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Background Should health systems invest more in access to care by expanding insurance coverage or in health care services including improving the quality of care? Comparing these options experimentally would shed light on the impact and cost-effectiveness of these strategies. Methods The Quality Improvement Demonstration Study (QIDS) was a randomized policy experiment conducted across 30 districts in the Philippines. The study had a control group and two policy intervention groups intended to improve the health of young children. The demand-side intervention in QIDS was universal health insurance coverage (UHC) for children aged 5 years or younger, and a supply-side intervention, a pay-for-performance (P4P) bonus for all providers who met pre-determined quality levels. In this paper, we compare the impacts of these policies from the QIDS experiment on childhood wasting by calculating DALYs averted per US$spent. Results The direct per capita costs to implement UHC and P4P are US$4.08 and US$1.98 higher, respectively, compared to control. DALYs due to wasting were reduced by 334,862 in UHC and 1,073,185 in P4P. When adjustments are made for the efficiency of higher quality, the DALYS averted per US$ spent is similar in the two arms, 1.56 and 1.58 for UHC and P4P, respectively. Since the P4P quality improvements touches all patients seen by qualifying providers (32% in UHC versus 100% in P4P), there is a larger reduction in DALYs. With similar programmatic costs for either intervention, in this study, each US$spent under P4P yielded 1.52 DALYs averted compared to the standard program, while UHC yielded only a 0.50 DALY reduction. Conclusion P4P had a greater impact and was more cost-effective compared to UHC as measured by DALYs averted. While expanded insurance benefit ceilings affected only those who are covered, P4P incentivizes practice quality improvement regardless of whether children are insured or uninsured.

Household air pollution (HAP) arising from the use of solid fuels for cooking is known to have adverse health effects including acute respiratory infections in children, which remains a major public health concern in developing countries. Hence, various interventions to reduce HAP have been advocated or piloted in many countries. To provide additional evidence on the effectiveness and applicability of the interventions in various settings, we investigate the effects of clean fuel for cooking on the risks of respiratory illness of children below five years old in the Philippines. We apply the propensity score matching method on a subsample of households culled from the 2013 round of the National Demographic and Health Survey to account for the systematic differences in their characteristics that could influence their choices of cooking fuel. We find that the use of electricity, liquefied petroleum gas, natural gas or biogas can lower by 2.4 percentage points the incidence of severe coughing with difficulty in breathing in young children. Our results support worldwide initiatives to promote the household use of clean fuels for cooking and heating to reduce HAP and its undesirable impacts on population health.

Improving clinical performance using measurement and payment incentives, including pay for performance (or P4P), has, so far, shown modest to no benefit on patient outcomes. Our objective was to assess the impact of a P4P programme on paediatric health outcomes in the Philippines. We used data from the Quality Improvement Demonstration Study. In this study, the P4P intervention, introduced in 2004, was randomly assigned to 10 community district hospitals, which were matched to 10 control sites. At all sites, physician quality was measured using Clinical Performance Vignettes (CPVs) among randomly selected physicians every 6 months over a 36-month period. In the hospitals randomized to the P4P intervention, physicians received bonus payments if they met qualifying scores on the CPV. We measured health outcomes 4-10 weeks after hospital discharge among children 5 years of age and under who had been hospitalized for diarrhoea and pneumonia (the two most common illnesses affecting this age cohort) and had been under the care of physicians participating in the study. Health outcomes data collection was done at baseline/pre-intervention and 2 years post-intervention on the following post-discharge outcomes: (1) age-adjusted wasting, (2) C-reactive protein in blood, (3) haemoglobin level and (4) parental assessment of child's health using general self-reported health (GSRH) measure. To evaluate changes in health outcomes in the control vs intervention sites over time (baseline vs post-intervention), we used a difference-in-difference logistic regression analysis, controlling for potential confounders. We found an improvement of 7 and 9 percentage points in GSRH and wasting over time (post-intervention vs baseline) in the intervention sites relative to the control sites (P ≤ 0.001). The results from this randomized social experiment indicate that the introduction of a performance-based incentive programme, which included measurement and feedback, led to improvements in two important child health outcomes.

While the importance of child education is universally recognized, there are still millions of children who are out of school in developing countries. In these countries, many children are left in the care of their kin when their parents die or work abroad. In this paper, we examine the welfare, particularly the school attendance, of the children under kinship care in the Philippines. Culled from the last seven rounds of an official national household survey, our dataset comprises 1,485 households with at least two members who are 6–12 years old, and one of them is the household head’s child or grandchild and the other is the head’s kin. Applying probit regression models, we find that a child under kinship care is about 3 % points less likely than the head’s own child to be attending school, other things being constant. However, there are no statistically significant differences in the likelihood of school attendance between the head’s own child and grandchild. While income deprivation keeps some children out of school, ensuring their schooling participation would require more transfers than are needed to lift their households out of poverty. Targeting these children through conditional cash transfer programs could mitigate the effect of the apparent parental bias toward their own brood.

While education is universally held to enhance a child human development, policies must still contend with parental biases. Here, we investigate if school attendance of young household members aged 6-12 years old varies with their kinship ties to the household heads in the Philippines. Applying probit regression techniques on a dataset culled from the five rounds of the Annual Poverty Indicators Survey, we find that the probability of attending school of the head’s own child is about 2.9-percentage points greater that that other relatives in the same age group, controlling for income and other factors. However, there are no differences in the likelihood of school attendance between the head’s own grandchildren and other relatives. Thus, policies should target children under kinship care since household heads are unlikely to treat them like their own, even if they can afford to send these children to school.

Results from the Philippine Quality Improvement Demonstration Study show that a policy that expands insurance coverage improves quality of care, as measured by clinical performance vignettes, among public physicians, and induces a spillover effect that improves quality among private physicians.