-depth interview with the patients revealed high ratings of 88% or higher for the service received at the health center versus an average score of 74% for EAMC. Very 0-2 per center, rated specific parameters unsatisfactory (table 8). few patients, of care as

The focus group discussion emphasized the importance the medicines readily available (table 9).

of having

The cost per completely treated patient (annex 4-5) at the health center level was Pi,587.80 (only P1,086 worth of medications provided versus expected retail cost of 6208.80) while in the hospital, the cost was Pi,850 (no medications provided). Family Planning:

Majority of the patients in the health center were follow-up cases versus the 70% new cases at the Philippine General Hospital. Among the new patients, history-taking was inadequate particularly the medical history. Much of the acceptable performance centered on reproductive and menstrual history-taking. Very few patients health center and underwent a physical examination in the neither was a pap smear taken. The health

centers and the PGH administered a family planning method in majority of the cases but only the PGH offered bilateral tubal ligation (table 10).

i0 For follow-up patients, PGH physicians asked about occurrence of side effects whereas this was not frequently done in the health centers. Among the health centers, Tatalon provided exceptional counselling. Very few physicians in the health centers or in PGH asked the patient to echo the messages provided (table Ii). In the in-depth interview, Tatalon and PGH received high rating of over 90% compared to 80% for the two other health centers. Very few or none gave a failing score for individual parameters of patient care (table 12). times for

The focus group discussion suggested later cut-off receiving patients in the center (table 13). The cost per acceptor in the health center compared to P772 in the hospital (annex 4-5). Comparison of Programs by Level Patients" Satisfaction Ratings: Based on was

P135.40

Observation

and

Based on a strict interpretation of the indicators, only the expanded program of immunization achieved passing scores. The NTP program, specifically care extended to new patients, and the FP program, at both levels, need much improvement as shown by the median summary scores (Table 14). The perception of good quality of care in the three programs was evident in the patients' ratings and global scores. There was no difference in patient satisfaction with services at the centers and the hospitals (Tables 15-16). DISCUSSION: Ideally, patient effectiveness outcomes. of care Although provided should this was one be reflected in of the stated

objectives, a proximate measure, in terms of quality of care provided, was chosen as the outcome with the practitionerpatient interaction as the unit of analysis. The available time and budget allowed only for a cross-sectional research design with a one-time slice of observation. Thus, patient outcomes could not be determined as follow-up is necessary to determine if the patient's tuberculosis got cured or if the child got sick of measles or if the woman became pregnant.

ii A quality assurance (QA) study is an evaluation with findings specific to the area of concern. Rarely are results of an evaluation generalizable to other areas, unless the area studied is "representative" of other areas. A QA study looks at the process of implementation itself, including the performance of detailed steps. The PRICOR indicators used in this study are very detailed and their primary use is to provide feedback to the persons in the areas studied. The process measures used are a combination of technical and subjective ratings. The same practitioner-patient interaction is evaluated using observations on technical parameters by a research assistant and the patient's expression of satisfaction with the service received. There wa_ some correlation between the two but this was not statistically significant. A possible explanation for this is that the technical assessment may be made on parameters different from what the patient was evaluating (e.g., did the physician inquire about side-effects Versus bedside manners of the physician). Supporting evidence is provided by the statistically significant consistency between what the patient said regarding individual parameters of quality (e.g. physician's bedside manners) and the global satisfaction rating.

In general, there was no difference in the services being provided by the hospital and the health centers in the three programs evaluated. Quality services as defined by PRICOR indicators are being provided by the EPI. However, failing scores were obtained in the other two programs of FP and NTP. This does not necessarily mean provided are substandard, only that The costs of providing the health center, primarily consultation are lower in that they the services being can be improved. the of the

services were much lower in because the fixed costs the health center than in

hospital. The patient will also receive more benefits in the center where they can get a sputum examination and be provided medications/supplies. For health centres to attract and hold patients, they must be assured of continuous supplies and easy access to the hospital upon referral.

