Let Us Work Together to Flatten the Curve

Position Statement from Concerned Faculty Members of the Department of Health Policy and
Administration, College of Public Health, University of the Philippines Manila
March 27, 2020
It has been 13 days since an Enhanced Community Quarantine was enforced by the National Government.
Since then, the number of COVID 19 cases - both confirmed and clinically assigned as COVID 19 cases have
been steadily increasing. There are reports and enormous requests for PPEs not only in the COVID
designated hospitals but also in the regions.
We implore the DOH, the Inter Agency Task Force and the members of the National Action Plan to:
A. Allow those in academia, the policy makers, the health service managers, civil society to help
them out. We have the expertise and are reaching to these entities- let us work together!

B. Be guided by the following principles

1. There must be equitable access to resources as the country addresses the COVID19 pandemic in
various ways, as an important principle to lessen its impact to the poor, the disadvantaged and
the vulnerable.
Of urgent concern is the logistic distribution of the PPEs by need rather than demand not
only to hospitals in the National Capital Region but also in preparation for the increase of
cases in the Visayas and Mindanao regions.

2. There has to be a balance between the need for transparency in reporting for public good and
public health while protecting and upholding confidentiality and privacy;

a. In order to come up with the best decisions under our current crisis situation, we need good
information about the incidence of COVID 19 as well as a clear idea of the needs and demand
of communities and health facilities. We can help government through our expertise. Allow us
to help. Share your information, facilitate the gathering of information for decision making.

b. People need to know what is happening and it is their right to be informed about what
government is doing for their safety and benefits.

3. Effectiveness of measures to mitigate transmission requires multi-faceted best-timed non-

pharmaceutical interventions, and to ensure effectiveness, LGU’s public health interventions will
have to be synchronized to be efficient, relevant and effective.

a. Refine clinical guidelines and protocol to adjust to resource limitations

b. Conserve resources, Minimize Donor Fatigue. Reassess plans to build more hospitals. We
need to use available resources and optimize what we have before we consider building new
wings and hospitals.

c. Protect our health care workers

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 4. The whole-of-government, whole-of-systems approach, is necessary to strengthen resiliency of
our local health system from communities to the apex hospitals.
Strengthen all LGU efforts in a manner consistent with community partnership and human
rights .

We, therefore, propose these guidelines as attached:

Department of Health Policy and Administration

Dr. Ronald Del Castillo, PsyD, MPH

Carmelita C. Canila ,MD , MPA Emerito Jose A. Faraon , MD, MBA Angelita V. Larin, MD, MS, MNSA, MHA

Fernando B. Garcia Jr., PhD Susan T Yanga-Mabunga, DDM, MScD Ronald T. Del Castillo, PhD

Ma. Esmeralda C. Silva , PhD Richard S. Javier, MBA Katherine Ann V. Reyes , MD , MPP

Carlos Primero D. Gundran, MD, MScDM, FPCEM

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 Health Systems Approach to Lessen the Burden on the Poor and the Need for Intensive Care

Introduction

Based on recent epidemiologic modelling of the Department of Health, CoVid19 cases in the Philippines
could reach up to 75,000 cases by June 2020 if not contained [Source: https://bit.ly/33OT7YR]. As of this
writing, the number of confirmed COVID-19 cases has already breached the 700-mark (March 26th), when
exactly this same day last week, there were only 217 (March 19th), and 52 one week earlier (March 9th)
[Source: DOH official FB page]

The recent pronouncement by the Department of Health points to an upward trend in positive cases
due to the increased capacity for testing [https://news.abs-cbn.com/video/news/03/24/20/biosafety-
threat-temporarily-halted-covid-19-testing-health-dept]. Except for the National Capital Region (NCR),
most private and government hospitals are Level 1 and 2 hospitals which would not have the capability
to treat severe COVID-19 patients at present (Table 1).

Table 1. PhilHealth-Accredited Private and Government Hospitals by Accreditation Level, 2016.

