We Prevent and Recover as One: Local Responses to Ramp up COVID-19 Vaccination Efforts in the Philippines

doi:10.21203/rs.3.rs-3565683/v1

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Research Article

We Prevent and Recover as One: Local Responses to Ramp up COVID-19 Vaccination Efforts in the Philippines

https://doi.org/10.21203/rs.3.rs-3565683/v1

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The Philippines is among the pandemic-affected nations globally. The study evaluated COVID-19 vaccination programs in the seven provinces in Region III. The framework for the study was the World Health Organization's Six Building Blocks of Health Systems: Leadership and Governance, Financing, Health Workforce, Information System, Medical Products/Vaccines, and Service Delivery. For implementers, purposeful sampling was used, while for vaccinees, convenience sampling was employed. A self-designed questionnaire, an interview, and focus group discussions (FGD) were used to acquire information from the participants. The mixed sampling design employs both probability random sampling and non-probability sampling to select a sample. The statistics revealed significant variations in the implementation of the COVID-19 vaccination program across the seven provinces of Central Luzon. Identifying practices analyzing reactions to the COVID-19 vaccination distribution are essential components of a successful immunization plan. The findings of this study may aid the government in correcting vaccination misconceptions and deficiencies.

pandemic

health

building blocks of the health system

vaccination

COVID 19

The emergence of a novel coronavirus, known as COVID-19, has been associated with respiratory complications. The World Health Organization (WHO) officially classified COVID-19 as a pandemic during the initial quarter of 2020. The Philippines experienced a significant impact from the pandemic. Since March 2020, the government has implemented a nationwide quarantine as a means of controlling the spread of the sickness. In early 2021, the scientific community devised a number of immunizations that underwent expedited clinical testing. The government has issued recommendations for vaccination as a means of protecting the general population and mitigating the impact of infectious diseases.

The House of Representatives passed Republic Act No. 11525, creating the Coronavirus Disease 2019 (COVID-19) Vaccination Programme, on February 23, 2021, speeding up vaccine procurement and administration. The Philippine National Deployment and Vaccination Plan for COVID-19 Vaccines was developed by the Department of Health (DOH) as the lead agency and with input from experts from various government agencies to synchronize and integrate the efforts of primary actors like the Office of the President, Inter-Agency Task Force for Emerging Infectious Diseases, Department of Health, and Department of the Interior and Local Government.

An operational guide for the COVID-19 vaccine deployment and vaccination programme and a law that expedites vaccine procurement should have encouraged local government units (LGUs) and society to participate in a coordinated vaccination campaign. The Department of Health reported 45,950,753 doses administered since March 1, 2021, as of October 1, 2021. Twenty-four million, three hundred eighty-nine thousand, nine hundred fifty-eight (24,389,958) people have received their first dose of COVID-19 vaccine, and twenty-one million five hundred sixty thousand seven hundred ninety-five have received two doses. Central Luzon, which includes Aurora, Bataan, Bulacan, Nueva Ecija, Pampanga, Tarlac, and Zambales, accounts for roughly four million of the vaccinees.

Despite recent progress, the Philippines maintains a high mortality rate, making vaccine acquisition and implementation a national priority. Vaccination is still limited to infected people, the elderly, those with chronic conditions, medical and emergency personnel, and the industry or economic front-liners, leaving much to be desired.

The research evaluates Region III's COVID-19 vaccination programs in Aurora, Bataan, Bulacan, Nueva Ecija, Pampanga, Tarlac, and Zambales. The World Health Organization's Six Building Blocks of Health Systems—Leadership and Governance, Financing, Health Workforce, Information System, Medical Products/Vaccines, and Service Delivery—provide a comprehensive view of Central Luzon's current situation.

The community quarantines imposed across countries have reinforced efforts to find effective solutions to counter SARS-CoV-2 or COVID-19 [1]. The impact of the pandemic worldwide prompted the need for new policies to mitigate and contain the pandemic [2]. Aside from partial or complete community lockdowns, initial strategies to reduce the transmissibility of the virus include non-pharmaceutical interventions such as developing and implementing policies on wearing face masks in public places, frequent hand sanitation, social distancing, travel restrictions, school and business closures [3].

According to [4], there is a prevailing belief among scientists that the implementation of early immunization strategies has the potential to effectively mitigate and ultimately bring a stop to the COVID-19 pandemic. In order to effectively manage the pandemic and mitigate the impact on public health, it is imperative to provide the vaccine to a significant proportion of individuals who are susceptible to the virus. This approach serves to safeguard against potential immunity and hence reduce the burden on hospitals, minimize morbidity and mortality rates, and facilitate a progressive reopening of the economy [5] [6] [16]). According to [4], the implementation of rapid mass immunization has the potential to effectively mitigate both the human and economic consequences associated with various health hazards.

