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There has been much debate recently about several issues related to the migration of physicians from developing to developed countries. However, few studies have been conducted to address these issues in a systematic fashion. In an attempt to begin the process of generating systematic data, we designed and distributed a questionnaire addressing several core issues surrounding physician migration to respondents selected on the basis of their special expertise or experience in India, Nigeria, Pakistan, Colombia, and the Philippines. The issues addressed relate to the reasons physicians migrate to developed countries, how migration is related to the structure of medical education, the effect that migration has on the health care infrastructure of developing countries, and various policy options for dealing with physician migration. Though responses varied somewhat by country, a desire for increased income, greater access to enhanced technology, an atmosphere of general security and stability, and improved prospects for one's children were the primary motivating factors for physician migration. A majority of respondents believed that physicians in developing counties are provided with highly specialized skills that they can better utilize in developed countries, but respondents were ambivalent with respect to the utility of educational reform. Responses varied significantly by country with regard to whether physician migration results in physician shortages, but there was widespread agreement that it exacerbates shortages in rural and public settings. With respect to policy options, increasing physician income, improving working conditions, requiring physicians to work in their home countries for a period following graduation from medical school, and creating increased collaboration between health ministries in developed and developing countries found the most favor with respondents. Keywords: Physician migration; Health policy; Developing countries; India; Pakistan; Nigeria; Columbia; The Philippines

A qualitative study into the health seeking behaviour of caretakers in response to ARI in children under five years of age was conducted in the province of Bohol, the Philippines. The study was designed to compliment survey data generated from a long running ARI intervention project, specifically to explain behaviours identified as problematic by the project. Results indicate the importance of folk diagnosis as a basis for selection of first resort for care in the management of childhood ARI. A cultural category, piang, was identified as a major factor influencing health seeking behaviour and delay in consulting the biomedical system where serious ARI exists. In addition, caretakers' financial situation and social contacts are important in their decision to seek biomedical assistance and are often implicated in delay in presentation and acting upon referral to hospital. Key words - ARI health seeking behaviour, delay, traditional healers, non-compliance

Abstract Background A large phase III placebo-controlled, randomized efficacy trial of an investigational 11-valent pneumococcal conjugate vaccine against pneumonia in children less than 2 years of age was conducted in the Philippines from July 2000 to December 2004. Clinical data from 12,194 children who were given either study vaccine or placebo was collected from birth up to two years of age for the occurrence of radiologically proven pneumonia as the primary endpoint, and for clinical pneumonia and invasive pneumococcal disease as the secondary endpoints. Several tertiary endpoints were also explored. Along the core trial, several satellite studies on herd immunity, cost-effectiveness of the study vaccine, acute otitis media, and wheezing were conducted. Results We describe here in detail how the relevant clinical records were managed and how quality control procedures were implemented to ensure that valid data were obtained respectively for the core trial and for the satellite studies. We discuss how the task was achieved, what the challenges were and what might have been done differently. Conclusions There were several factors that made the task of data management doable and efficient. First, a pre-trial data management system was available. Secondly, local committed statisticians, programmers and support staff were available and partly familiar to clinical trials. Thirdly, the personnel had undergone training during trial and grew with the task they were supposed to do. Thus the knowledge needed to develop and operate clinical data system was fully transferred to local staff. Trial registration Current Controlled Trials ISRCTN62323832

Abstract Background The goal of this Geographic Information System (GIS) study was to obtain accurate information on the locations of study subjects, road network and services for research purposes so that the clinical outcomes of interest (e.g., vaccine efficacy, burden of disease, nasopharyngeal colonization and its reduction) could be linked and analyzed at a distance from health centers, hospitals, doctors and other important services. The information on locations can be used to investigate more accurate crowdedness, herd immunity and/or transmission patterns. Method A randomized, placebo-controlled, double-blind trial of an 11-valent pneumococcal conjugate vaccine (11PCV) was conducted in Bohol Province in central Philippines, from July 2000 to December 2004. We collected the information on the geographic location of the households (N = 13,208) of study subjects. We also collected a total of 1982 locations of health and other services in the six municipalities and a comprehensive GIS data over the road network in the area. Results We calculated the numbers of other study subjects (vaccine and placebo recipients, respectively) within the neighborhood of each study subject. We calculated distances to different services and identified the subjects sharing the same services (calculated by distance). This article shows how to collect a complete GIS data set for human to human transmitted vaccine study in developing country settings in an efficient and economical way. Conclusions The collection of geographic locations in intervention trials should become a routine task. The results of public health research may highly depend on spatial relationships among the study subjects and between the study subjects and the environment, both natural and infrastructural. Trial registration number ISRCTN: ISRCTN62323832