12 Because patient of their departments high may fixed cost component, hospital outcontinue to provide services in these

programs but should be encouraged to preferentially treat those who can benefit more from their specialized equipment and personnel (e.g., difficult to treat tuberculosis). This can be attempted by requiring patients to show referral letters from treated, to letter. the lower level facility or, if they insist to be impose a user's fee in lieu of the referral

CONCLUSIONS

AND

RECOMMENDATIONS: that in the is no marked and the health centres difference in is more costly setting. It to the centers the and the to is and

This study demonstrates hospitals studied, there

quality of services provided provide such services from recommended that : i. results of this hospitals studied; study

that it hospital back

be _relayed

2. trainers and supervisors indicators for primary health

be taught how to use care in their work;

PRICOR

3. guidelines be circulated that all consultations for EPI, FP and NTP be initially handled at the local health center level and only referred to the hospital if there is a need for the use of higher technology or in the case of complications; 4. a system of incentives and disincentives be established to support the functioning of a referral network. LIMITATIONS :

The process of observation may sometimes affect the persons being observed such that they will modify their performance. Therefore, what is being observed is not routine or usual but instead is better or improved (Hawthorne effect). The effect will wane with time as the observed individuals will get used to the presence of the observers. Unfortunately, the observation period was too short for the individuals being observed to revert to "usual" behavior. Thus, it is possible that the programs may actually be worse than what is reported here.

The

second

limitation

is

the

use

of

different

methods

to

collect costs. Ideally, one should undertake full costing as. was done in the health centers. Unfortunately, this was not possible in the hospitals. Thus, the average costs obtained

13 in the health centers and not subjected and tO the hospitals were merely contrasted an incremental cost analysis.

Acknowledgements The author thanks:

* the Quezon City Health Department, East Avenue Medical Center and Philippine General Hospital Department of Obstetrics and Gynecology for participating in .the study; * Dr. Cito Maramba and Ms. Marie Manalo, research associates,

for supervising the team of research assistants who collected the data, keeping the study on schedule and for keeping the files in order; * Dr. Arnold Agapito for collecting the health center for costs; quality

* PRICOR for providing the indicators assurance and access to the local QA studies; * the Philippine funding the study. ,Institute for Development

Studies

for

REFERENCES

14
Health Care in the Social Science Philippines: and Medicine

i. Phillips DR. Primary Banking on the Barangays? 1986;23:1105-ii17.

2. Sixma HJ, Langerak EH, Schrijvers GJP, et.al. Attempting to Reduce Hospital Costs by Strengthening Primary Care Institutions: The Dutch Health Care Demonstration Project in the New Town of Almere. Journal of the American Medical Association 1993;269:2567-2572.

3. Valeza F, Mantala M, Cruz N, the Tuberculosis Control Program Report Submitted to the Department

et.al. Systems Analysis of in the Province of Quezon. of Health, October, 1990. in Family

4. Solter C. An Assessment of the Quality" of Care Planning in Four Regions in the Philippines 1992. 5. Blumenfeld S. Report of Bulacan Province, Philippines 6. PRICOR. Primary Health the DOH/PRICOR 1990. Care Thesaurus: Center Systems

Analysis,

A List for Human

of Service Services,

and Support 1988.

Indicators.

Bethesda.

7. Dawson S, Manderson L Manual. WHO/TDR/SER/MSR/92.1.

and

Tallo

V.

The

Focus

Group

Table 1, Numberof Practitioner-Patient Interadlons Observed N (New : Follow-Up)

Tuberculosis Program Balara Commonwealth Totalon EastAvenueMedical Center 32 (7 : 25) 31 (10:21) 36 (0 : 36) 100 (44 _56)

FamilyPlanning Program 30 30 48 100' (:9: 2:1). (10:20) (14 : 34) (72 : 28)

Expanded Program ofImmunization 60 37 36 59

T OT AL

122 98 120 259

T OTA L

199

208

192

599

* Philippine GeneralHospital

Table 2. Numberof Patients In-Depth" for Interviews

Tuberculosis FamilyPlanning Expanded Program T O T A L Program Program of Immunization Balara Commonwealth Tatalon EastAvenueMedical Center .... 13 15 13 34 21 13 12 35* 27 12 13 39 61 40 38 108

,.

