Risk factor contributions to socioeconomic inequality in cardiovascular risk in the Philippines: a cross-sectional study of nationally representative survey data.

BACKGROUND: Primary prevention of cardiovascular diseases (CVD) increasingly relies on monitoring global CVD risk scores. Lack of evidence on socioeconomic inequality in these scores and the contributions that specific risk factors make to this inequality impedes effective targeting of CVD prevention. We aimed to address this evidence gap by measuring and decomposing socioeconomic inequality in CVD risk in the Philippines. METHODS: We used data on 8462 individuals aged 40-74 years from the Philippines National Nutrition Survey and the laboratory-based Globorisk equation to predict 10-year risk of a CVD event from sex, age, systolic blood pressure, total cholesterol, high blood glucose, and smoking. We used a household wealth index to proxy socioeconomic status and measured socioeconomic inequality with a concentration index that we decomposed into contributions of the risk factors used to predict CVD risk. We measured socioeconomic inequalities in these risk factors and decomposed them into contributions of more distal risk factors: body mass index, fat share of energy intake, low physical activity, and drinking alcohol. We stratified by sex. RESULTS: Wealthier individuals, particularly males, had greater exposure to all risk factors, with the exception of smoking, and had higher CVD risks. Total cholesterol and high blood glucose accounted for 58% and 34%, respectively, of the socioeconomic inequality in CVD risk among males. For females, the respective estimates were 63% and 69%. Systolic blood pressure accounted for 26% of the higher CVD risk of wealthier males but did not contribute to inequality among females. If smoking prevalence had not been higher among poorer individuals, then the inequality in CVD risk would have been 35% higher for males and 75% higher for females. Among distal risk factors, body mass index and fat intake contributed most to inequalities in total cholesterol, high blood sugar, and, for males, systolic blood pressure. CONCLUSIONS: Wealthier Filipinos have higher predicted CVD risks and greater exposure to all risk factors, except smoking. There is need for a nuanced approach to CVD prevention that targets anti-smoking programmes on the poorer population while targeting diet and exercise interventions on the wealthier.

Associations between health-related quality of life and measures of adiposity among Filipino adults.

OBJECTIVE: Estimate associations between the health-related quality of life (HRQoL) and adiposity in a low-income population. METHODS: In a cluster random sample of 3796 Filipinos aged 40-70 years in Nueva Ecija province, we measured body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and six dimensions of HRQoL using the 20-item Short Form Health Survey. We stratified by sex and used nonparametric regression to graph mean HRQoL in each dimension by BMI, WC, and WHR. We used ordinary least squares regression to estimate differences in each HRQoL dimension by categories of BMI, WC, and WHR adjusted for sociodemographic characteristics and smoking. RESULTS: Mean HRQoL was lowest for health perception (Males: 67.5 (SD = 15.9); Females: 66.7 (15.8)) and highest for role functioning (Males: 97.5 (12.9); Females: 97.4 (13.3)). Mean (SD) values of BMI, WC, and WHR were 22.1 (3.6), 84.8 cm (9.5), and 0.9 (0.1), respectively for males, and 23.7 (4.2), 86.5 cm (10.2), and 0.9 (0.1), respectively, for females. There was no evidence that higher BMI was associated with lower HRQoL. Adjusted mean social functioning was 4.92 (p = 0.076) higher for males with high BMI risk (8.6% prevalence) compared with acceptable BMI risk (50.3%). Mean social functioning was 3.61 (p = 0.012) and 5.48 (p = 0.017) lower for females with high WC (44.7%) and WHR (83.1%), respectively, compared with those with low WC (23.8%) and WHR (3.6%). Mean physical functioning was lower by 2.70 (p = 0.204) and 1.07 (p = 0.198) for males and females, respectively, with high compared with low WC. Mean physical functioning was 3.93 (p = 0.037) lower for males with high (7.6%) compared with low (38.8%) WHR. Mean role functioning was 1.09 (p = 0.124) and 2.46 (p = 0.158) lower for males with borderline and high WHR, respectively. CONCLUSIONS: There is discordance between future adiposity-related health risk and current experience of HRQoL.

