The coronavirus disease (COVID-19) pandemic and subsequent public health interventions have disrupted food systems all over the world. In the Philippines, where stringent lockdown rules have been implemented, households living in poverty have had to rely largely on food aid in the form of food packs distributed by local governments and private donors. An evaluation of the commonly distributed food items reveals a diet that addresses acute hunger but does not contain sufficient nutrients to promote and maintain health. Such a diet puts low-income households at a greater risk of acute and chronic disease. The negative health impact of commonly distributed food packs on food aid-dependent households shine a light on how the COVID-19 pandemic and public health policies exacerbate health inequities. A primary care perspective is essential in creating food security policies that can effectively address acute hunger and malnutrition without contributing to the long-term deleterious effects of inadequate nutrition on the health of indigent communities.

Background. The primary goal of providing social protection to informal sector workers is to guarantee a minimum level of income and dignity that allows for better protection against income shocks and other vulnerabilities. With the passage of the Universal Health Care Act in the Philippines, the determination of factors affecting enrollment and retention into social health insurance among informal sector workers in the Philippines is crucial to design appropriate policies and programs fit to their needs. Methods. This study aimed to identify factors that affect social health insurance enrollment and retention of the informal sector in the Philippines through qualitative research methods of face-to-face, semi-structured focus group discussion and key informant interviews. Results. The analysis identified five broad themes that affect informal sector enrollment and retention in social health insurance: 1) overlaps in categorization, 2) insufficient or inappropriate social health insurance initiatives for the informal sector, 3) awareness and understanding of social health insurance, 4) supply side factors, and 5) convenience and amount of premium payment. Conclusion. Informal workers are individuals who are not covered by protective labor laws and tend to not belong or contribute to a national health insurance scheme. In the case of the Philippines, the diversity of informal work and dynamic nature of the sector works against an ideal one-size-fits-all solution to increasing informal sector enrollment and retention to social health insurance.

Background PhilHealth, the social health insurance (SHI) agency of the Philippines, still does not sufficiently cover the informal sector workers (ISWs) - or the “missing middle”. Previous approaches had limited success. The impetus for finding solutions to protect the missing middle still remains. Methods A multi-component action research was done to address the complex social problem. Literature review and interviews were conducted to understand the nature of ISWs. National survey data was analyzed for factors affecting the ISWs' membership and retention in SHI. Findings were triangulated to construct evidence-based and context-rich marketing personas to understand PhilHealth's target clients. Using Human-Centered Design Thinking (HCDT), solutions that aim to address the low retention of ISWs in health insurance (HI) were proposed. Results The exact nature of ISWs is still unknown. Costly insurance premiums, poor knowledge of SHI, low perceived value of SHI, and inconvenient payment mechanisms contribute to low participation in SHI. Every additional 1000 PHP (∼20 USD) income increases odds of being an active member by 4%. Those who access private facilities are 2.8 times more likely to be active members. Those who perceive themselves to be sickly were 52% more likely to drop-out of the insurance. The results were fed into the HCDT process producing four prototypes: 1) solutions that explore partnership of PhilHealth with other organizations, 2) use of mobile application platforms for payment and member status updates, 3) automated algorithm to identify and calculate fair premiums, and 4) integration of money-saving strategies. Conclusions The government needs to step-up current efforts to extend health financial risk protection for the ISWs. PhilHealth can take advantage of the research results by testing the prototypes produced, and by adopting the HCDT process to improve their service and coverage for the informal sector. Key messages This government-funded project integrated principles of public health, epidemiology, health financing, participatory governance, and implementation research to address a complex social problem. The results provide a better understanding of the informal sector workers’ nature and needs with regards health insurance and can help PhilHealth improve coverage of informal sector workers.