TO T A L

75

"

81

91

247

" Philippine GeneralHospital

/-7
Table3. OualtyAssuranco. ndicators I forPatientsIn ExpandedProgramof Immunization

IvlWJNIZATIONSERVICE INDICATORS Actual Immunization SessionObservations Does the healh worker I. examinevaccination cardsor questionmothersto determineImmuRlzatlons needed 2. administeral vaccineswith sterileneedles. 3. protect BCG, polioand measles vaccinesfromheat duringuse. 4. recordrequiredinformationonvaccinesadministered on vaccinationcards? 5. tel the motherwhatvaccineswere administered. 6, advise+the mother regardingpossiblesideeffects, 7. ad',Ir, the motherwhatto do In case of side effects. e 8. tel the molher of thechild(ran) about the nextrequired Immunizations. 9. Immunizethe child?

Balar.aCommo .nv_ealth n = 60 n = 37

Tatalon n ,, 36

EastAvenue IvbdlcalCenter n "-59

59'

36"

36

59

59_ 60

37x 36:36

35

59 59

58

35

36

57

43 5 5 47

12 20 20 32

33 13 12 34

46 . 22 19 48

60

37

36

59

"vidualy perfect score - childmissingreceivedora__.ll poliovac_;ine

Table4, SummaP/of In-Dept_ Ir_ervl_

for Expanded ProgrtmofImmunlz|tlon Commonwealth n = 12 24 Tatalon n = 13 26.23 East Avenue. Modlc=lCenl_r rt=3g 28.3t

Balnra n= 27 Metro Age _ m._ k=_fo dltoneglungo? mlleplt meier at Ilbr, eng gamot mp4rll (riNrr_d from out=Ida) _rnagtgtng engpe_r_ rnagant_ =met s_L_tyo rage Ibe pangsagot po emgglnawas= Inyo? welt= blnlgyanng gamot_" . Ineknrnin (PE, Hickory)". nlreeetshan - Anopo _ slnebl? wal8 InumCW_oy eng g|cnot IdnalaltCoNeNp_dlng= (dlegl_o_t) magpa.lab,_am. ( z_ _pplj r._T': bumallk pagbebego,a pamumuhey . (_i.TC_,z_(.z me=Ibm pang =_got : _,lnibl e kungkalIanbsbellk b '" Hlndl Oo _.i_ blblgyen markaOneaerblsyong ng blnlblgayse Inyo _k_) seen engO ay hlndl cayonealslyahtm f kehltko_ at eng 100 _._/maswang-masW=kWo, ,_nong marka engIbll_lgay nlnyo? . ',..h/trl_e grade: _= nslblnlg_ ng doktor?(hlndlkaeall eng paghlhlnt_y) ....kgblrrfl_Imen megbills masyadong mabllls maWadong matagel _ngo ng doldor? 97.63 _ 28.07

20 4 0 0 1 2

6 4 2. 0 1 o

10 3 0 0 0 0

29 2 G 0 2 1

0 26 O I

12 0 0 0

10 2 I 0

25 13 0 1

4 0 7 0 12 0 4

2 3 2 0 "$ 0 O

1 3 3 0 5 0 1

3 6 13 0 15 0 2

4 23

1 11

1 12

6 33

B6,GB

88.85

_G.97

24 3 0

8 2 2

10 2 0

33 6 O

l_rnagan_a
_:._men

1G 11

B 4

13 0

30 S

,yo, liEmmgallng
i k_mrr_, en m _ mmap/om _pallw_n,g?

