Older people’s visual impairment: situational analysis of programmes and services in the Philippines
Older people’s visual impairment: situational analysis of programmes and services in the Philippines WHO Library Cataloguing-in-Publication Data Older people’s visual impairment: situational analysis of programmes and services in the Philippines 1. Health services for the aged. 2. National health programs. 3. Vision disorders. I. World Health Organization Regional Office for the Western Pacific. ISBN 978 92 9061 784 6 (NLM Classification: WT31) © World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications–whether for sale or for non-commercial distribution–should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines (fax: +632 521 1036, email: publications@wpro.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Photo credits: AFP Acknowledgements iv Abbreviations and acronyms v 1. Introduction 1 Ageing and health in the Philippines 1 Visual impairment 2 Objectives of this study 2 Methodology and overview 3 2. Situation analysis 5 Key actors and structures 5 Legal and policy framework 6 Philippine Plan of Action for Senior Citizens 8 Overview of the health system in the Philippines 9 Health promotion for age-related visual impairment 9 Health programmes and services for older people 10 Health financing 14 Health technology 14 Rehabilitation 15 Discussion 15 3. Conclusions and recommendations 18 APPENDIX A. Questionnaire for informant interviews 19 APPENDIX B. Questionnaire for focus group discussions with older people 21 APPENDIX C. Suggestions for using the questionnaires 23 APPENDIX D: Key informants 25 References 27 Table of contents iv Acknowledgements This report documents the findings of a situational analysis of current services and programmes for age-related visual impairment in the Philippines, undertaken by the Philippine Eye Research Institute (PERI) of the National Institutes of Health, University of the Philippines, Manila, on the request of the World Health Organization (WHO) Regional Office for the Western Pacific. The report was prepared by a team comprising Leo D. P. Cubillan, Geniel Ann B. Ignacio, and Jean Ramon Yap, staff of the Philippine Eye Research Institute (principal consultants), and Andreas Mueller, Britta Baer and Anjana Bhushan, with supplementary technical inputs from Pauline Kleinitz of the World Health Organization Regional Office for the Western Pacific. Additional technical inputs from Mylene Benigno, WHO Representative’s Office in the Philippines are gratefully acknowledged. CALABARZON Cavite, Laguna, Batangas, Rizal and Quezon (Region of the Philippines) DDH Davao Doctors Hospital DDO Degenerative Disease Office DOH Department of Health DSWD Department of Social Welfare and Development EOR error of refraction FSCAP Federation of Senior Citizens Associations of the Philippines GDP gross domestic product GRACES Golden Reception and Action Center for the Elderly and other Special Cases HMO health maintenance organizations LGU local government unit NCD noncommunicable disease NCR National Capital Region NGO nongovernmental organization NPBP National Prevention of Blindness Program OSCA Office of Senior Citizens Affairs PHAP Pharmaceutical and Healthcare Association of the Philippines PhilHealth Philippine Health Insurance Corporation PPASC Philippine Plan of Action for Senior Citizens PWD people with disability RHU rural health unit SPMC Southern Philippines Medical Center VAT value-added tax WHO World Health Organization WVMC Western Visayas Medical Center Abbreviations and acronyms v
1Population ageing is a key public health challenge confronting the Western Pacific Region. Globally and in the Region, the proportion of people aged over 60 years is growing faster than any other age group, as a result of both declining fertility rates and longer life expectancy (1). The increase is especially rapid in low- and middle-income countries, significantly narrowing the window of time available to prepare to confront this inevitable change. For example, the population of the Philippines will increase by 35.4% over the next two decades, projected to reach over 126 million by 2030 (2). In 2010, life expectancy was 72.6 years for women and 66.0 years for men (3). The proportion of people aged 60 years and above is expected to increase from 5.7% of the population in 2010 to 10.0% in 2030 (2). Population ageing represents the success of public health and development policies, but also poses challenges to societies and health systems, as they aim to maximize the health and functional capacity of older people and their social participation and security. Ageing and health in the Philippines In recent decades, health indicators in the Philippines have improved, as evidenced by a decline in the levels of child and maternal mortality, as well as in communicable diseases. However, progress has slowed in recent years due to several factors, such as the poor health status of those from less developed areas or marginalized groups. The Philippines is classified as a lower middle-income country with a gross domestic product (GDP) estimated at US$ 284.6 billion in 2014 (4). The total expenditure on health per capita is estimated at 119 international dollars, while the total expenditure on health as a percentage of the GDP is 4.6% (5). As a population group, older people in the Philippines improved their poverty incidence ranking from third lowest in 2006 to second lowest in 2009, relative to eight other population groups (6). However, significantly large numbers of older people continue to live in poverty. In 2010, only 10.6% of older people held academic degrees and about 55.4% had received elementary education (6). In 2010, healthy life expectancy (HALE)1 in the Philippines was 63.2 years for women and 57.4 years for men at birth, and 14.3 years for women and 11.9 years for men (6). According to the 2008 National Nutrition Survey conducted by the Food and Nutrition Research Institute, older people commonly face nutritional conditions such as chronic energy deficiency, malnutrition and anaemia (6). Older people also have a high incidence of chronic degenerative diseases such as hypertension and high levels of bad cholesterol. In 2010, about 410 000 or 6.5% of older people had disabilities, including low vision, problems with hearing and partial deafness (6). 1. Introduction 1 Healthy life expectancy (HALE) is an estimate of the number of years that a person can expect to live in good health, taking into account age-specific mortality, morbidity and functional health status. 2Visual impairment The World Health Organization (WHO) estimates 285 million people globally are visually impaired, of whom 39 million are blind and 246 million have low vision (7). At least 65% (154 million) of visually impaired people and 82% (32 million) of the blind are in the 50 years and older age group. WHO estimates that age-related blindness is increasing worldwide. Cataract is the number one cause of blindness in the world and accounted for an estimated 51% of blindness in 2010 (8). Other causes of age-related blindness include glaucoma (8%), age-related macular degeneration (5%) and diabetic retinopathy (1%). Uncorrected refractive errors (43%) and cataract (33%) are the main causes of visual impairment in the world. Approximately 90% of those affected live in developing countries (8). ln the Western Pacific Region, an estimated 90 million people are visually impaired, of which an estimated 10 million are blind (8). In the Philippines, according to the latest National Survey on Blindness in 2004 conducted by the Philippine Eye Research Institute, the crude prevalence of blindness in people aged 50 years or older is 4.62% (9). Blindness is estimated to affect 270 000 elderly Filipinos (9). The primary causes of blindness include errors of refraction (prevalence 2.06%) and cataract (1.83%) (9). Other leading causes of visual impairment are retinopathy, maculopathy, glaucoma and corneal opacity (9). Objectives of this study The study aims to assess the current situation of eye health services for older people in the Philippines, with the following specific objectives: • to identify key relevant national programmes, policies and legislation; • to map relevant stakeholders involved in the provision of refractive, optical, low-vision, and vision rehabilitation services and programmes in the Philippines; • to plot human resources involved in service delivery, including training institutions; • to outline commonly utilized service delivery models, including service promotion, funding mechanisms, referral and delivery processes; • to assess the demand for and barriers to access refractive, optical, low-vision and vision rehabilitation products and services; and • to make recommendations for strengthening refractive, optical, low-vision and vision rehabilitation services for older people in the Philippines. 