Region Level 1 Level 2 Level 3

Private Government Private Government Private Government

NCR 72 24 33 7 31 25

CAR 8 11 2 2 1 1

I 24 15 20 5 1 3

II 24 23 8 2 0 1

III 76 43 37 3 5 4

IVA 51 31 42 4 2 1

IVB 30 26 21 0 3 1

V 15 15 13 4 1 2

VI 8 29 13 2 6 3

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 Region Level 1 Level 2 Level 3

Private Government Private Government Private Government

VII 17 19 14 2 7 1

VIII 16 20 6 2 1 1

IX 21 9 7 2 0 1

X 24 16 19 5 2 1

XI 26 9 17 2 3 2

XII 30 9 13 0 1 2

CARAGA 3 7 5 3 0 0

ARMM 10 19 0 2 0 0

Source: PhilHealth data, 2016

As it is, there are not enough hospital beds, more so for beds for critical care and isolation which are
needed for severe COVID-19 cases. Despite the availability of hospitals in the NCR, more than 4 private
hospitals have already reached their full capacity and are unable to admit more patients [Source:
https://bit.ly/2vVjsbi].

Method and Results

Looking at the infrastructure at the community-level, a quick survey among purposively selected Local
Government Units (LGUs) was conducted to look into the community-based facilities that would serve as
staging grounds to address the needs of those who have COVID-19 concerns as well as those classified as
PUMs, PUIs and confirmed cases. A total of 25 LGUs were surveyed within a 24-hour period from 23-24
March 2020. The data collected were culled from publicly available information from Internet sources
(social media announcements, LGU Facebook pages) and interviews with health workers when applicable.
Significant findings of the survey include:
• At the community level, two (2) most common ways for people to convey their COVID-19
concerns are through the Barangay Health Emergency Response Teams, or BHERTs (50%)
and/or through a LGU hotline (39%).

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 • Among LGUs surveyed, almost half of the LGUs which made their interventions public
indicated that PUMs were advised to do home quarantine while 26% identified
barangay special care facilities where PUMs could temporarily stay. Among those who
are instituting home quarantine, there were some LGUs which designated these barangay
facilities as spaces for those violating their home quarantine as well.

• Half of the LGUs surveyed had dedicated facilities for PUIs. A third of cities surveyed had
dedicated quarantine buildings while an equal number sent their PUIS to hospitals. Two
out of three municipalities with available information had an identified facility, such as
barangay/ municipality isolation unit, hospital and evacuation center.

• Two out of five LGUs surveyed indicated that mild COVID-19 cases will be referred to their
district and provincial hospitals while 35% will refer to their regional hospital.

• Consistent with DOH protocol, severe COVID-19 cases will be sent to higher-level
hospitals. Among those surveyed, these were the nearest provincial or regional hospitals.

Policy Issue

The imposition of the enhanced community quarantine has created a massive influx of people from Manila
to the provinces outside of NCR. It is likely that there were asymptomatic COVID-19 patients that joined
this movement. Lockdowns, in its various iterations, has not fully hampered the mobility of people across
municipal and city borders.

Local hospitals outside of the NCR, particularly those in the Visayas and Mindanao areas, are more
vulnerable to being overwhelmed once the PUIs with severe symptoms, mild and severe COVID-19 cases
start coming in. These areas have long suffered from chronic lack of resources, including health facilities.
It is painfully obvious that there will come a time when there will not be enough beds to accommodate
those who need treatment. This is further compounded by the likelihood that there will be no alternative
hospitals to take them to.

This brings to light the need for an infrastructure to be in place that ensures that patients can get the
appropriate care that they need that is not necessarily hospital based. The results of a small survey suggest
that there are resources available at the community level that should be organized and integrated into the
network of facilities to decongest hospitals. For example, the DPWH report that there are 110 completed
evacuation centers nationwide can be used as health facilities for PUIs. It can accommodate an estimated
number of 4,620 persons (based on a 12 square meter per patient safety standard of DOH) [DPWH
Evacuation Center Projects Ready for COVID Patients;
http://www.dpwh.gov.ph/DPWH/news/18797 ].

Objectives:
This health systems approach is primarily aimed at ending the epidemic, the most effective and fastest
way possible through collaboration between and among LGUs, national government, civil society
organizations, and the private business sector.

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Specific objectives include preventing transmission, suppressing the rate of increase in patients,
decongesting hospitals, minimizing the number of critically ill patients requiring intensive care, mitigating
the impact of the epidemic especially among the poor, disadvantaged, the vulnerable, and society in
general.

Principles:
1. There must be equitable access to resources as the country addresses the COVID19 pandemic
in various ways, as an important principle to lessen its impact to the poor, the disadvantaged
and the vulnerable.
2. There has to be a balance between the need for transparency in reporting for public good and
public health while protecting and upholding confidentiality and privacy;
3. Effectiveness of measures to mitigate transmission requires multi-faceted best-timed non-
pharmaceutical interventions, and to ensure effectiveness, LGU’s public health interventions
will have to be synchronized to be efficient, relevant and effective.
4. The whole-of-government, whole-of-systems approach, is necessary to strengthen resiliency of
our local health system from communities to the apex hospitals.