22 G 1

9 3 0

10 3 0

30' 9 O

nallntlndlhen

2 19 3 3 2

2 7 4 1 n

1 10 2 1 "

1 19 4 16

lalyonI Suhestlyon: __lng mw gemot/tao/gamlt BEL._p_/_ mge gemlt/sarblsyo n= Ibl pangmagot

/q

Table 5. Summary of Focus Group Discussions on Expanded Immunization Program

_1(#of FGD) Center

Consultations (average) # of Previous Grades

Experience Best

Expedence Worst

Suggestions

_[_lara i_[(FGD= 1)

2,2,1

86.67

good reception, safe vaccination

waiting for a long time, masungitang doktor,

walang singitan, more doctors,medicines

i_Commonwealth ;i _GD = 2)

1,1,1,2,2

89

outreach program of health center mothersneed not go to the health centers

masungitang health worker masyadongmatagal dahil hindinasusunod ang number, hirap, mahal ang singilng donasyon, lackingin facilities, tardy healtll workers,

dapat sundanang numero,

huwag magpilitng presyo ng donasyon have their own healthcenter in their area

Iatalon _GD = 2) ,:

3,1,1,6,3,4,

90.83

binigyankaagad ng gamot, maasikaso

dati masungit

t_rJust Avenue _Medical Hospital i'_._i (FGD = 3) ';_ "

3,2,1,1,2,2, 3,3,3,5,2

74.09

OK lang,

nauubusanng bakuna,

sana palaging may bakuna,

maganda ang pinabalik-balik lalo na bigyanng BCG kapag pagtanggap, sa toga taong malalayo panganak, maayos palagi kung ang tirahan, pupunta, hinditinatanggapagad, magingmas maasikaso ang marami siyang matagal maghintay mga healthworkers, natutunansa posterna nagsasabing estudyanteng scheduleng bakuna nag-asikaso sa baby inaasikaso kaagad

Table 6. Quality Assurance Indicators New PatientsIn, for Tuberculosis ControlProgram Balara Commonwealth. I. DIAGNOSIS A. History Doesthe healthworker ask about: 1. cough> x weeks " 2. fever > x weeks 3. weightloss - 4. dyspnea(difficultybreathing ) 5. chestpain 6. hem0ptysls(coughing blood) 7. familyhistory 8..prevloustreatmentfor TB B. PE Doesthe healthworker examinef_ 9. lymphadenopathy (enlarged .lymph nodes) _10.chestsignabnormalities 11.hepatosplenomegaly 11. OUNSELLING C Doesthe healthworker counselabout
'_" " e

Tatalon n=0

n=7

n=10

' EastAvenue MedicalCente n=44

4 0 4 1 0 2 2 4 .

,5 5 3 4 2 2 0 5

41 34 23 29 29 24 9 18

10 "

u 0

2 0

42 5

'_12. Importanceof sputumexam _3. Importanceof returning results for 4. courseof eventsIf sputumIs found _Osltive

7 6 5

10 5 3

0 0 0

III. TAKING SPUTUM SAMPLE A. Multi-SampleApproach Does the healthworker 15. explainwhY 16. providematerialsfor overnight (take.home) sample 17. tell when to retumwithovernight sample B. InstructRe: SputumProduction Does the healthworker 18. explainspttting deep cough vs. 19. describedifferencesbetween salivaand sputum(consistency, 1 0 6 3 0 0 3 7 3 10 0 0

clar)

Table7. QualityAssurance Indicators forFollow-Upatients P inTuberculosis Control Program" Balara. Commonwealth Talalon EastAvenue Medical Center n = 25 n=21 n =36 n=56

FOLLOW-UP FORMFORTB A.BeginTherapy Doesthehealthworker 1. provide drugs 2.tellwhen1oreturn, mphasizing e Importance fmaintaining o contact B.Minimize efaults D DoesIhehealthworker 3. completectivetherapy a register 4.setappointments, verify thatpatient understands

22 16

11 5

32 29

1_ 39

2_" 17

14 10

34 18

37 29

C.Continue Therapy Doesthehealthworker ,5.askadverse reactions, reassure patientorchange ( drugs) 6.repealImportance fcompleting o regimen 0 3 0 0 0 3 5 22