3Methodology and study overview Questionnaires were developed to guide the situational analysis of the services and programmes for age-related visual impairment in the Philippines, based on existing frameworks of health systems as well as ageing and health, disability and visual impairment. The questionnaires covered the following themes: • Priorities, policies and programmes: existence of and compliance with guidelines and policies used in the country for the management of age-related visual impairment; • Service delivery: availability of national data on the prevalence of age-related visual impairment; the distribution of and access to health services in the country; • Health workforce: distribution of ophthalmologists and other health professionals who deal with age-related visual impairment; • Health technology: availability and accessibility of equipment used for the diagnosis and management of age-related visual impairment; • Health promotion for age-related visual impairment: availability of materials and methods for promoting health information on the disease topic; and • Health financing: provision and coverage of government health insurance for age-related visual impairment. The situational analysis followed three phases. The first phase comprised methodology and questionnaire development. Relevant stakeholders, such as government agencies, health managers and health workers, blindness-related organizations, associations for older people and medical organizations, were consulted to identify appropriate topics and issues. Older people, including those currently receiving treatment, were also consulted, to explore their needs and receive feedback. The second phase comprised implementation of the draft methodology. National and regional data were gathered from available databases as well as records of agencies and organizations. Three urban sites (two large and one small) – Quezon City, Davao City and Iloilo City – were visited, representing each of the main islands in the Philippines. The first site, Quezon City, is the most populous city in the Philippines, with a total population of 2 751 579 in 2010, with 151 966 (0.55%) individuals aged 60 and above. (10). It is the largest city by area in metro Manila, comprising six districts, with a total of 142 barangays. The second site, Iloilo City, is the capital of the province of Iloilo and the regional centre of the Western Visayas region (Region VI). It is composed of seven districts (Jaro, Molo, La Paz, Lapuz, Mandurriao, Villa Arevalo, and Iloilo City), with a total of 180 barangays. In 2010, Iloilo City had a total population of 421 976, of which 35 405 (8.4%) were aged 60 years and above (10). The third site, Davao City, is the fourth most populous city in the Philippines, with a population of 1 443 890 (in 2010), and is the regional centre of Davao region (Region XI) (10). It is composed of three congressional districts 4and a total of 182 barangays. The number of people aged 60 years and above is 86 712 (6% of the total population) (10). Heads of concerned national and regional institutions, including the Department of Health, the Department of Social Welfare and Development and city health offices, key officials and informants from the health sector and nongovernmental actors were interviewed at each site. In addition, three focus group discussions with 19 older people in total were conducted to capture the perspectives of older people. Appendix D provides a list of informants. The third phase comprised finalization of the questionnaires, based on the experience of implementation, final consultation with stakeholders and report writing. The report includes key lessons learned as well as the complete set of questionnaires (see appendices A and B) and suggestions for their use (see Appendix C). It is hoped that these materials will be used as a basis for similar studies on age-related visual impairment in other country contexts in the future. 5Key actors and structures Department of Social Welfare and Development The Department of Social Welfare and Development (DSWD) is the primary branch of government that meets the needs of the poor, vulnerable and disadvantaged. Its mission is to develop, implement and coordinate projects and programmes on social protection and poverty reduction. It functions as the government’s focal point department on ageing. The DSWD’s programmes include the provision of social welfare and development technologies that cater to older people and people with disabilities (PWDs) across the country. The intergenerational programme, piloted in NCR, responds to the physical, social and psychological needs of older people, and includes services such as day-care services for children, special children and older people; child- minding services; and volunteer development services. A group home for older people, a community-based living arrangement piloted in Region III, aims to accommodate a group of six to eight older people in an independent living home setting. They are supervised by a social worker either from the government units or the private sector. The foster home programme for older people and PWDs was launched in Regions II and XII. It also caters to older people and PWDs who are abandoned, neglected and not attached to the community. The DSWD manages three centres to care for abandoned older people. These are the Haven for the Elderly in Tanay, Rizal, the Home for the Aged in Regions IX and XI, and the Golden Reception and Action Centre for the Elderly and other Special Cases (GRACES), the newest residential care facility. Under the volunteer service programmes, individuals, groups and organizations provide services for residents of the home facility. These volunteers are trained, monitored and evaluated by the facilitators of the programme. Department of Health The Department of Health manages the Philippine health system and is mandated to develop health policies and programmes, formulate and enforce regulatory guidelines and standards, build the capacity of partners through technical assistance, monitor the programmes of these partners, and provide specialized tertiary care. Both local government units (LGUs) and the private sector provide health services to communities and individuals. Rural health units (RHUs), established in each municipality, provide access to primary health care services such as maternal and child care, nutrition services and direct service functions. The provincial governments provide secondary hospital care. 2. Situation analysis: programmes and services for age-related visual impairment 6In addition to these public facilities, the private sector caters to the health needs of almost 30% of the population(11). The DOH and the Philippine Health Insurance Corporation (PhilHealth) regulate and monitor these for profit and nonprofit organizations and providers. The Commission on Higher Education regulates health science universities and institutions, while the Philippine Regulation Commission regulates health professionals. Degenerative Disease Office, DOH The Degenerative Disease Office (DDO) of the DOH sets national health objectives and priorities and develops policies, standards and guidelines, as well as plans, programmes and projects to prevent and control degenerative diseases. One of the programmes of the DDO is the National Prevention of Blindness Program (NPBP). The goal of the programme is to reduce the prevalence of avoidable blindness in the Philippines and promote the provision of quality eye care. Its objectives are: (i) to strengthen partnerships among and with stakeholders to eliminate avoidable blindness in the Philippines; (ii) to empower communities to take proactive roles in promoting eye health and preventing blindness; (iii) to provide access to quality eye-care services for all; and (iv) to work towards poverty alleviation through preservation and restoration of sight to indigent Filipinos. The 2010 targets of the NPBP include: (i) to increase the cataract surgery rate from 730 to 2500 by the year 2010; (ii) to reduce visual impairment due to refractive errors by 10% by 2010; and (iii) to reduce the prevalence of visual disability in children from 0.3% to 0.20% by 2010. However, no reports are available that document the progress against these targets. The DDO acknowledges the lack of developments in the past, but is optimistic of better results under the new leaders installed in the past couple of years. The DDO is developing a set of clinical practice guidelines for visual screening of Filipinos aged 25 years and above, which includes older people. Other partners The DSWD provides accreditation, licensing and registration for NGOs to recognize and permit their operations under a set of minimum standard guidelines. Of the approximately 1000 DSWD-recognized NGOs in 2014, approximately 200 cater to older people, 100 PWDs in general and about 10 to those who are blind. The Federation of Senior Citizens Associations of the Philippines (FSCAP) is an NGO established by the leaders of the Offices of Senior Citizens’ Affairs (OSCAs) in different regions of the country. Some FSCAPs are not yet recognized by the DWSD. Legal and policy framework Among the principal health-related laws, several relate to older people, including Republic Act no. 7432 (13), known as the Senior Citizens Act; Republic Act no. 9994, known as the Expanded Senior Citizens Act; and Republic Act no. 9241 (14), which amends Republic Act no. 7875 on national health insurance. This legal framework mandates the establishment of the Office of Senior