Proposed Guidelines:
A. Strengthening of community-based surveillance
1. Shift the focus of the Barangay-level health teams’ tasks to actively monitor, the way they have
always been doing, those who have fever, cough, colds, and difficulty of breathing,
2. Identify and record, or regularly update any existing registry of all individuals with NCD
comorbidities, pregnant/lactating mothers, those immunocompromised and other persons with
special needs.
3. Identify and record those with travel history, most especially to already identified hotspots of
COVID19 infection (based on the DOH COVID19 tracker in its official website).
4. For those exhibiting signs and symptoms, Barangay-level health teams shall immediately refer (by
text or phone or by email) to the Rural or City Health Offices within 4-8 hours.
5. Rural and City Health Offices must set up a call center or community hotline, with different mobile
numbers (from different service providers), through which Barangay-level health teams will
inform or refer to the higher-level facilities.
6. Rural and City Health Offices shall strengthen their surveillance system enabling daily reporting to
Provincial Epidemiology Surveillance Units at the Provincial Health Offices and subsequently to
the DOH Regional Offices
7. Aggressively monitor clusters of individuals with flu-like signs and symptoms or pneumonia cases
in barangays. Should this happen, the Barangay-level health team shall immediately report it to
the Rural or City Health Offices.

B. Strengthening service delivery from community-based surveillance

1. Immediately contact patients, presumptive or otherwise, who have been reported by Barangay-
level health teams using multi-media or social media within 4-8 hours, to assess the patient's
condition.
2. Physically deploy primary health professionals to assess individuals in need of further testing or
hospitalization should there be no or limited multi-media or social media.

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 3. For those requiring further physical consultation at the Rural or City Health Offices, separate
treatment hours and flow of patients, declared as PUMs or PUIs or neither of the two but are
manifesting COVID19 signs and symptoms, from others who are consulting the public health
centers for other reasons.
4. Individuals manifesting mild flu-like signs and symptoms must remain at home and contact the
Rural or City Health Office if their signs and symptoms worsen.
5. Individuals with non-communicable diseases like diabetes, hypertension, and cardiovascular
illnesses, who are immuno-compromised, elderlies who manifest mild flu-like signs and symptoms
shall immediately contact the Rural or City Health Offices and must not wait for their signs and
symptoms to deteriorate.
6. Rural or City Health Offices shall refer, conduct patients who manifest deteriorating signs and
symptoms requiring higher level of health care, with the proper PPEs, complying to proper
disinfection guidelines for the transportation facilities after conducting patients.
7. Continue and robustly implement regular public health programs in communities.
8. Ensure sustainable home-based services, medicines, and food/nutritional supplies to those who
are elderly, with NCD comorbidities, and immuno-compromised to protect them from contracting
COVID10.

C. Testing for COVID19 infection

1. Cognizant of the temporary lack of trained health professionals, testing kits, testing sites and PCR-
laboratories, patients shall be prioritized for testing, as follows:
a. Hospitalized patients and symptomatic healthcare workers shall be the first priority for testing.
b. Patients in long-term care facilities or 65 years of age and older, with underlying medical
conditions, or first responders exhibiting signs and symptoms shall be the second priority for
testing.
c. Individuals manifesting mild symptoms, who are from areas where there is local community
transmission or in areas with an increased hospitalization of patients with laboratory-
confirmed COVID19.

2. Once the country has already acquired more testing kits, human resources have been trained,
diagnostic laboratories have been established for COVID19 testing, the list of individuals to be
tested shall be expanded. And the strategy to increase access to COVID19 testing by a wider
population shall be developed.

D. Protecting health workers

1. Health workers from Barangay-level health teams to rural/city health centers, all hospitals must
wear universally acceptable Personal Protective Equipment when they do community-based
surveillance, getting specimen (such as swabbing), managing patients regardless if they are
PUM, PUI or laboratory-confirmed COVID positive

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 2. National and Local Government Units, private health care facilities shall provide sustainable
supply of PPEs to respective health facilities and health workers
3. Train health workers on general precautionary measures
4. Organize teams of health workers who will go on rotation to ensure that everybody gets enough
rest, proper self-care, ensure mental health and well-being.