Table8. Summery of In-Depth IntervleWs for'l'uberculosls Control rogram P Balara Commonwealth Tatalor_ EestAvenue ,. M_dlcalCenter n=13 n=15 n=13 n=34 MeanAgo Bai_ Jeyo cl_ nagtungo? malsplt . malapltat IJl_l8ng gamot rop,rll (rebrrtd from out,ida) gumsgallng ang pelyente rnaganda_g serblsyo mga Iba pangsegot Anopo ang glnerwu Inyo? sa wals blnlgyan ng gamot(vaccines. pills,injections, contraceptives) ineksardn (PE, History,sputum, Y,-rw) nlremebihan Ass po sng slnebl? 0 wals I InumlNltuloy gamot ang 2 :, klnalqlabasan/pWndlngs (dlognosls) 3 megpa-lebel<sam(sputunVx-rey/dugo,etc) 4 bumsllk 5 psgbsbsgo sa pamumuhw (lifestylechanges) Slnsblbe kungkallanbuballk? 0 Hlndl 1 So 41.3 41.4 49 42.875

B 4 O 1 0 0

8 6 1 0 0 0

8 '4 1 0 0 0

18. 7 6 0 2 I

0 5 8 0

1 7 6 1

0 8 5 0

., 0 7 24 3

2 7 0 2 1 1

4 3 O 6 2 0

1 6 _ 3 2 0

2 11 5 14 2 0

2 11

3 12

| 12

2 32

Kung blbigy_nng merJKt ng serblsyong a binlblgW aa Inyo

kungnan ang 0 ay hlndlkayonaslslyahankahltkontlat ang I00 ay manyang-masuya keys, anongmarks angIbtblgWnlnyo? Avtrage Grade: Ores no Iblnlgey dokl:or? ng (hlndlkssslleng peghlhlntey) t kntamtamaneng bills 2 mseyadong mabllls 3 masyadongmatagal i,Paklld'oJngo doktor? ng 1 maganda 2 katamtaman 3 hlncll maganda 91.92 69.63 i]8.85 74.12

10 2 1

10 4 1

10 3 0

25 4 5

8 5 0

9 6 1

13 0 0

24 9 1

"Serus',,o?
1 2 3 maWos kstarntuman hlndlmalyo= 10 3 0 14 0 1 $2 I 0 ' 28 5 1

_igpapalk, vensg? .' :: t nsllnUndlhan 2 nallntlndlhang kaunU n 3 hindlnalin1_ndlhan _*komandasyonI Suhsstiyon: 0 wala 1 palaglng mw gamoUtao/gemlt 2 mnyos na mgs gamlt/serbltTo 3 ragsIbe pangsagot

10 2 1

1 0 0

t2 1 0

32 2 0 ,'

4 7 1 0

6 2 7 0

9 3 0 1

17 3 11 _"

Table 9, Summary of FocusGroup Discussionson Tuberculosis Control Program

Center (#of FGD)

#of Previous Grades Consultations (average)

Best Experience

Worst Experience

Suggestions

Balara (FGD = 2)

1,2,1,2,3

94

free medicinesfor TB, gumagalingkami, maayos ang serbisyo

kapag araw ng pagkuhang gamot dapat meronagad othersourcesof free medicinenot offered by health center (prescriptiondrugs), librengx-ray, have own laboratory

Commonwealth (FGD = 1)

2,1

100

free medicinesfor TB, gumagalingkami, maayosang serbisyo, iniistimanaman ng maayosat saka tinuturuan

Tatalon (FGD = 2)

4,2,2,3,2,2

85.83

inaasikasokaagad pinabalik-balikkasi ang naiskumuha walang gamot, ng gamot hindinakakuhang mabilis ang serbisyo gamot dahilmay Xmas pady, walang doktorkasi dagdaganang nagkasakitang empleyadopara kanyangpamangkin dadami ang titingin at sana huwag magsasawa sa pagserbisyo

EastAvenue i MedicalHospital ilI(FGD 2) =

1,2,4,4,3,2

83.33

maganda ang workmanship ng doktor, libre sa konsulta, mababait

kulang sa gamit katuladng walang bakantengwheelchair, wala pang binibigay na reseta kahit ilangbalik na

hindi pa nakikitaang kahuluganng serbisyo, sana ang toga doktor ay talagang hasa na sa kanilangtrabaho