Abstract Background Verbal autopsy methods are critically important for evaluating the leading causes of death in populations without adequate vital registration systems. With a myriad of analytical and data collection approaches, it is essential to create a high quality validation dataset from different populations to evaluate comparative method performance and make recommendations for future verbal autopsy implementation. This study was undertaken to compile a set of strictly defined gold standard deaths for which verbal autopsies were collected to validate the accuracy of different methods of verbal autopsy cause of death assignment. Methods Data collection was implemented in six sites in four countries: Andhra Pradesh, India; Bohol, Philippines; Dar es Salaam, Tanzania; Mexico City, Mexico; Pemba Island, Tanzania; and Uttar Pradesh, India. The Population Health Metrics Research Consortium (PHMRC) developed stringent diagnostic criteria including laboratory, pathology, and medical imaging findings to identify gold standard deaths in health facilities as well as an enhanced verbal autopsy instrument based on World Health Organization (WHO) standards. A cause list was constructed based on the WHO Global Burden of Disease estimates of the leading causes of death, potential to identify unique signs and symptoms, and the likely existence of sufficient medical technology to ascertain gold standard cases. Blinded verbal autopsies were collected on all gold standard deaths. Results Over 12,000 verbal autopsies on deaths with gold standard diagnoses were collected (7,836 adults, 2,075 children, 1,629 neonates, and 1,002 stillbirths). Difficulties in finding sufficient cases to meet gold standard criteria as well as problems with misclassification for certain causes meant that the target list of causes for analysis was reduced to 34 for adults, 21 for children, and 10 for neonates, excluding stillbirths. To ensure strict independence for the validation of methods and assessment of comparative performance, 500 test-train datasets were created from the universe of cases, covering a range of cause-specific compositions. Conclusions This unique, robust validation dataset will allow scholars to evaluate the performance of different verbal autopsy analytic methods as well as instrument design. This dataset can be used to inform the implementation of verbal autopsies to more reliably ascertain cause of death in national health information systems.

Abstract Background Despite the importance of mortality data for effective planning and monitoring of health services, official reporting systems rarely capture every death. The completeness of death reporting and the subsequent effect on mortality estimates were examined in six municipalities of Bohol province in the Philippines using a system review and capture-recapture analysis. Methods Reports of deaths were collected from records at local civil registration offices, health centers and hospitals, and parish churches. Records were reconciled using a specific set of matching criteria, and both a two-source and a three-source capture-recapture analysis was conducted. For the two-source analysis, civil registry and health data were combined due to dependence between these sources and analyzed against the church data. Results Significant dependence between civil registration and health reporting systems was identified. There were 8,075 unique deaths recorded in the study area between 2002 and 2007. We found 5% to 10% of all deaths were not reported to any source, while government records captured only 77% of all deaths. Life expectancy at birth (averaged for 2002-2007) was estimated at 65.7 years and 73.0 years for males and females, respectively. This was one to two years lower than life expectancy estimated from reconciled reported deaths from all sources, and four to five years lower than life expectancy estimated from civil registration data alone. Reporting patterns varied by age and municipality, with childhood deaths more underreported than adult deaths. Infant mortality was underreported in civil registration data by 62%. Conclusions Deaths are underreported in Bohol, with inconsistent reporting procedures contributing to this situation. Uncorrected mortality measures would subsequently be misleading if used for health planning and evaluation purposes. These findings highlight the importance of ensuring that official mortality estimates from the Philippines are derived from data that have been assessed for underreporting and corrected as necessary.