The prompt and efficient implementation of vaccination procedures is important in order to achieve widespread immunization against SARS-CoV-2, including a significant proportion, if not the entirety, of the population. The potential strategies identified in the literature for addressing the issue at hand include the prioritization of vaccinations, enhancement of delivery mechanisms, and the promotion of public awareness [17][9]. The urgency of the global infection rate necessitates prompt vaccine production by both international governments and corporations [10]. Public health authorities encounter difficulties stemming from public hesitancy [11]and insufficient vaccine availability.

The Philippine government had initially scheduled the commencement of its vaccination program in February 2021 with the objective of achieving herd immunity against the COVID-19 virus. However, due to limited availability of vaccines and the need to address specific handling and storage requirements, supplementary preparations were undertaken. Republic Act 11525, enacted in February 2021, serves to advance the cause of immunization and streamline the process of vaccine acquisition, as well as the implementation of the Philippine National Deployment and Immunization Plan for COVID-19 Vaccines. Nevertheless, the COVID-19 initiative necessitates the active participation of all individuals and equitable availability of vaccines and related services. The importance of effective governance in the delivery of health services cannot be overstated in the present context.

While a substantial body of research supports the efficacy and importance of vaccination, there is a limited number of studies that have specifically investigated the expeditious assessment of the COVID-19 immunization deployment. A comprehensive nationwide study conducted in the United States centered on the phenomenon of vaccination hesitancy. An effective strategy for COVID-19 immunization will involve the identification of distinct population groups and the barriers they face. The utilization of rapid evaluation techniques can assist the government in addressing misconceptions and deficiencies that arise during the mid-implementation phase of the roll-out process.

Theoretical Framework

The WHO defines a health system as all organisations, institutions, resources, and people working to improve health. This includes health-related acts and health-determinant changes. Public health programs and the pyramid of healthcare institutions that provide personalised medical treatment by State and non-State actors provide preventative, promotive, curative, and rehabilitative interventions [12]. Respecting people and budgeting fairly are the health system's goals. Health systems need people, data, supplies, transportation, communications, and leadership. Thus, improving health systems requires addressing these issues.

Health systems are complicated and have direct and indirect responsibilities across various industries, making performance evaluation challenging. In response, the WHO and its partners have been striving to build a broad-based consensus on important indicators and effective techniques and measures of health systems capacity, including "inputs," "processes," and "outputs," and to tie them to indicators of "outcome." Harmonized health systems monitoring and assessment can reduce disease spread and boost efficiency.

Nevertheless, it is imperative to acknowledge the existence of practical challenges that must be resolved prior to achieving a higher level of harmonization. The presence of numerous analytical and strategic frameworks in the field of health systems gives rise to significant possibilities of redundancy, overlap, and ambiguity. There are several established frameworks that are now in use. These frameworks include the World Health Organization (WHO) framework for health systems performance assessment, the World Bank control knobs framework, and the WHO building blocks framework. These frameworks exhibit diverse initial perspectives, leading to distinct focuses on various outcomes that need to be monitored. Efforts are currently underway to establish theoretical frameworks for the enhancement of health systems, as well as to construct a systematic classification system that would enable the elucidation of indicators, data sources, collection methods, and the analytical approaches that underlie the processes of monitoring and assessment. Nevertheless, the selection of the strategic framework does not inherently have a significant impact on the monitoring and evaluation method. Numerous similarities exist throughout the diverse strategic frameworks for health systems, enabling a unified approach to the selection of indicators and measurement methodologies.

This study is structured around the WHO framework that describes health systems in terms of six core components or “building blocks”: (1) Leadership and Governance, (2) Health Financing, (3) Health Workforce, (4) Health Information System, (5) Medical Products/Vaccines/Technology, and (6) Service Delivery.

The six building blocks contribute to the strengthening of health systems in different ways. Some cross-cutting components, such as leadership/governance and health information systems, provide the basis for the overall policy and regulation of all the other health system blocks. Key input components to the health system include specifically, financing and the health workforce. A third group, namely medical products and technologies and service delivery, reflects the immediate outputs of the health system, i.e., the availability and distribution of care. Inevitably, any type of division of a complex construct such as the health system is fraught with problems. This is also true for the framework, which focuses on health sector actions and underplays the importance of actions in other sectors. It does not take into account actions that influence peoples’ behaviors, both in promoting and protecting the health and the use of healthcare services.