Table 10. QuaityAssurance IndicatorsforNe_ Patientsin FamilyPlanning Program Balara Commora_ealh Tatabn FA/VIILYPLANNINGSERVICE DELIVERY INDICATORS: A. History. Doesthe healthworker 1, ask women 15.44 about reproductive historyand intentions ask appropriate reproductivehistoryquestions 2. about previous use of childspacingmethods 3. about reasonsforstoppingor _thching methods 4. aboutnumber, spacingand outcomeof pregnancies ask eppropdatequestions regardingpersonaland family conlderalions child spacing clent of 5. if andv_en clientJpadner ould Ike to have children w 8. aboutotherpersonaland family factorsaffecting a method Ealectlon (personalpreferences,partner/family approval, 5 4 2 3 2 10 2g 45 5 2 6 7 2 9 13 3 10 5_ 3( 51 8 8 12 5_ n=8 n=10 n'-14 PhILGenera Hospital n-,72

privacy)
take adequate medicalhistoriesfrom childspacingpatients 7. about breastlumps,cancer 8. abouthistoryof heart disease,iver diseaseor high blood pressure 9. abouthistoryof pelvicinflammatorydisease 10. abouthistory of confirmedor suspecledvenereal disease 11.about history of bloodclotsor thromboembo| i2. aboutoceurenceof severeheadaches 13. about regularityof menstrualperiods 14, aboutcurrent breastfeeding i5. cun'erdreproductive status (datesof lastmensesand mostrecer_t ntercourse) i 0 1 4 6 1 3 14 30

0 0

0 1

.0 0

17 6

"1 0 2 2 8

1 1 (; 3 9

3 1 5 2 10

8 8 35 16 57

B, Physical Examination, Does the health worker conduct physical examination of child spacing client. 16. take the blood pressure 17. examine breasts for lumps 18. perform pelvic exam lg, examine patient for signs of anemia 6 0 0 1 0 1 0 0 3 1 0 0 48 14 67 27

C. Laboratory Tests. Does the health worker 20, lake pap smear 0 0 1 19

D. Admlnlstedng Child Spacing Methods 21. Does the health worker administer child spacing method. (if yes, choose0ne of the following) Prescdbe or dlstdbute condom, pills or foam Insert IUD Measure client and prescribe or distribute diaphragm Prescribe or distribute recommended supplies for zaturalchild spacing
,f

13

44

9' 3

10 7

2"

Administerinjedable contraceptive or implant Schedule BTL

1'

1 25

!2. Does the health worker counsel client about how to use '=elhod

10

13

36

* 2 patientswere administered2 forms of contraception simultaneously.

Table 11. Quality AssuranceIndicators forFollow-Up Patients in FamilyPlanning Program 8alara Commonwealth Tatalon n= 22 n=20 n=34 FollowUp. Does the healthworker Phil.Gener_ n=28

1. ask:usersaboutsideeffects 2. explainthe correctuse of spacingmethods 3. explainthe possibleside effects of selectedmethods 4. explainv_en andwhere to gofor resuppllesand checkup 5. ask the patientto repeat key messagesand/or demonslraterequiredsldlls
0

8 8 3 3 0 1 0

4 7 2 4 0 0 0

3 29 2 31 0 1 5

2_ 8 13 22 0 1 3

6, askthepatient to repeat commonsideeffects of his/herselectedchildspacingmethod 7, ask patient to repeatwhenand whereto returnfor supplies and checkups 8. askthe patientif there are questionson the use of childspacingmethod.