Background: Studies focusing on the Integrated Management of Childhood Illness (IMCI) program in the Philippines are limited, and perspectives of frontline health care workers (HCWs) are largely absent in relation to the introduction and current implementation of the program. Here, we describe the operational challenges and opportunities described by HCWs implementing IMCI in five regions of the Philippines. These perspectives can provide insights into how IMCI can be strengthened as the program matures, in the Philippines and beyond.Methods: In-depth interviews (IDIs) were conducted with HCWs (n = 46) in five provinces (Ilocos Sur, Quezon, National Capital Region, Bohol and Davao), with full transcription and translation as necessary. In parallel, data collectors observed the status (availability and placement) of IMCI-related materials in facilities. All data were coded using NVivo 12 software and arranged along a Social Ecological Model.Results: HCWs spoke of the benefits of IMCI and discussed how they developed workarounds to ensure that integral components of the program could be delivered in frontline facilities. Five key challenges emerged in relation to IMCI implementation in primary health care (PHC) facilities: 1) insufficient financial resources to fund program activities, 2) inadequate training, mentoring and supervision among and for providers, 3) fragmented leadership and governance, 4) substandard access to IMCI relevant written documents, and 5) professional hierarchies that challenge fidelity to IMCI protocols.Conclusion: Although the IMCI program was viewed by HCWs as holistic and as providing substantial benefits to the community, more viable implementation processes are needed to bolster acceptability in PHC facilities. [ABSTRACT FROM AUTHOR]

Abstract Background Few studies have described heterogeneity in Schistosoma japonicum infection intensity, and none were done in Philippines. The purpose of this report is to describe the village-to-village variation in the prevalence of two levels of infection intensity across 50 villages of Samar Province, the Philippines. Methods This cross-sectional study was conducted in 25 rain-fed and 25 irrigated villages endemic for S. japonicum between August 2003 and November 2004. Villages were selected based on irrigation and farming criteria. A maximum of 35 eligible households were selected per village. Each participant was asked to provide stool samples on three consecutive days. All those who provided at least one stool sample were included in the analysis. A Bayesian three category outcome hierarchical cumulative logit regression model with adjustment for age, sex, occupation and measurement error of the Kato-Katz technique was used for analysis. Results A total of 1427 households and 6917 individuals agreed to participate in the study. A total of 5624 (81.3%) participants provided at least one stool sample. The prevalences of those lightly and at least moderately infected varied from 0% (95% Bayesian credible interval (BCI): 0%–3.1%) to 45.2% (95% BCI: 36.5%–53.9%) and 0% to 23.0% (95% BCI: 16.4%–31.2%) from village-to-village, respectively. Using the 0–7 year old group as a reference category, the highest odds ratio (OR) among males and females were that of being aged 17–40-year old (OR = 8.76; 95% BCI: 6.03–12.47) and 11–16-year old (OR = 8.59; 95% BCI: 4.74–14.28), respectively. People who did not work on a rice farm had a lower prevalence of infection than those working full time on a rice farm. The OR for irrigated villages compared to rain-fed villages was 1.41 (95% BCI: 0.50–3.21). Discussion We found very important village-to-village variation in prevalence of infection intensity. This variation is probably due to village-level variables other than that explained by a crude classification of villages into the irrigated and non-irrigated categories. We are planning to capture this spatial heterogeneity by updating our initial transmission dynamics model with the data reported here combined with 1-year post-treatment follow-up of study participants.

Background and objectives Despite a substantial reduction in the mortality rate of children under 5 years in the past 25 years, pneumonia remains the single-largest infectious cause of child deaths worldwide. This study explored the chronological order of visited healthcare facilities and practitioners, and the factors affecting mothers’ intention to seek care before the hospitalisation of children with pneumonia. Methods and analysis A qualitative research design was employed using theory of planned behaviour as a framework for the analysis. Using purposive sampling technique, 11 mothers, whose children under 5 years old were hospitalised with severe pneumonia, were recruited for individual semi-structured interviews. Their sociodemographic information was analysed using descriptive statistics. Results Mothers brought their sick children to multiple facilities, and 1 to 19 days had passed before hospitalisation. We identified four major factors determining mothers’ intentions: (1) doing something useful for the sick child, (2) expecting the child to receive the necessary assessment and treatment, (3) accepting advice to visit a healthcare facility and be referred to a hospital and (4) considering issues and benefits associated with hospitalisation. Mothers noticed their children’s unusual symptoms and monitored them while applying home remedies. They also took their children to traditional healers despite knowing that the treatments were not necessarily effective. Mothers expected children to be checked by health professionals and listened to advice from family members regarding the facilities to visit, and from healthcare staff to be referred to a hospital. Financial issues and the double burden of housework and caring for the hospitalised child were mothers’ major concerns about hospitalisation. Conclusion Children were hospitalised after several days because they visited multiple healthcare facilities, including traditional healers. Improving care quality at healthcare facilities and reducing financial and mothers’ burden may reduce the hospitalisation delay for children with pneumonia. [ABSTRACT FROM AUTHOR]