The Philippines has been hit hard by the COVID-19 pandemic, with 1.06 million confirmed cases and 17,500 deaths as of May 3, 2021. These numbers are likely just the tip of the iceberg as the pandemic’s indirect health effects have largely gone unmeasured. As we described in an earlier blog, in 2020, seasonally adjusted insurance claims for high-burden diseases declined by almost 60 percent compared to the previous year, reflecting the pandemic’s broad disruption of inpatient care services. In a paper released today, we publish fuller details of that research.
To complement our analysis of insurance claims and provide a more holistic picture of the health impact of the pandemic, we’ve analyzed inpatient and outpatient visits from government hospitals and primary care facilities. A significant portion of the population is not captured in the health insurance data. Despite high reported health insurance coverage, some Filipinos do not avail themselves of PhilHealth (the national health insurer) inpatient benefits, and PhilHealth does not provide comprehensive primary care or outpatient benefits. This new analysis paints a worrying picture of a decline in important health services, especially among children.
COVID-19 pandemic in the Philippines
The numbers of reported COVID-19 cases in the Philippines provides a grim, if incomplete, picture of the pandemic’s ongoing impacts (see Figure 1.).
Figure 1. COVID-19 cases in the Philippines
Source: Our World Data
The government imposed a series of lockdowns in 2020 to control the spread of the virus, and in April 2021, imposed another strict lockdown in the capital to try and curb the second wave of infection. (Details of the government’s response to the pandemic are set out in a recent CGD working paper here.)
The COVID-19 pandemic has had devastating economic consequences. The Philippine economy declined by almost 10 percent in 2020. While it was estimated to grow by 6-7 percent this year, such growth now seems unrealistic given the recent reintroduction of lockdowns.
Measuring the broad health impact of COVID-19
Measuring the magnitude of the impact of the pandemic on healthcare utilization is challenging, especially in low- and middle-income countries where health information systems are weak. In 2016, only 90 government hospitals in the Philippines used the integrated hospital operations and management information system. The devolved governance structure of the health system makes it hard to collect admissions and outpatient visits from local governments.
Without readily available data on hospital admissions and outpatient visits, we earlier used health insurance claims from the national health insurance agency, or PhilHealth, which covers almost all hospitals (both public and private) in the country. Insurance claims data can demonstrate the health impact of the pandemic on utilization of the pandemic. However, given the limitations in our health insurance data, we sought to triangulate our earlier findings with hospital admissions and outpatient visits, in order to validate our initial analysis.
We requested the Department of Health (DOH) to provide us with data on visits and admissions from government health facilities. Primary care facilities, or Rural Health Units, are expected to provide essential and comprehensive healthcare services in local communities, while hospitals provide higher levels of inpatient care. The DOH requested all government hospitals and primary care facilities to submit aggregate admission data as part of its effort to monitor health programs during the pandemic. However, our analysis only includes those facilities that submitted and completed the monitoring questionnaire – 60 out of the 410 government hospitals (17 percent) and 114 out of the 2,500 (5 percent) government primary care facilities.
Decline in pediatric-related hospital admissions
Figure 2 shows the median quarterly admissions of 60 government hospitals in the Philippines. We observed a large variation in admissions across specialties. The median admissions for adult internal medicine and pediatrics declined by 40 percent and 70 percent, respectively in the second quarter compared to the period in the previous year. Similar to our findings using insurance claim data, we did not observe significant improvement in admissions for adult internal medicine until the fourth quarter of 2020, which suggests admissions have continued to decline. Indeed, the sharp decline in pediatric cases suggests that children are bearing the brunt of the pandemic.
Surgery admissions declined during the first national lockdown (April and May 2020) but recovered in the third and fourth quarters of 2020. Our results support our initial findings using health insurance claims. That is, medical claims suffered a sharp decline, but no substantial change in certain procedural claims.
Figure 2. Median hospital admissions in the sample of government hospitals
Note: The national government declared a public health emergency and imposed strict lockdown in mid-March 2020.
Decline in primary care visits among vulnerable populations
In parallel we examined access to essential outpatient services in Rural Health Units. Again, similar to hospital admissions in which pediatric cases suffered the largest decline, consultations among children under five years of age fell by about 44 percent in the second quarter compared to the same period in the previous year. The decline worsened in the third and fourth quarters in 2020. Consultations for the elderly population have also declined by 30 percent in the second quarter with no substantial recovery in the second and third quarters of 2020.
Multiple supply and demand factors could have contributed to the large decline in outpatient visits particularly among vulnerable populations. However, the strict stay-in-home orders for children and elderly throughout the pandemic period may have largely contributed to the precipitous decline.
Key public health programs appear to have been severely affected by the pandemic. Directly observed therapy for TB and hypertension consultations have remained below the pre-pandemic levels, with no significant recovery throughout the year. The median TB consultations in the second quarter of 2020 declined by almost 40 percent compared to the same period in the previous year.
We observed a different trajectory for maternal and child health services. Child delivery and prenatal care appear to have declined in the first and second quarters of 2020, but then recovered.
Figure 3. Median number of visits or consultations in the sample of government primary care facilities
While our initial analysis only captures data from a sample of government primary care facilities and hospitals, it supports and validates our findings from health insurance claims data. That is, broad-based decline in medical cases and heterogenous impact across procedures and surgical cases. Arguably, the data we used in the study, albeit limited, remains one of a kind. The healthcare utilization pattern of non-COVID patients was barely examined throughout the pandemic. Of course, this is exacerbated by the limitations of the country’s weak health information infrastructure.
Our findings should prompt the government to actively measure utilization of essential healthcare services not only by COVID-19 patients but non-COVID-19 patients as well. This is critical in developing a more evidence-based and holistic public health response. As the saying goes: If you can’t measure it, you can’t improve it.
Our data revealed a critical insight that was not entirely captured in the health insurance data: children seem to be bearing the brunt of the pandemic’s collateral health impact. The decline in healthcare use among children, especially when combined with the suspension of face-to-face classes, have tremendous socioeconomic and health repercussions in the medium to long term. Further analysis is needed to examine the full extent of these impacts.
We will release the full report with a more in-depth analysis later this month. Watch this space for more.
Valerie Gilbert Ulep is a research fellow at the Philippine Institute for Development Studies (PIDS). He is currently the project director of different research projects on health financing, health service delivery, and nutrition and human capital. Prior to joining the PIDS, he worked at the World Bank in Washington, DC and Delhi offices. He was a doctoral fellow at the University of Toronto’s Centre for Global Health Research. He holds a PhD in health economics.