Citizens Affairs (OSCA) in every city and municipality, headed by a senior citizen appointed by the mayor for a three-year term. The 71 Philippine National Statistics Office, 2010 2 Federation of Senior Citizens Association of the Philippines, 2011 3 Older people with registered addresses from a different regions Table 1: Population aged 60 years and above and regional data on membership of the FSCAP Region Population aged 60 years and above1 (%) Population of FSCAP members aged 60 years and above2 (% of population) NCR 424 718 156 691 (0.36%) CAR 234 182 71 651 (0.31%) Ilocos (I) 707 941 313 325 (0.44%) Cagayan Valley (II) 776 301 51 700 (0.07%) Central Luzon (III) 399 865 276 074 (0.69%) CALABARZON (IV-A) 614 307 224 097 (0.36%) MIMAROPA (IV-B) 530 198 65 462 (0.12%) Bicol (V) 336 781 255 756 (0.76%) Western Visayas (VI) 209 917 178 120 (0.84%) Central Visayas (VII) 267 928 232 383 (0.87%) Eastern Visayas (VIII) 278 935 14 516 (0.05%) Zamboanga Peninsula (IX) 216 586 26 104 (0.12%) Northern Mindanao (X) 678 590 87 480 (0.13%) Davao Region (XI) 111 299 129 344 (1.16%)3 SOCCKSARGEN (XII) 93 775 132 568 (1.41%)3 CARAGA (XIII) 181 141 26 812 (0.16%) ARMM 167 839 - TOTAL 6 230 303 242 086 Municipal or City Social Welfare and Development Officer is to assist the head and coordinate with the DWSD in performing the functions of the OSCA. These functions include: (i) planning, implementing and monitoring programmes under the Act, (ii) developing a list of available and required services that can be provided to older people, (iii) maintaining and updating the list of older people and issuing a national uniform individual identification card, (iv) serving as a general information and liaison centre to cater to the needs of members, (v) monitoring compliance with the provisions of the Act, particularly the grant of discounts, (vi) reporting to the mayor any violations in the provisions, and (vii) assisting older people in filing complaints and concerns. 8Philippine Plan of Action for Senior Citizens The Philippine Plan of Action for Senior Citizens (PPASC) 2006–2010 (6), formulated by the DSWD, provided measures that respond to the concerns of older people. Collaboration between sectors, including the public and private sectors, was a key strategy for implementation. Under the Plan, OSCAs were reestablished and became functional in about 85% of the cities and municipalities. The National Centre for Geriatric Health was set up in 2010 to become the first premiere geriatric facility in the country, marking an important milestone. The DOH initiated several projects on general health, in partnership with other government agencies as well as private organizations. The interagency assessment of the PPASC 2006–2010, conducted towards the end of its implementation period, highlighted several challenges, including: (1) Absence of or inadequate monitoring and evaluation among participating agencies: In the absence of clear guidelines on regular monitoring and reporting, several agencies lacked appropriate information on programme implementation and evaluation that could guide future action. (2) Noncompliance by local government units (LGUs): Services for older people often constituted only a fraction of the health budget allocated by LGUs, which were to cover all population groups, including funding gaps in maternal and child health. Similarly, the OSCAs struggled with prioritizing funds for older people, as their time was preoccupied with other, competing issues, such as registration and recruitment of members. (3) Lack of technical assistance to LGUs in translating laws into local ordinances: During the interview, some key informants also reported that LGUs have difficulty in implementing the DOH’s policies and ordinances of the DOH, since they lack professionals and experts who can convert the laws into programmes and activities for older people. They are able to provide programmes covering only common issues such as hypertension and diabetes, not visual impairment. (4) Changes in focal points for older people with inadequate handover of information: Inadequate handover of information on the programmes and activities of the FSCAP and OSCA, during points of turnover in focal points, due to retirements, promotions and other reasons, hampered their continuity and sustainability. (5) Limited awareness of budget allocation for older people: Based from the interview, most informants in LGUs and OSCAs were not aware of the budget allocated for older people. In practice, they relied mainly on the budget provided by city or municipal offices, even if it did not match the mandated budget allocation by the LGUs, which is approved and set every official year. The assessment recommended to: (i) ensure full implementation of Republic Act No. 9994, (ii) address elder abuse, (iii) advocate for a convention or treaty on the rights of older people, (iv) formulate positive ageing strategies, (v) expand data banks on older people, (vi) provide additional tax exemptions for children who assist senior citizen parents, (vii) create comprehensive programmes 9for increased mobility of older people, and (viii) provide funding for implementation of programmes, projects, activities and services for older people. The PPASC 2012–2016 (15) builds on these lessons learned and aims to improve implementation. In terms of health, it contains new objectives on advancing health and well-being into old age, through actions to ensure access to and availability of quality and appropriate health and nutrition services for older people, such as a study on the development of a PhilHealth Geriatric Package, collaboration with hospitals and academic programmes on gerontology, promotion of healthy lifestyles among older people, and implementation of active ageing programmes in hospitals, barangay health units and health maintenance organizations (HMOs). The objectives refer to the creation of a supportive and enabling environment, through care and support for older people and their families, more comprehensive legislation and policies, and strengthening of community-based and residential institutions for older people. Overview of the health system in the Philippines The decentralized structure of the Philippine health system, introduced under the 1991 Local Government Code, gives LGUs responsibility for providing basic health services, including health promotion and disease prevention, with guidance from Regional Centres for Health Development of the DOH. LGUs run barangay health centres, staffed by barangay health workers, community health workers and midwives, as well as rural health centres, staffed by doctors, nurses, midwives, medical technologists, sanitary inspectors, nutritionists and volunteer health workers. These are the first point of contact for communities. The DOH and its partner agencies maintain national databases on population and health outcomes of older people, although concerns about data quality and accuracy remain. National data on the prevalence of visual impairment are available from the Philippine Eye Research Institute, National Institutes of Health, University of the Philippines Manila. Health promotion for age-related visual impairment The DOH, with partner LGUs, is committed to empowering communities to take proactive roles in promoting eye health and preventing blindness. Currently, health promotion at the barangay and municipal levels comprises teaching about common noncommunicable diseases (NCDs). However, visual impairment is often not discussed. Targeted activities for older people take place during Elderly Filipino Week in the first week of October. These might include free general check-ups in health facilities in most LGUs, although few provide specific services for eye health, such as screening and eye examinations. During this week, private sector sponsors and donors assist by providing spectacles and mobilizing funds for surgeries. In addition, NGOs are important partners in health promotion, including as part of medical missions and services to residential institutions and communities, however, these rarely focus on eye health. Pamphlets and visual materials such as posters and banners about common diseases are available in hospitals and clinics. Older people, however, report that they do not usually use these materials because 10 they are unable to read and understand them properly, or lack the time to do so. Although older people participate in health promotion and education activities offered in health centres or communities, they also pointed out that these usually focus on NCD risk factors and conditions, such as hypertension and diabetes. Some older people have suggested other health topics to the barangay health workers and midwives, but these are not usually given priority. Collaboration and partnerships between different hospitals and academic institutions have been established to develop programmes on gerontology and promote healthy lifestyles among older people. However, older people are often not aware of these services or institutions. They are more familiar with the services provided by NGOs, which they consider more accessible. Other avenues for consultation that older people consider more common and convenient include medical and