Table 12. Summa_ of In-Depth Interviewsfor FamilyPlanningProgram Balera n = 21 Mean Age: Bakerkayo dlto negtzJngo? malapit melepit at lib_ ang gemot reperal (referred from outside) gumagallng ang pasyenta maganda end serbisyo Arm go ang ginawa sa inyo? wala blnlgyan ng gamot(vaccines, pills.lnJectlons.contracepLivss) Ineksamin (PE, Histz)ry,sputum, x-ray) niresetehan Ano po ang sinabi? wala InumlrVCuloy ang gamot kinalalabaseNps_dings (diagnosis) magpa*lab el<sam(sputum/x-ray/dugo.etc) bumallk pegbebago se pamumuhw (life_yle changes) toga Iba pang sagot $inebi ba kung kailen babalik? Hlndl Oo Kungbiblgysn ng marka ang serbisyong binibigay sa Inyo kung saan ang 0 ay hindi kayo nesisiyahan kahit konU at ang 100 ay masayang-masaya kayo, enong marka ang Iblblgay nlnyo? Average grade: Ores na iblnlgay ng dok_r? (hindi kasali ang paghlhintay) katamtamen ang bills masyadong mabills masyadong matagal Paldldtungong doktor? megende katamtaman hlndl maganda ..ae_lsyo? maayos kstamtaman "' hlndl meayos ! Pegpapeliwanag? ;_ nallntJndlhan neiintJndihan kaunt_ ng hindi naiintindihan _ekomendasvon / Suha'stiyon: _,i: Wale " Palaglngmay gamot/tao/gamtt maayos ne rage gamit/serbisyo toga Iba pang sagot 12 1 7 1 8 1 8 0 8 3 1 0 2g 1 4 1 20 1 0 12 0 1 11 1 0 34 1 0 lg 2 0 11 1 1 12 0 0 33 1 1 18 3 0 10 3 0 11 1 0 32 3 0 17 4 0 6 3r 0 12 0 0 32 2 1 61.1g I]3.46 92.67 g1.11 13 8 g 4 3 g 4 31 1 8 0 0 I 0 3 7 4 2 0 0 0 0 8 3 0 1' 0 0 0 0 5 26 2 2 0 0 1 7 13 0 0 12 1 0 0 8 4 0 C 7 2i_ O 10 2 3 0 0 g 3 1 0 0 " 10 2 0 0 0 1[ 1:: C 11 28.05 Commonwealth n = 13 27 Tatalon n=12 28.83 PhilippineGeneral Hospital n=35 31.0:

Table 13.Summaryof FocusGroupDiscussions on Family Planning Program

Center (#of FGD)

#of Previous Grades Consultations(average)

Best Experience

Worst Experience

Suggestions

Tatalon (FGD = 3)

1,1,3,1,3,3

97.67

OK, hindinabuntis, maasikaso palagi

hindimadisiplina, sanaang cut-off ime t matapang, ay 11:00at hindi 0:00 1 pinapagalitan kapag maraming tao .

Philippine eneral G Hospital (FGD = 2)

1,1,1,1,1

88.83

OK lang, magandaang serbisyo, magandamagexplainangdoktor, mabait, inaasikaso kaagad

PERCENTILi DISTRIBUTIONOF SUMMARYSCORES = FOR QUALITY ASSURANCEPER PROGRAMPER CENTER Expanded Program of Immunization Balara Commonwealth Tatalon EastAvenue MedicalCenter MIn 4 3 6 5 25th %lie 6 6 7 6 50th %lie 7 7 7 7 75th %lie 7 8 9 8.5 Max 9 9 9 9 perfect score = 9 Tuberculosis ControlProgram:New Patients MIn 3 3 na 25th %lie 7 6 na 50th %lie 7 8.5 na 75th %lie 8 9 na Max t2 14 na perfect score = 19 Tuberculosis ControlProgram:Follow-upPatients MIn 2 0 0 25th %lie 2 0 3 50th %lie 3 1 4 75th %lie 4 3 4 Max 5 4 6 perfect score= 6 FamilyPlanning Program:New Patients MIn 3 6 25th %lie 6.75 6.25 50th %lie 7.5 8 75th %lie g 9 Max 10 12 perfect score = 22 FamilyPlanning Program:Follow-up Patients MIn 0 0 25th %lie 0 0 50th %lie 1 0 75th %lie 2 1 Max 4 5 perfect score= 8 4 7 7.5 8.75 10 3 5 6 7 9

0 1 2 4 6

*5 7.5 10 12 20

0 2 2 2.75 6

*0 1 2 3 7

*patients from ReproductiveHealthCenter,UP-PGH