How the Philippines integrated malnutrition management into its health system

Experience from the Republic of the Philippines

[Editor’s Note: This is the fourth post in a blog series on sustainable strategies to improve access to wasting treatment. The series is spurred by the historic half a billion dollars pledged by donors this year to improve child nutrition with an aim to review strategic ways to use this funding. This blog aims to provide a country example of integration. Insights highlighted are based on a report showcasing the experience of integrating treatment services for severe acute malnutrition into the national health system in the Republic of the Philippines.]

Though the Philippines has made significant investment and progress in child health in recent years, the level of stunting remains high at 28.8% (2019). However, the country has made some progress toward the World Health Assembly (WHA) targets to reduce stunting. Similar trends are seen in the reduction of the prevalence of wasting, with a reduction from 8% in 2015 to 5.8% in 2019. At this current state of progress, the country will be on track to achieve the SDG goal of <3% of wasting prevalence by 2030.

To address malnutrition, the Philippines introduced the management of severe acute malnutrition (SAM) in 2008 as a Nutrition in Emergencies intervention for disaster-affected communities. In 2015, the Philippines Integrated Management of Acute Malnutrition (PIMAM) guidelines were adopted by the Department Of Health (DOH) to support the integration of treatment for children suffering from SAM into the on-going routine health and nutrition services at national and local levels. The PIMAM was made part of the basic primary health care (PHC) services in 2017 and the universal health coverage (UHC) law has supported the integration process further.

This blog details the significant progress made by the Philippines for the integration of PIMAM into the national health system, based on this report. As in the resource guide developed by R4D and UNICEF to identify integration actions that can help achieve early detection and treatment of child wasting within routine PHC systems, the Philippines reviewed the current status and key actions needed across each of the World Health Organization (WHO) health system building blocks.

Leadership and governance

Current Status: Today, PIMAM has been embedded in most of the laws, guidelines and administrative orders developed in recent years, although some gaps remain. This achievement is thanks to a strong national commitment to scale up provision of services for the management of SAM through the national health system. National guidelines for PIMAM supporting comprehensive child healthcare are now developed, and ongoing work is happening to integrate it into the Integrated Management of Childhood Illness Program (IMCI), which includes SAM management, and child hospital care and through a national level PIMAM technical working group to oversee wasting scale up within the health system.

Lessons learned:

• To achieve greater integration, PIMAM should be championed and systematically coordinated at the local level.
• Integration of SAM management into UHC planning is critical to ensure synergies with other health programs and avoid overburdening services at the Local Government Unit (LGU) level.
• For integration of SAM services to work, governments must lead the process.

Health financing

Current Status: The budget of the DOH has massively increased over the past years reflecting the increased priority for health care and UHC. However, the budgets allocated to nutrition programs at local level are still insufficient. PIMAM supplies are included in the DOH budget, but there are implementation and coordination challenges related to the funding of the LGUs annual costed plans.

Additionally, the National Health Insurance Program (NHIP) through Philippine Health Insurance Corporation (PhilHealth), a Government Corporation attached to the DOH, was established to provide health insurance coverage for all Filipinos. A draft package of services and corresponding standards for the management of SAM was developed from primary to tertiary levels of care in 2019, following the expansion of the primary care benefits of PhilHealth as a commitment to achieving Universal Health Coverage. This package is undergoing pilot-testing to support seamless operationalization.

Lessons learned:

• Continued financial commitment is needed to support PIMAM.
• Advocacy and strengthened nutrition governance are required for local government to prioritize budget allocated to nutrition.

Service delivery

Current Status: Today PIMAM capacities are available in 81 provinces; however, quality services and good coverage are still hampered by system bottlenecks. Challenges that impact the ability to integrate SAM management into the health system include the absence of functional two-way referral systems and fast turnover of health workers at all levels of the health system. But UHC efforts are promising and will contribute to scaling up the delivery of integrated SAM services.