dental missions at the barangay and municipal levels. Health programmes and services for older people One target of the NPBP is to ensure that all hospitals and health centres have professional eye health providers by 2010. Specifically, the aim was to train and deploy at least one primary eye-care provider per barangay, and one mid-level eye-care health provider per municipality. The NPBP has also aimed to improve the capabilities of at least 500 ophthalmologists in performing cataract surgery. In 2007, there were a total of 1781 licensed hospitals in the Philippines, 701 (or about 39%) of which were owned by the government and 1080 (or 61%) privately owned. There are 76 provincial, 16 regional and 56 DOH-retained hospitals. Among the government hospitals, about 8% are located in the National Capital Region (NCR), 9.5% are in CALABARZON, 8.6% in Central Visayas, and 8.4% in Western Visayas. The DOH and National Statistical Coordination Board statistics from 2006 also show a higher percentage of government health workers deployed in the NCR, with 22% of doctors, 15.6% of nurses and 28.8% of dentists. Outside the NCR, the distribution of doctors is concentrated in Central Luzon (9.6%), Western Visayas (8.9%) and CALABARZON (8.4%). Similarly, nurses were concentrated in Western Visayas (11.1%) and CALABARZON (10.5%). Notably, regions closer to the capital have a higher proportion of government health workers compared to more remote regions. Similarly, the distribution of specialists and general practitioners is largely concentrated in Metro Manila, compared to the three major regions. According to the Pharmaceutical and Healthcare Association of the Philippines (PHAP), 68% of ophthalmologists were based in Metro Manila in 2008. Private clinics and specialists are available and well distributed in many areas, except in remote areas. However, the consultation and management fees they charge may be considered expensive by older people, especially those from low-income households. Services for older people in Quezon City The DOH Centre for Health Development for NCR (including Quezon City) is currently undertaking strategic planning. Their programme for older people focuses on the distribution of pneumococcal and influenza vaccines. The Prevention of Blindness Programme, which was recently revived, focuses on establishing eye-care teams in the NCR. Eye-care services are integrated within the health centre services at the barangay health centre level. 11 The OSCA and FSCAP organizations in the regions observe Elderly Filipino Week by cooperating with the city and municipal government units to conduct activities for older people. In Quezon City, a free medical check-up for all older people is offered, but visual screening is not included. The Quezon City Vice-Mayor’s office implements a regular but limited eye screening programme (thrice a week) for people of all ages, with the help of the districts and other departments of the city government. The city health office and barangay health centre offer no additional health promotion activities targeted at older people. At the barangay level, older people who complain of visual impairments and those needing treatment or surgery are referred to the doctor, because barangay health workers are not allowed to diagnose patients and barangays are not equipped for vision testing. One general physician is available for consultation in the barangay health centre on a prescribed schedule. If the doctor is unable to treat the patient, the patient is referred to a hospital or eye centre. The city government is affiliated with three private eye centres, which function as referral centres for treating visual impairment. If the medical desk of the OSCA is unable to treat the patient, the patient is referred to the eye centre. Older patients with PhilHealth membership who are referred by the OSCA are entitled to free treatment. Free intraocular lenses are provided only to indigent patients. The East Avenue Medical Centre is a government-run hospital in Quezon City, which houses the DOH Eye Centre, a nonprofit specialized government institution for ophthalmology. The centre provides comprehensive and subspecialty clinical services, catering to both private and indigent patients. The Golden Reception and Action Centre for the Elderly and other Special Cases (GRACES) is a residential institution for older people and clients with special cases, run by the DSWD. The institution has one doctor who rotates among other DSWD institutions, six nurses, caregivers and house parents. Patients who complain of vision impairment are first checked and assessed by the doctor to see if they can be treated within the institution. The centre’s doctor examines older people for vision problems only if they complain about their vision; no regular vision checks are provided. In urgent cases, or if the doctor is unable to provide treatment, the patient is referred to a nearby hospital. It is important to note that the institution relies heavily on donations by charitable organizations for free glasses and medicines. The centre prioritizes purchase of medicines and devices for residents by the urgency of the intervention. The centre also organizes weekly health education event for health service providers and residents in the form of a short lecture, which could address issues related to visual impairment or healthy ageing. Services for older people in Iloilo City In the DOH Centre for Health Development for Region VI in Iloilo City, a single programme coordinator handles the essential NCD programmes, specifically, the prevention of blindness programme, the health and wellness programme for PWDs and the senior citizens programme. Adhering to administrative orders issued by the national office of the DOH is an overall priority. The prevention of blindness programme specifically covers access to quality eye care for the indigent population and access to cataract surgery, including cataract and errors of refraction for older people. Medical missions help fill the gap in providing services to respond to the health needs of older people, 12 including vision screening. NGOs and private firms participate in these medical missions and provide free spectacles to older people. In the city of Iloilo, health centres for each of the seven districts have a rotating general practitioner for consultation, who provides care for visually impaired older people from all barangays in the district. At the barangay level, older people with vision impairments can consult barangay health workers. If needed, patients are referred to one of the district health centre, which can perform simple eye examinations such as visual acuity testing and fundoscopy. In more complex cases, older people are referred to the Western Visayas Medical Centre (WVMC) or to private clinics. There are no community- based services at the barangay and city levels to screen, treat, manage and rehabilitate older people with visual impairments. There are also no barangay level health promotion activities that target older people. The Iloilo City FSCAP lacks funds to pursue self-initiated programmes such as health promotion or vision rehabilitation services for members. Instead, private individuals and groups coordinate with the organization to provide specific health promotion and vision-related services, though these often remain ad hoc. The Iloilo City Health Office provides laboratory and pharmaceutical services to older people. In alignment with the DOH programme, older people are provided with free pneumococcal and influenza vaccination. The city also has a health promotion and education officer, although activities usually do not focus on causes and prevention of age-related visual impairment. The government-run WVMC, a DOH hospital located in Iloilo City catering to all provinces of the island of Panay, has an ophthalmology department situated in the outpatient department. An ophthalmologist examines older people who complain of vision impairments. In case the vision loss can be corrected by spectacles, patients receive the needed specifications from ophthalmologists and purchase spectacles in opticians’ shops outside the hospital. Currently, the hospital does not offer regular community-based services, except when the need arises. Eye health is promoted through pamphlets and radio advertisements. The hospital also conducts glaucoma screening during the annual glaucoma week and on Fridays. The Eye City Iloilo, a private clinic run by four ophthalmologists with subspecialisation, can carry out on-site refraction for older people who present for consultation and complain of blurred vision, with an optician available for the purchase of spectacles. While no community-based services are offered, eye health is promoted through pamphlets. Asilo de Molo, a nursing home run by the Daughters of Charity sisters and partially funded by the Iloilo City government, covers the island of Panay, comprising four provinces (Aklan, Antique, Capiz and Iloilo). Forty per cent of government funding is earmarked for responding to health needs, such as providing medicines and surgical procedures. The institution purchases medicines for glaucoma and dryness of the eyes for patients, as well as