Persistent effects of temporary incentives: Evidence from a nationwide health insurance experiment.

Temporary incentives are offered in anticipation of persistent effects that are seldom estimated. We use a nationwide randomized experiment in the Philippines to estimate effects of two incentives for health insurance three years after their withdrawal. We find that both temporary incentives had persistent effects on enrollment. A premium subsidy had a small but highly persistent effect. Application assistance offered to those initially unresponsive to the subsidy had a much larger but less persistent effect. The subsidy persuaded those with higher initial stated willingness to pay to enroll and keep enrolling. The offer of application assistance to initial non-compliers with the subsidy achieved a larger immediate effect by drawing in those who stated they valued insurance less and were less likely to re-enroll when the incentives were withdrawn.

Filling Potholes on the Road to Universal Health Coverage in the Philippines.

The fraction of health-care costs financed from prepayment sources is a critical indicator of progress toward Universal Health Coverage. But it does not tell how prepayment varies with the level of health-care costs and between poorer and richer patients. This paper used survey data from the Philippines to estimate inpatient costs paid by the National Health Insurance Program (aka PhilHealth) in 2013-2017 when attempts were made to extend population, service and financial coverage. The mean fraction of the inpatient bill paid by PhilHealth increased by 21 percentage points. Expansions of population coverage do not appear to have been primarily responsible for this increase. Despite the introduction of a catastrophic cover benefit package, the fraction of inpatient costs that were prepaid increased more at lower costs than at higher costs. PhilHealth payments for inpatient care were pro-rich but became substantially less so, possibly because hospitals were no longer permitted to charge poor patients in excess of reimbursement ceilings. Overall, prepayment of inpatient costs increased and became more pro-poor, reflecting gains in insurance and equity.

Effectiveness of clinic-based cardiovascular disease prevention: A randomized encouragement design experiment in the Philippines.

RATIONALE: Evidence on effectiveness of routine clinic-based cardiovascular disease (CVD) prevention in low- and middle-income countries is lacking. This study aimed to provide evidence on exposure to primary prevention of CVDs obtained through visits to public health clinics in the Philippines that are responsible for operating a widely-adopted CVD risk screening and management protocol. METHOD: In a 2018 cluster-randomized experiment in Nueva Ecija province, participants aged 40-70 with no history of CVD in randomly selected communities were offered a money-prize lottery ticket if they visited a public health clinic for a check-up. The induced variation in clinic visits was used to estimate effects of a check-up on exposure to CVD prevention indicators (measurement, diagnosis and medication of physiological CVD risk factors, and medical advice about behavioural risk factors), as well as on health behaviour and predicted 10-year CVD risk score. RESULTS: Going for a check-up at a public clinic raised a weighted average of effect sizes of the prevention indicators by 0.16 (95% CI 0.06 to 0.26, FWER-corrected p = 0.0218). Disaggregated analyses revealed positive effects on blood pressure measurement and receipt of medical advice, but no significant effect on diagnosis or medication of either hypertension or diabetes/dyslipidaemia. Despite high baseline prevalence of CVD risk factors and increased receipt of medical advice, there were no significant effects after six months on health behaviour, physiological risk factors or CVD risk score. CONCLUSION: Getting Filipinos to health clinics responsible for opportunistic CVD risk screening had a muted impact on exposure to CVD prevention and no significant impact on health behaviour and predicted CVD risk. Issuing well-founded protocols may be insufficient to ensure exposure to CVD prevention through routine clinic visits.

Health conditions, payments, proximity, and opportunity costs: Examining delays in seeking inpatient and outpatient care in the Philippines.