Lessons learned:

• More investment in nutrition training for health workers at the community level, regular supportive supervision, and systematic screening of children is needed to improve early detection of malnutrition.
• The routine child growth monitoring program, which uses local level data generated from Operation Timbang Plus, can be leveraged for early detection of severe malnutrition and facilitation of timely admission into outpatient or inpatient care.
• Boosting demand generation from the communities is needed to improve access and utilization of child health and nutrition services.

Health workforce

Current Status: The Philippines faces imbalances in the development and distribution of health workers. The top three challenges identified for the integration of health workforce for SAM management include the availability of trained human resources for nutrition, the absence of SAM modules in medical and paramedical curricula, and the lack of supportive supervision due to stretched workforce, leading to insufficient mentoring and skills development for health workers.

Lessons learned:

• There is a need for greater geographic distribution and training of health workers.
• SAM management should be included in job descriptions, preservice education curriculum modules, and ongoing professional development training.

Health information system

Current Status: SAM indicators (admission and discharge outcomes [cured, dead, defaulted]) have been adopted and integrated into the Health Management Information System (HMIS), through UNICEF’s technical assistance to the DOH, which simplifies the collection and reporting processes. Previously, reporting of SAM indicators was done using parallel and offline systems which contributed to the workload of both local health staff and partners.

Lessons learned:

• Continuous monitoring of potential challenges that may arise within the HMIS is beneficial to support and adjust implementation.
• There is a need to improve completeness and accuracy of SAM reports sent by health facilities and ensure the data collected supports decision-making and planning processes.

Nutrition supplies

Current Status: The DOH has been working towards a more integrated supply management system for all health and nutrition supplies. In 2016, the DOH started procurement of Ready-to-Use Therapeutic Food (RUTF) and the first batch of this life-saving treatment through government funds was delivered in March 2017. The DOH has continued to allocate budgetary resources for the procurement of RUTF to cover a proportion of the caseload. RUTF has also been registered into the Food and Drug Administration (FDA) and classified as a Food for Special Medical Purposes, facilitating its procurement and delivery by the national supply chains system.

Additionally, the government has enacted policies to keep the prices of medicine down. However, supply chain management up to the last mile (delivery at health facility) remains a challenge and local governments need further financial support to ensure availability of supplies in their health facilities.

Lessons learned:

• Continued improvements of the national supply chain system are needed to ensure availability and tracking of treatment.
• Decentralization of budget for SAM management to local governments should be encouraged given current budget limitations and stock-outs in health facilities due to supply chain inefficiencies.

Momentum toward improving SAM integration must be maintained

The government of the Philippines has been working to integrate SAM management into the national health system in a more harmonious way than when it was vertically integrated. While there are several remaining challenges for SAM integration across the health system building blocks, the provision of UHC provides great potential to fully integrate SAM management through the overall strengthening of the health system. Maintaining the momentum of the political leadership — at all levels of government — demonstrated in the Philippines will be vital to ensure continuous success of this strategy.

Authors: Mueni Mutunga, Nutrition Specialist, UNICEF Regional office of East Asia and Pacific; Rene Gerard Galera, Nutrition Specialist, UNICEF Philippines; Minh Tram Le, Nutrition Specialist for the Care for Children with Wasting, UNICEF Headquarters; Alexandra Farina

Catch up on the series

• Improving access to malnutrition treatment within primary health care
• Strategic opportunities to scale ready-to-use therapeutic foods
• Optimizing primary health care to treat child wasting
• How the Philippines integrated malnutrition management into its health system
• Q&A: Strategic approaches to improve access to wasting treatment in Ethiopia

To address malnutrition in the Philippines, the government has worked to integrate severe acute malnutrition management into primary health care. In this blog, @UNICEF & R4D experts detail the progress made and highlight areas for improvement. https://t.co/ayRBAcjT1r

— R4D (@results4dev) March 9, 2023