Integrating COVID-19 Vaccination in Primary Care Service Delivery: Insights From Implementation Research in the Philippines

Juan Bernardo Lava; Vergil de Claro; Maria Socorro Quiñon; Rodney Labis; Wendel Marcelo; Miguel Angelo Lucero; Ophelia Mendoza; Laurentiu Stan

doi:10.9745/GHSP-D-23-00202

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FIGURE 1
PhilHealth’s Primary Care Benefit Package Services and Payment Mechanisms
Abbreviation: PhilHealth, Philippine Health Insurance Corporation.
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FIGURE 2
Map of Province of Iloilo, Philippines Showing Public Health Facilities and Clusters of Subprovincial Health Systems
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FIGURE 3
Public Health and Primary Care Integration Model in Province of Iloilo With Interventions Shown Across the Service Delivery Process
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FIGURE 4
Distribution of COVID-19 Vaccine Doses Across Age Groups and Vaccine Types, Province of Iloilo, Philippines
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FIGURE 5
Reasons for Vaccine Hesitancy, Survey Results, Province of Iloilo, Philippines^a
^a Survey conducted in March 2023.

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TABLE 1.

Summary of Project Performance, Province of Iloilo, Philippines, as of April 30, 2023

RE-AIM Dimensions/ Indicators	Projected, No. (%)	Post-Intervention Performance, No. (%)	Means of Verification	Remarks
Reach
Proportion of population that was registered to a primary care provider^a	420,000 (≈20.0)	405,826 (19.3)	Facility-level data and program reports	The cumulative total population registered with a primary care provider includes individuals registered before the study. However, a substantial portion of the overall result can be attributed to the interventions implemented during the study.
Effectiveness
Number of individuals that had FPE (including health profiling)	72,000 (100.0)^a	110,795 (153.9)	Facility-level data; program reports	Our observations indicate that the rotating barangay-based model, which involved conducting scaled-down mass registration activities in each barangay (village) without the need for additional personnel, had a greater impact on the increase in first-patient encounters compared to both continuous facility-based model and mass registration approaches.
Number of WRA given FP services	3,240 (100.0)^b	10,369 (320.0)	Facility-level data; program reports	The total number of WRA with contraceptive methods initiated was not accurately tracked. However, we were able to document 1,099 WRA as new or other acceptors, and the remaining only received FP counseling services.
Number of individuals given COVID-19 vaccination	33,957 (100.0)^c	15,628 (46.0)	Facility-level data; program reports	The primary COVID-19 vaccine series coverage was already high at the start of the study. However, the lower-than-expected results can be attributed to challenges in closely monitoring adaptive measures for vaccination and vaccine supply shortages during the study period.
Adoption
Number of primary care facilities who participated in the intervention	43 (100.0)	36 (81.4)	Program reports	Only 36 of all 43 public primary care facilities participated in the study. Among the 36 facilities, 27 were accredited by PhilHealth by the end of the intervention.
Implementation
Fidelity (adherence to steps and intervention protocol)	Consistency between recommended and implemented processes in the intervention protocol	See remarks	Minutes of mid-implementation review and pause-and-reflect sessions; focus group discussion transcripts	Modifications in the registration activities were made. Initially, the registration format consisted of 2 designs: (1) facility-based registration and profiling setup and (2) a mass registration activity held once per local government unit with additional workforce support. Adopted a patient-centric approach through the rotating barangay-based model. Also, a vaccine hesitancy survey was later introduced to gather additional information on the topic.
Maintenance
Number of primary care facilities continuing to implement the intervention after the study period	36 (100.0)	36 (100.0)	Observation checklist; post-implementation review; facility-level data	To date, the facilities are actively implementing the intervention, and the ReachHealth project continues to provide the necessary technical assistance to ensure sustained implementation in these sites. Furthermore, a select number of consultants were hired directly by the primary care facilities in the months after the engagement as full-time staff and continue to implement the model.
Increase in the amount of health insurance reimbursements	No target indicated; baseline was <PhP4,000 or US$80	PhP553,915 or US$11,078	Observation checklist; post-implementation review; facility-level data	At the beginning of the activity, the participating health facilities generated less than PhP4,000 in health insurance reimbursements. The significant increase at post-intervention assessment was considered a critical driver for sustained financing of the intervention.

Abbreviations: FPE, first patient encounter; FP, family planning; PhilHealth, Philippine Health Insurance Corporation; PhP, Philippine peso; WRA, women of reproductive age.
↵^a Based on a 30–35 daily average count of FPE considering the available medical consultants and number of days allocated to conduct the FPE within the intervention period.
↵^b Based on the proportion of WRA among the target population estimated using the family planning estimation tool; potential reach was adjusted for an anticipated higher attendance, particularly among stay-at-home mothers, given the type of outreach activities.
↵^c Based on the estimated reach of 10% of eligible individuals who had not received COVID-19 vaccination among the target population.

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TABLE 2.

Facilitators and Barriers to Implementing an Integrated Primary Care Service, Province of Iloilo, Philippines

RE-AIM Dimensions	Facilitators	Barriers
Reach	Endorsement from the municipal health officer and mayor Availability of human resources for health Positive reception of the Konsulta package by local health teams Close proximity of the primary care services to households	Lack of support from local chief executive Insufficient human resources Inadequate financial support for conducting mass registration activities Considerable distance from the site of registration and profiling
Effectiveness	Availability of vaccines and family planning commodities Involvement of the family decision-maker Presence of physician for patient persuasion, in contrast to other health care workers	Misinformation by organized local groups Absence of vaccines and family planning commodities Timing of profiling activity (weekdays meant fewer working individuals and more senior citizens)
Adoption	High interest of municipal health officers Provision of incentives for municipalities committed to implementation (i.e., augment human resources) Initial funding for the hiring of medical consultants to provide technical support	Obtaining approval from local legislative body to participate in the intervention takes time Unfavorable perception of the current capitation amount of the primary care benefit package considered to be below the market cost
Implementation	Existence of efficient knowledge-sharing channels through multistakeholder group chats and frequent meetings Effective utilization of weekly reports and regular feedbacking of implementation challenges	Lengthy process in securing primary care facility accreditation from public health insurance Lack of resources to conduct mass registration in certain settings
Maintenance	Commitment of local chief executives and municipal health officers to generate reimbursements from implementing the intervention	Lack of support from local chief executives Inadequate national-level support to address broader issues, such as accreditation of electronic medical records and changes and agile policies to respond to diverse circumstances