visual aids (spectacles are purchased in Iloilo but special low-vision aids have to be purchased in Manila). These can, however, only be purchased when funding is available. In specific cases, the institution may also pay for surgery to reduce visual impairment. Volunteer doctors provide regular health check-ups to the residents. However, for vision impairments, 13 residents are usually referred to provincial government-run hospitals. Visual checks are done only through medical missions by outsiders, while health promotion on the signs and symptoms of visual impairment is implemented through lectures by the nurses of the institution. Services for older people in Davao City The DOH Centre for Health Development for Region XI in Davao City handles the essential NCDs programme, including primary eye care for older people. Currently, the main focus is on health workforce capacity building, including organizing eye health teams in each province. Under the Davao City government, another office concerned with older people’s affairs is the City Social Services and Development Office, the social welfare arm of the city government, which provides basic social programmes and services, including to older people. The Davao City Health Office and the Davao City OSCA have an ongoing free eye screening programme held on the first Tuesday of every month in the city hall. Patients requiring cataract surgery are referred to NGOs such as the Jubilee Foundation and Mabuhay Foundation, which mobilize funding. Free reading glasses are sometimes provided to older people because one of the city councillors is an optometrist. At the barangay level, older people with vision impairment are referred to the Southern Philippines Medical Centre (SPMC), because barangay health workers are not allowed to diagnose patients and barangays are not equipped for vision testing. One general physician is available per district and rotates among member barangays. Health promotion activities are offered at the purok level and are open to all residents. However, only limited time is dedicated to each health programme. There is no specific focus on older people or on age-related visual impairment. The SPMC, previously known as the Davao Medical Centre, a government-run hospital with patients from all over Mindanao, has an ophthalmology department, with ophthalmologists also being available in the outpatient department. No community-based services are available for older people. In previous years, the SPMC ophthalmology department has been very active in conducting medical missions. Only older people who complain of vision impairments and are referred by barangay health workers are seen in the hospital. For patients requiring spectacles, refraction is carried out and patients are advised to visit an optical shop located in the hospital, where spectacles may be purchased. Every August, during sight- saving month, eye health is promoted through educational radio advertisements. The Davao Doctors Hospital, a private hospital in the city of Davao, acts as a referral centre for more remote areas on the island. Currently, the hospital does not run any community-based services for older people. Refraction may be done for patients but prescription of spectacles is constrained by the lack of optometrists in the hospital. Health promotion activities are being implemented for some diseases on certain days through lectures to local barangays, but these are not targeted to older people. Home for the Aged, a nursing home in Region XI run by the DSWD, provides health services to its residents, but does not specifically cater to visual impairments. A general physician is assigned to the centre by rotation. All services provided by the centre are funded by the government and are highly dependent on this funding. Medicines may be bought using these funds; visual aids such as spectacles 14 are donated by sponsors or private institutions. No regular vision checks are conducted for residents. Only those who complain about their vision are seen by the centre physician during a visit. Residents with such complaints are usually referred to institutions linked to the centre. However, priority is given to acute health concerns of residents. Health education activities for residents are provided by the focal person of the DSWD regional field office, social workers and the head of the institution. Health financing Older people are entitled to specific privileges, including a 20% discount and exemption from the 12% VAT for goods and services from all establishments. This exemption includes tax (i) on the purchase of medicines and medical supplies, (ii) on professional fees of attending physicians in private hospitals, medical facilities and outpatient clinics, and (iii) on medical and dental services, and diagnostic and laboratory fees in private hospitals, medical facilities and outpatient clinics, among others. In addition, guidelines issued by the DOH and PhilHealth entitle older people to receive free medical and dental services and exempt them from diagnostic and laboratory fees in all government facilities. The law also provides for social pensions and mandatory PhilHealth coverage of older people from low-income households, stating that “all indigent senior citizens shall be covered by the national health insurance program of PhilHealth. The LGUs where the indigent senior citizens reside shall allocate the necessary funds to ensure the enrolment of their indigent senior citizens in accordance with the pertinent laws and regulations” (16). Aside from the existing provision of coverage for cataract surgery among PhilHealth members, including older people, there are no specific benefits for those who have age-related visual impairment. According to Proclamation 470, the first week of October of every year is declared as Linggo ng Katandaang Filipino or Elderly Filipino Week. However, older people report that, in practice, most private clinics, especially in the provinces, do not recognize these privileges, and do not provide discounts on services. As a result, older people often do not access medical check-ups due to financial constraints. Cataract surgery is offered at the provincial and regional hospitals as well as at private clinics, and cost of surgeries in government facilities are covered by PhilHealth or available at a minimal cost. Objectives under the PPASC 2012–2016 aim to ensure older people’s access to available and appropriate health services. A proposal to develop a comprehensive PhilHealth Geriatric Package is currently being considered. Health technology At the barangay level, tools and equipment for visual screening and comprehensive eye examinations are normally not available. Patients, especially older people, who experience visual impairment, are referred to an available general practitioner at the RHU. However, not all RHUs are able to provide eye health services due to lack of equipment. Patients who cannot be managed at the RHUs are referred to municipal or city health offices, or government hospitals that can cater to their needs. Focus group discussions highlighted that corrective treatment, such as spectacles and contact lenses, 15 can be purchased in optical shops in malls and private clinics, and even from vendors in side streets. Informants also reported instances where free eyeglasses were provided by the City Health Office, Haligi Foundation, Rotary Club, Lions Club and other nongovernmental institutions. Medications and eye drops could be availed of in government hospitals and local pharmacies; although some needed written prescriptions, most could be bought over the counter. One of the NPBP’s targets is to ensure that all provincial, regional and DOH-retained hospitals are equipped with the appropriate technology for cataract surgery. Key informants highlighted that many provincial and some regional hospitals lack the appropriate technology for cataract surgery. In those cases, patients are referred to other regional hospitals or DOH hospitals in the cities. In addition, since private facilities are usually better equipped, patients who can afford to pay often choose to access care in the private sector. Rehabilitation Low-vision devices and vision rehabilitation training can improve the quality of life for people with irreversible vision loss. However, rehabilitation and low-vision services are currently not available at the barangay and municipal levels or in Regional Centres for Health Development. One low-vision specialist was identified in Iloilo City and patients referred to him, although low-vision aids, were not available in this clinic. Vision rehabilitation and low-vision services are unavailable at the barangay and city levels of Iloilo City. Patients needing such services may also be referred to Western Visayas Medical Center. Since special low-vision aids are unavailable in the WVMC, due to the absence of a low-vision specialist, patients may have to be referred to Manila. In Quezon City, low-vision services and aids are available at the East Avenue Medical Centre and St. Luke’s Medical Centre, but these are considered highly expensive. The SPMC and Davao Doctors Hospital (DDH) ophthalmology departments do not have low-vision services or