Like other developing countries, the Philippines commits to achieving universal health coverage. To identify the factors - including health care needs, financial and physical access, and opportunity costs - associated with delays in seeking outpatient (OP) and inpatient (IP) care among household members with illness, injury or advised by a doctor, this paper estimates Cox and Weibull proportional hazard models using a nationally-representative sample of households surveyed in 2011, when the Philippine government just started implementing major health reforms. Our results indicate that the delays in seeking OP care tend to be shorter for the very young (5 years old or below), the elderly (65 years old or above), and those with prior poor health. Similarly, delays in seeking IP care tend to be shorter among the very young and those requiring maternity services. Moreover, having a college-educated head of household is associated with shorter delays in seeking OP and IP care. Delays in seeking OP care are shorter in the National Capital Region than in other regions, but longer OP delays are associated with presence of a nearby public health facility. Deferrals in seeking IP care are shorter and delays in seeking OP care are longer when the sick or injured member is employed. When the spouse of the household head is employed, IP care is likewise postponed further. Relative to the poorest income quintile, the second- and third-income quintiles tarry longer. Last, insurance coverage and urban location are not found to be significant correlates. To enhance the effectiveness of recent reforms on utilization, these results suggest deepening the awareness of the covered population of their insurance benefits or to monitor the quality of local health facilities, especially that received grants. Labor policies that reduce the opportunity cost of seeking care among the employed may also be considered.

Cooking and coughing: Estimating the effects of clean fuel for cooking on the respiratory health of children in the Philippines.

Household air pollution (HAP) arising from the use of solid fuels for cooking is known to have adverse health effects including acute respiratory infections in children, which remains a major public health concern in developing countries. Hence, various interventions to reduce HAP have been advocated or piloted in many countries. To provide additional evidence on the effectiveness and applicability of the interventions in various settings, we investigate the effects of clean fuel for cooking on the risks of respiratory illness of children below five years old in the Philippines. We apply the propensity score matching method on a subsample of households culled from the 2013 round of the National Demographic and Health Survey to account for the systematic differences in their characteristics that could influence their choices of cooking fuel. We find that the use of electricity, liquefied petroleum gas, natural gas or biogas can lower by 2.4 percentage points the incidence of severe coughing with difficulty in breathing in young children. Our results support worldwide initiatives to promote the household use of clean fuels for cooking and heating to reduce HAP and its undesirable impacts on population health.

Effects of Price, Information, and Transactions Cost Interventions to Raise Voluntary Enrollment in a Social Health Insurance Scheme: A Randomized Experiment in the Philippines.

A cluster randomized experiment was undertaken testing two sets of interventions encouraging enrollment in the Individually Paying Program (IPP), the voluntary component of the Philippines' social health insurance program. In early 2011, 1037 unenrolled IPP-eligible families in 179 randomly selected intervention municipalities were given an information kit and offered a 50% premium subsidy valid until the end of 2011; 383 IPP-eligible families in 64 control municipalities were not. In February 2012, the 787 families in the intervention sites who were still IPP-eligible but had not enrolled had their vouchers extended, were resent the enrollment kits and received SMS reminders. Half the group also received a 'handholding' intervention: in the endline interview, the enumerator offered to help complete the enrollment form, deliver it to the insurer's office in the provincial capital, and mail the membership cards. The main intervention raised the enrollment rate by 3 percentage points (ppts) (p = 0.11), with an 8 ppt larger effect (p < 0.01) among city-dwellers, consistent with travel time to the insurance office affecting enrollment. The handholding intervention raised enrollment by 29 ppts (p < 0.01), with a smaller effect (p < 0.01) among city-dwellers, likely because of shorter travel times, and higher education levels facilitating unaided completion of the enrollment form. Copyright © The World Bank Health Economics © 2015 John Wiley & Sons, Ltd.

Do piped water and flush toilets prevent child diarrhea in rural Philippines?

Similar to other developing countries, diarrhea in the Philippines continues to be among the top causes of child mortality and morbidity. In pursuit of its Millennium Development Goals, the Philippine government commits to reduce child deaths and provide water and sanitation services to more rural households by 2015. Applying propensity score matching on the 1993, 1998, 2003, and 2008 rounds of the National Demographic and Health Survey to estimate the average treatment effect on the treated, it is found that the incidence of diarrhea among under-5 children is lower by as much as 4.5% in households with access to piped water and 10% in those with their own flush toilets, relative to comparable households. These findings underscore the need to ensure the quality of drinking water from the pipe or from other improved sources at the point of use, and the provision of improved and own sanitation facilities.