E. Service Delivery Network

1. Manage the flow of people and patients moving through the referral process for COVID-19
patients. This should be supported by an active and functional network of facilities.
2. The forward flow of the referral process starts at the time when a person expresses their COVID-
19 concerns, particularly whether they feel any of the symptoms, have travel history and/or
contact with the COVID-19 patient.
a. Design and implement a gatekeeping mechanism at the barangay-level through a hotline.
This should be constantly communicated through various media channels and house-to-
house campaigns.
b. Ensure a functional and active BHERTs, in line with the DILG MC 2020-062 and the Municipal
Orders promulgated by the respective LCE. BHERTs shall regularly coordinate with the
Barangay Health Teams, if the former has different members than the latter. These teams
can be tapped for sustained monitoring of households. Their functions could include:
i. Identify households with vulnerable members (with travel history, age, comorbidities)
ii. Conduct an inventory of residences to include information on space availability, size of
household, etc. Health information at the household level can be sourced from the
family folders kept at the barangay health station.
iii. Serve as gatekeeper and system navigator for persons with COVID-19 concerns, PUMs
and PUIs.
iv. Monitor movements of members of households within their jurisdiction, particularly
those are under home quarantine or self-isolation
3. Establish a network of facilities for PUMs, PUIs and mild COVID-19 cases from the barangay to the
provincial/ regional levels.
.
a. By default, severe COVID-19 cases are referred to and treated at Level 3 facilities.
b. Barangay Isolation Units and/or Barangay Special Care Facilities can be set up to
accommodate PUMs, PUIs or mild COVID-19 patients, depending on the more pressing need
of the barangay (e.g. PUMs/PUIs breaking their home quarantine, PUIs with mild symptoms).
c. Dedicated evacuation centers, gyms/ basketball courts, places of worship could be revamped
to special care facilities or isolation units.
d. Ensure that selected district and provincial health facilities are adequate and sustainably
equipped to handle mild COVID-19 cases.
e. Private hospitals should be a part of the network of facilities. The public hospitals cannot
handle the expected surge of patients. It is important to set guidelines on the engagement of
private hospitals in the network early enough.
f. Although recovered COVID-19 patients are likely to be brought back to their residences, PUIs
whose tests turn out to be negative can fall through the cracks. It is important that the system
can bring these people back to their residences, especially during the enhanced community
quarantine where mobility to and from LGUs are severely restricted.
g. The referral system should be clearly articulated to households via various media channels
and house-to-house campaigns. The flow of referral of persons with COVID-19 concerns,
PUMs, PUIs and patients should be clearly communicated for people not to “jump the line”

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F. Partnerships

1. Contiguous LGUs, or island groupings shall coordinate strategies for implementing best-timed
non-pharmaceutical interventions, community surveillance, referrals, testing.
2. LGUs shall work with national government, private sector and Civil Society Organizations
to achieve the objective of ending the pandemic while mitigating its impact to the whole
Philippine society, most specially the poor, disadvantaged and vulnerable.

G. Implementation structure
1. Barangay Health Teams shall work with the Barangay Disaster Response Reduction Committee.
2. Barangay Health Teams with their representation at the Rural Health Units or City Health Offices
shall be responsible for reporting to the Municipal Epidemiology and Surveillance Unit, and
feedback loop back to the barangays.
3. MESU will in turn be the link to the Provincial Epidemiology and Surveillance Unit, and the
Regional Epidemiology and Surveillance Unit (RESU).
4. For service provision, the Service Delivery Network or the Inter-local Health Zones shall be
strengthened for COVID19 response.

Together, we can #FlattenTheCurve.

References:
Centers for Disease Control and Prevention. March 2020. Criteria to Guide Evaluation and Laboratory
Testing for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html

Centers for Disease Control and Prevention. March 2020. Interim U.S. Guidance for Risk Assessment and
Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to
Patients with Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-
ncov/hcp/guidance-risk-assesment-hcp.html

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Ferguson N, Laydon D, Nedjati-Gilani G., Imai N., Ainslie K., Baguelin M, etal. 2020. Impact of non-
pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand. Imperial
College London. WHO Collaborating Centre for Infectious Disease Modelling.
Ministry of Health, Labor and Welfare. Decisions Made by the Headquarters for Novel Coronavirus
Disease Control. February 25, 2020. Basic Policies for Novel Coronavirus Disease Control (Tentative
translation). https://www.mhlw.go.jp/content/10200000/000603610.pdf

Ministry of Health, Labor and Welfare. PCR testing system for novel corona virus covered by medical
insurance. https://www.mhlw.go.jp/english/

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