aids. Discussion The situation analysis highlights a number of issues and potential options for action as part of broader efforts to reorient health systems to meet the needs of older people. Ensuring older people’s access to eye health services is part of the universal health coverage agenda. The existing policy and legal framework, including the NPBP and PPASC, provide a strong basis for responding to the eye health needs of older people. A key limitation, also raised during the PPASC review, is the absence of an appropriate monitoring and evaluation of progress in implementing the plan, including an accountability and compliance mechanism for participating agencies and partners at different levels of governance. The establishment of such a mechanism would help to address the turn- over of focal points for older people and eye health, identified as an additional challenge. With regard to health promotion for age-related visual impairment, it is the mission of the DOH and partner LGUs to empower communities to take a proactive role in promoting eye health and preventing blindness among Filipinos. While there are no distinct programmes that address this goal, current health promotion activities at different levels, including lectures, workshops, and community events, provide potential entry points for integrating eye health messages. Tailoring selected activities 16 to the needs of older people, including for age-related visual impairment, could be one way to reorient activities, building on synergies between health promotion and healthy ageing across the life course. While several good practices exist in some municipalities, e.g. free visual screening for adults, including older people, some activities are organized on ad-hoc basis and remain dependent on available resources and individual champions. The review also finds a general lack of targeting and tailoring of activities to older people despite the evidence on the high disease burden related to avoidable visual impairment in older people. For example, there are no programmes and services that particularly address the eye health needs of older people, especially older people with visual impairment. There are also few programmes that deal with eye health and age-related visual impairment specifically. Key informant interviews have pointed out that few health offices have developed actions and targets for specific age groups, such as older people, within their eye care programmes. Similarly, few community-based services and health promotion activities are targeted to older people. Although these interventions are, in principle, universally accessible, older people might inadvertently be excluded, since they face particular barriers to access. As population ageing advances, it will be critical to review the accessibility of interventions and ensure appropriate coverage among older people. Targeting older people is an opportunity to improve the effectiveness and quality of existing efforts on eye health, especially given that the vast majority of avoidable visual impairment appears in people aged 50 years and above. The limited availability of appropriate resources, including human resources for health and health technologies, poses additional challenges. Despite the NPBP’s target to equip provincial, regional and DOH-retained hospitals with the appropriate technology for cataract surgery, informants reported that most hospitals lack such technology and equipment. Tools and equipment for visual screening and comprehensive eye examinations are usually not available at the barangay and RHU levels. Similarly, the operationalization of the NPBP’s aim of mobilizing and training eye health professionals at the barangay and municipal levels has been equally challenging. Informants spoke of limited numbers of health workers who can respond to the needs of the visually impaired, especially older people. Doctors, specifically ophthalmologists and nurses, are concentrated in the NCR and nearby regions, resulting in geographical barriers to access by Filipinos living in remote areas of the country. Partnerships between city and municipal health offices, OSCA and others have been critical to progress in each site. Another significant barrier encountered by visually impaired older people is the financial cost of accessing services and devices. Focus group discussions highlighted that financial constraints are a primary reason for missing or delayed seeking of health-care. For example, one participant reported, “Masyadong mahal. Imbis na ipang-check-up, ibibili na lang ng makakain. Okay pa naman ang mga mata ko.” (It’s too expensive. Instead of availing the services, we’ll just use the money to buy food. My vision is still okay.) Another participant had never been to an eye doctor, while others had their eyes checked 2–4 years ago. Consultation and treatment fees were reported to range from PHP 300 to PHP 2500 per visit, depending on the type of procedure and facility. Corrective treatment such as spectacles and contact lenses were reported to be available for sale in optical shops, malls and private clinics. While some hospitals and private clinics also offered low-vision services and aids, patients considered these as very expensive. As a result, the provision of spectacles and other devices remains dependent on donors and sponsors. Lastly, despite the entitlements enshrined in the Expanded Senior Citizens Act of 2010, informants reported that private clinics and hospitals in the regions do 17 not always acknowledge the entitlements of older people to discounts. There were limited monitoring and remedial actions taken, partly because of the lack of awareness among older people on the penalties that apply to those who do not comply with the provisions of the Act. The lack of awareness and information, including health-related information, was an additional barrier in access to services underlined by informants. Focus groups discussions highlighted that many older people were not aware of the availability of any services and programmes for age-related visual impairment provided by the government. One participant said, “Wala naman ganu’n para sa mga matatanda na galing sa gobyerno e. Parang hindi pa nagkakaroon nang ganu’n.” (There is no such thing [eye health programmes and services] that comes from the government. It seems that nothing like that has ever existed.). Focus groups also showed that there was more awareness of medical missions that sometimes delivered eye-care services in the community. Another participant commented, “Hindi rin madalas. Pag Elderly Filipino Week, du’n madaming ginagawa. May mga check-up, minsan namimigay ng salamin. Pero kung sino lang ‘yung mauna.” (It is also not often. If the Elderly Filipino Week comes, there are a lot of activities. There are check-ups. Sometimes, they give away eyeglasses for free. But it’s limited to those who are seen first.) There was some awareness of available services by private providers, including private clinics or ophthalmologists as well as optical shops in malls, which offer similar services. These preliminary findings highlight the need to foster the health literacy of older people, a topic that is likely to grow in importance as population ageing advances. Other barriers identified were the lack of responsiveness of the health system and sociocultural or language barriers. Addressing these will need to include efforts to “reinvent” ageing, tackle outdated mindsets and promote positive images of older people and their contribution to society. An informant spoke about the conventional image of ageing, where age-related visual impairment might be perceived to be a “natural” aspect of ageing. An older person might think, “Ah, matanda na ako, wala na okay lang yan, ganyan naman talaga, matanda na ako.” (Ah, I’m old. It’s okay, it’s normal. I’m old.) Family members and even health workers may also have similar mindsets and say, “Ay, matanda ka na. talagang wala na, malabo na talaga yang mata mo eh.” (Ah, you’re old. It’s really happening. You have poor vision.) Leadership and action are needed by the health sector and others to promote health at all ages, including older age, and to view older people as valuable assets for their families, communities and societies. Lastly, focus group discussions stressed the link between visual impairment and older people’s ability to carry out activities of daily living and function independently. Reorienting eye health programmes to older people’s needs thus provides a critical opportunity to promote healthy ageing, improve overall quality of life for older people and maintain their active participation in society as they grow older. 18 It is recommended that programmes and services specific to the needs of older people with visual impairment, including blindness, be further developed. Specifically, the following are suggested: ● For the DOH: ● Recognizing that the vast majority of avoidable visual impairment appears in people aged 50 years and above, ensure a more targeted approach to reach older people in order to improve effectiveness and quality of existing efforts on eye health. ● Continue to formulate new or improve existing guidelines and policies to ensure health services, including eye health services, meet the needs of older people in the Philippines. ● At the primary care level, ensure staff have the capacity to make appropriate referrals, particularly for older people. ● At the tertiary care level, ensure staff have the capacity to provide low vision services, including to older people. ● Integrate eye health and eye care into health campaign policies and health promotion in various media, to increase the awareness of older people and their families about visual impairment. ● Continue to support research on the eye health situation of older people in the Philippines, particularly on their knowledge, attitudes and practices (KAP). ● Strengthen collaboration with other Ministries, professional organizations and NGOs, and communities of older people themselves to work jointly on addressing the eye health needs of older people. ● For the DSWD: ● Consider visual impairment as a priority for the health of older people and integrate it in the PPASC’s current provisions related to ageing and health. ● Take necessary steps to effectively implement PPASC 2012–2016. ● Build evidence on a creating a PhilHealth geriatric package, in collaboration with DOH and other partners. ● Strengthen collaboration with different partners on ageing and eye health for older people, including the Department of Health and other government institutions, NGOs, Older People Associations etc. ● For PhilHealth: ● Include the provision of low vision devices for older people into existing benefit package. ● Conduct a more comprehensive information campaign about the provisions of the National Health Insurance Act, specifically on the entitlements of older people, and penalties for those who fail to comply. ● For NGOs working with and for older people: ● Recognizing the importance of addressing avoidable visual impairment among older people, include eye health as a key focus in activities and services targeted at older people. 3. Conclusions and recommendations 19 20 Policies and programmes: Target respondents: Government (national, regional, local) ● Do you have policies that focus on the eye-care needs of older people? ● If yes, what is their scope? Please provide a copy/ies. ● Do you have programmes that focus on the eye-care needs of older people? ● If yes, what is their scope? Please provide a copy/ies. Services: Target respondents: hospitals (national, provincial, district), LGUs/barangay health centres ● What is the proportion of patients aged 60 years and above at your hospital/facility? ● Are eye-care services available at your hospital/facility? ● If yes, what proportion of people using these services are men and women aged 60 years and above? ● If your hospital is unable to provide the specific eye care that older people need, what is your advice to them? ● For what kind of eye or vision problems do older people commonly seek your services? ● Do you regularly check visual acuity (distance or near) in older patients as part of their routine health examination? ● What is the proportion of older patients that commonly request refraction or spectacles? ● If you find that an older patient requires spectacles, how do you proceed? ● What do you believe to be the main barriers to accessing eye-care services by older people at your hospital/facility? Rate significance (1—4, 1 being insignificant and 4 being very significant) ● Financial/economic barriers ● Sociocultural/language ● Financial/economic barriers ● Sociocultural/language barriers ● Distance from hospital/facility ● Physical accessibility ● Lack of responsiveness of the hospital/facility to the health needs of older people ● Older people’s lack of knowledge and awareness ● Older people’s restricted mobility ● Other (please specify). ● Are there community-based services available for screening, treatment, management and rehabilitation of eye or vision problems in older people? APPENDIX A. Questionnaire for informant interviews 21 Target respondents: nursing homes ● What proportion of residents report or show signs of eye or vision problems? ● If residents report or show signs of eye or vision problems, what is your advice to them? ● Does the nursing home carry out regular vision checks for residents? ● Does the nursing home facilitate access to or provide any form of vision aids, e.g. reading glasses, loupes, magnifiers, etc. to residents? ● Where can medicines be purchased for residents? Target respondents: NGOs, older people’s associations, LGUs ● Does your organization/association engage in promoting eye health for older people? ● If yes, please provide information on how this is done and what the main messages are. ● Please provide a copy/copies of print materials, if any. Rehabilitation: Target respondents: Government (national, regional, local), NGOs, hospitals (national, provincial, district), LGUs/barangay health centres ● Do you provide vision rehabilitation/low-vision services? ● If yes, what type of services do you provide? ● If yes, what proportion of people using these services are older men and women? ● If your hospital/facility is unable to provide vision rehabilitation/low-vision services, what is your advice to patients who need these? ● What do you believe to be the main barriers to accessing vision rehabilitation/low-vision services for older people? Rate significance (1—4, 1 being insignificant and 4 being very significant) ● Financial/economic barriers ● Sociocultural/language barriers ● Distance from hospital/facility ● Physical accessibility ● Lack of responsiveness of the hospital/facility to older people’s health needs ● Older people’s lack of knowledge and awareness ● Older people’s restricted mobility ● Other (please specify). ● What problems, if any, are you facing in relation to your eyes? ● Do you have difficulty in reading or seeing things that are close to your eyes? ● If yes, have you acquired reading glasses for this problem? ● If not, why not? (What barriers do visually impaired older people experience?) ● Rate significance (1– barriers) ● Distance from hospital/facility ● Physical accessibility ● Lack of responsiveness of the health facility to my health needs ● Knowledge and awareness ● My own lack of mobility ● Not important for my well-being ● Other (please specify) ● If yes, where did you go for the glasses? How much did you pay? ● Are you satisfied with the glasses? If not, what problems are you facing with them? ● Have you needed follow up or change of glasses based on further deterioration? If not, why not? ● What eye-care services are you aware of? ● Are these services easily available to you? ● What may be the reasons for you not access needed eye-care services? (What barriers do visually impaired older people experience?) Rate significance (1-4, 1 being insignificant and 4 being very significant) ● Financial/economic barriers ● Sociocultural/language– barriers ● Distance from hospital/facility ● Physical accessibility ● Lack of responsiveness of the facility to my health needs ● Knowledge and awareness ● My own lack of mobility ● Not important for my well-being ● Other (please specify) APPENDIX B. Questionnaire for focus group discussions with older people 22 23 ● Do you regularly visit your ophthalmologist? ● If not, why not? (What barriers do visually impaired older people experience?) Rate significance (1-4, 1 being insignificant and 4 being very significant) ● Financial/economic barriers ● Sociocultural/language– barriers ● Distance from hospital/facility ● Physical accessibility ● Lack of responsiveness of the hospital/facility to my health needs ● Knowledge and awareness ● My own lack of mobility ● Not important for my well-being ● Other (please specify) ● If yes, for what services do you visit the ophthalmologist? ● Private clinic? ● Public hospital? ● How many times in a year? ● Were you satisfied with the services you received? ● When was your last eye examination? ● Are you aware of the signs and symptoms of some common causes of age-related visual impairment? (e.g. cataract, errors of refraction, glaucoma, age-related macular degeneration, diabetic retinopathy) ● How did you come to know of these? ● Are you currently undergoing treatment for any age-related visual impairment? ● How was the problem detected? ● If yes, approximately how much are your out-of-pocket expenses? ● Where are you purchasing the required treatment? ● Are you aware of any promotion and education on eye health being done in your community? ● If yes, what information was provided? ● Are you undergoing any form of rehabilitation for visual impairment? ● If yes, which centre are you visiting? ● Are you making use of any low-vision aids? (Give examples to clarify, if needed.) ● If yes, approximately how much are your out-of-pocket expenses? The following are some suggestions for using the questionnaires: Before the interview ● Identify and contact the key informants to be interviewed. ● Provide an information sheet regarding the project. ● Explain why they have been chosen as a key informant. ● Organize a schedule for the interview. ● Explain the purpose of the interview, including: ● Background of the project ● Methodology through data collection by interviewing key informants ● Analysis after the interview. ● Explain the structure of the interview: ● Semi-structured ● Use of indicator questions and probing questions when necessary ● Questions may be asked during the interview ● The interview will take approximately one hour. ● Explain the terms “confidentiality” and “consent”: ● Confidentiality: only the study team will have direct access to the information collected. ● Answers will be analysed based on the study objectives. ● Consent: ● All participants should receive information about the study prior to the interview. ● All participants must participate voluntarily and may withdraw at any time. • Seek permission to quote from their comments. • Ask permission to record the interview. ● If permitted, make sure that a tape recorder is used and functional during the interview. • Provide contact information of the study team. • Ask the respondents if they have any questions and answer them. During the interview • Ensure that questions are open-ended and clear. • Ask only one question at a time. • Ask probing questions, such as “why” and “how” to better understand the strengths and weaknesses of the eye health system. APPENDIX C. Suggestions for using the questionnaires 24 25 • Plan for one member of the study team to ask the questions while the other takes notes. • Note down everything verbatim as much as possible. Include observations made during the interview in the notes. • Remain neutral. • Be encouraging. • Allow for smooth transitions from one topic to the next. • Be systematic and do not lose control of the interview. • Thank the key informant. After the interview • Hold a debriefing session to review the notes taken during the interview. • Assess and give feedback about the interview. • Transcribe the interview notes immediately after the interview. • Carefully record and file all information sources and assessment reports. Note: During focus group discussions, it was noted that older people who participated in discussions would initially provide only brief or vague answers. It was found that follow-up questions were necessary to explore further and have a more detailed discussion. NATIONAL OFFICES Dr Rosario Uy Chair, Degenerative Diseases Office, National Centre for Disease Prevention and Control, DOH Shelley Dela Vega Director, Institute of Aging, National Institutes of Health University of the Philippines Manila President of the Philippine Geriatric Society Arturo Alcantara Task Force Informatics Team, PhilHealth Joanna Foz Focal person, Department of Social Welfare and Development Joanna Hizon Focal person, Department of Social Welfare and Development DOH REGIONAL AND CITY OFFICES Niña Allen Galema Programme Coordinator, NCD Section, DOH NCR Carol Anne Molave Programme Coordinator, NCD Section, DOH NCR Cristina de Guzman Programme Coordinator, DOH Regional Office VI Jennifer Marie Villarte Programme Manager, DOH Regional Office VI John Richard Lapaswa Programme Manager, DOH Regional Office VI Rosemarie Basañes Regional Manager, NCD Section, DOH Regional Office VI Fe M. Justimbaste Chief Nurse, Quezon City Health Office Mae Delmo Assistant City Health Officer, Iloilo City Health Office Josephine Villafuerte City Health Officer, Davao City Health Office Ma. Rosalita B. Domingo Programme Coordinator, Davao City Health Office GOVERNMENT HOSPITALS Dino Ruiz Focal person, DOH Eye Centre, NCR Neal Torre Focal person, DOH Eye Centre, NCR Josephine Cadayonan Chairperson, Department of Eyes, Ears, Nose and Throat, SPMC Perfecto Domingo Jr Retina specialist, SPMC Luisito Gahol Chairman, Department of Ophthalmology, DDH Noel Tongson Training Officer, Department of Ophthalmology, WVMC Nathaniel Chan The Eye City, Iloilo City PRIVATE HOSPITALS Shiela Jimenez Head, Low-Vision Section, St Luke’s Medical Centre Mavi Rondaris Section Chief of Public Health Ophthalmology, St Luke’s Medical Centre Felix Rey Villa Chief Medical Officer, The Medical City Iloilo APPENDIX D: Key informants 26 27 LOCAL GOVERNMENT UNITS Maria Noemi G. Eleba Barangay health worker, Quezon City Maila Buyco Medical Officer, Sto. Rosario Health Centre, Iloilo City Judy Albarico Barangay health worker, Iloilo City Joeriza Mamigo Barangay health worker, Iloilo City Bernadeth Lulang President, Barangay Health Workers Federation, Davao City DSWD OFFICES Patti Gordovez Programme Coordinator, Office of the Senior Citizens Affairs, Quezon City Gerardo Cañonero Programme Coordinator, Office of the Senior Citizens Affairs, Iloilo City Judith Marti Focal person, DSWD Regional Office VI Angelic Paña Focal person, DSWD Regional Office XI Cynthia Umbaña Focal person, DSWD Regional Office XI Placer Callanga Nurse, Golden Reception and Action Centre for the Elderly and other Special cases (GRACES) FSCAP and OSCA Elpidio Azuelo Vice President, Federation of Senior Citizens Association of the Philippines, Iloilo City Albina Sarona President, Federation of Senior Citizens Association of the Philippines, Davao City Benjamin Vencio Vice President, Federation of Senior Citizens Association of the Philippines, Davao City July Albarico Office of the Senior Citizens Affairs, Quezon City Neriza Namigo Office of the Senior Citizens Affairs, Quezon City Felix Ray Villa Office of the Senior Citizens Affairs, Quezon City Francisca Bernardo Office of the Senior Citizens Affairs, Quezon City Patty G. Gandog Office of the Senior Citizens Affairs, Quezon City Fe Basa Office of the Senior Citizens Affairs, Quezon City Camilo Villaprudente Office of the Senior Citizens Affairs, Iloilo City Herminia Amaguin Office of the Senior Citizens Affairs, Iloilo City Editha Lumandog Office of the Senior Citizens Affairs, Iloilo City Salvador Cordero Office of the Senior Citizens Affairs, Iloilo City Delfin Punzalan Office of the Senior Citizens Affairs, Iloilo City Eden Punzalan Office of the Senior Citizens Affairs, Iloilo City Ricardo Lachica Office of the Senior Citizens Affairs, Iloilo City Rodrigo Naval Office of the Senior Citizens Affairs, Iloilo City Atty. Ricaflor Obsequio Office of the Senior Citizens Affairs, Iloilo City Bonifacio Rellagros Office of the Senior Citizens Affairs, Iloilo City Azucena Bajao Office of the Senior Citizens Affairs, Davao City Filomena Dilambid Chapter President, FSCAP St Luke’s Chapter Cornelia Virule FSCAP, St Michael Chapter NONGOVERNMENTAL ORGANIZATIONS Lester Parba Medical Coordinator, Resources for the Blind, Davao City Magdaline Tumilba Head of the Social Services, Asilo de Molo 1 Regional framework for action on ageing and health (2014-2019). Manila: WHO Regional Office for the Western Pacific; 2014. 2 Ageing and Health: Philippines. Country fact sheet. Manila: WHO Regional Office for the Western Pacific; 2014. 3 World Population Prospects, 2010 revision [online database]. New York: United Nations; 2013 (http://esa. un.org/wpp/Excel-Data/population.htm, accessed 20 September 2013). 4 Philippines. In: Data [online]. Washington DC: The World Bank Group, 2014 (http://data.worldbank.org/ country/philippines, accessed 1 July 2915). 5 World health statistics 2013. Geneva: World Health Organization; 2013 (http://www.who.int/gho/ publications/world_health_statistics/EN_WHS2013_Full.pdf, accessed 25 March 2015). 6 Philippine Plan of Action for Senior Citizens (2011 – 2015). Manila: Department of Social Welfare and Development; 2011. 7 WHO Media centre. Visual impairment and blindness, fact sheet no. 282. Geneva: World Health Organization; 2014 (http://www.who.int/mediacentre/factsheets/fs282/en/, accessed 25 March 2015). 8 Towards Universal Eye Health: A Regional Action Plan for the Western Pacific (2014–2019). Manila: WHO Regional Office for the Western Pacific; 2014. 9 Cubillan LDP, Olivar-Santos EO, Agulto M. Third national survey on blindness in the Philippines. Manila: Department of Health, Institute of Ophthalmology, National Institutes of Health-Philippines, University of the Philippines Manila; 2004. 10 Philippine Statistics Authority [online]. (https://psa.gov.ph/statistics/census/population-and-housing, accessed 25 March 2015) 11 The Philippines health system review (Health Systems in Transition, Vol. 1 No. 2). Manila: World Health Organization; 2011. 12 National Prevention of Blindness Program. In: Department of health, Republic of the Philippines [online]. (http://www.doh.gov.ph/content/national-prevention-blindness-program.html, accessed 15 July 2015). 13 Republic Act No. 7432, an act to maximize the contributions of senior citizens to nation building, grant benefits, special privileges and for other purposes. Manila: Government of the Philippines; 1992. 14 Republic Act no. 9241, an act amending Republic Act no. 7875, otherwise known as “an act instituting a national health insurance program for all Filipinos and establishing the Philippine health insurance corporation for the purpose”. Manila: Government of the Philippines; 2004. 15 Philippine Plan of Action for Senior Citizens 2012–2016. Manila: DSWD; 2012. 16 Republic Act No. 9994, an act granting additional benefits and privileges to senior citizens, further amending republic act no. 7432, as amended, otherwise known as “an act to maximize the contribution of senior citizens to nation building, grant benefits and special privileges and for other purposes”. Manila: Government of the Philippines; 2010. References 28 29 30
asdf asdf asdf asdfdd s