The framework does not address the underlying social and economic determinants of health, such as gender inequities or education, and also does not deal with the substantial and dynamic links and interactions that exist across each component. On the other hand, focusing on these separate components helps put boundaries around this complex construct and permits the identification of indicators and measurement strategies for monitoring progress.

The monitoring and evaluation framework shows how health inputs and processes (e.g., health workforce and infrastructure) are reflected in outputs (e.g., interventions and available services) that in turn are reflected in outcomes (e.g., coverage) and impact (morbidity and mortality). The added value of the framework is that it brings together indicators and data sources across the results chain in its entirety, i.e., from “inputs/processes”, “outputs”, and “outcomes”, to “impact”. It is designed to address monitoring and evaluation needs for different users and multiple purposes, including (1) monitoring of program inputs, processes, and results, required for the management of health system investments; (2) health systems performance assessment, as the key for country decision-making processes; and (3) evaluating the results of health reform investments and identifying which approaches work best.

Research Paradigm

Figure 1 shows the study's paradigm: the COVID-19 vaccination program's six building blocks. The survey questionnaire assesses LGU program implementation and detects any significant differences. To triangulate LGUs' COVID-19 immunization program evaluations, vaccine recipients' opinions will be sought. The implementation challenges will also be identified.

The outcome is COVID-19 vaccination program implementation status and recommended strategies/policies to improve vaccination program in Central Luzon Local Government Units.

Statement of the Problem

The data collected answered the problem statements to wit;

1) How may the status of the implementation of the COVID-19 vaccination program in selected LGUs in Central Luzon be described in terms of:

a) Leadership and Governance;

b) Financing;

c) Health Workforce;

d) Information System;

e) Medical Products/Vaccines; and

f) Service Delivery

2) Is there a significant difference in the implementation status of the COVID-19 vaccination program among the local government units in Central Luzon?

3) How may the challenges encountered in the implementation of the COVID-19 vaccination program in Central Luzon be described?

4) What strategies and policies may be offered based on the findings to make the COVID-19 vaccination program implementation more efficient?

Hypothesis

This study is anchored on the hypothesis that there is no significant difference in the implementation of the COVID-19 vaccination program among Local Government Units (LGUs) in Central Luzon.

The researchers conducted interviews with respondents who were purposefully selected. These respondents were provided with a questionnaire that was created by the researchers. Additionally, they also took part in a focus group discussion (FGD). The individuals in question are recipients of vaccines and suppliers of health services in the Central Luzon region. Vaccines are chosen by the utilization of convenience sampling. The sample design employed in this study is a combination of different sampling methods. These methods involve the selection of a sample by either probability random sampling or non-probability sampling techniques [16]. The probability random sampling method is a quantitative research approach that entails selecting a sufficiently large number of units from a population in a manner that allows for the determination of every element within the population. In contrast, the non-probability sampling method involves selecting cases that deviate or are extreme in nature, with the selection process being driven by specific interests or purposes, such as outlier sampling instead of deli sampling.

The study employed a mixed methods approach to analyze focus group discussions, interviews, and self-made questionnaires. The triangulation approach, according to [14], [15], and [16], is beneficial for gathering distinct but complementary data on the same issue. This was done to better comprehend the study challenge and integrate quantitative methodologies' strengths and drawbacks.

The triangulation design, a one-phase design, combines quantitative and qualitative methods. Due to its single-phase timing, this approach is called concurrent triangulation [14]. The two data sets are integrated by integrating the findings during interpretation or by changing the data to make analysis easier. Using the triangulation design's convergent model, quantitative and qualitative data on the same phenomena are collected and analyzed separately. The results are then compared and contrasted during interpretation. This verifies, validates, or corroborates quantitative data with qualitative observations. It will be easy to draw trustworthy and well-supported findings.

The validating quantitative data model was used to validate and improve survey results by adding open-ended qualitative questions. Quantitative and qualitative data were collected. Qualitative items in a quantitative survey don't provide rigorous qualitative data, but rather intriguing statements that can be used to support and amplify the quantitative survey's conclusions [17].

Focus group discussions, interviews, and Department of Health-Central Luzon Center for Health Development vaccination records were used. Sixteen COVID-19 immunization policies and guidelines from March to September 2021 were consulted. Triangulation and reliable conclusions were possible. As a courtesy, Local Government Units were contacted before data collection to learn about local regulations.

Descriptive and in vivo coding was used to classify respondent replies into the topic grid for qualitative data analysis. The final themes were produced, examined, and reformed from emergent themes and sub-themes. The data examined COVID-19 vaccination program implementation practices. The data was used to create suggestions to address gaps and issues and encourage communities to join government COVID-19 prevention efforts.

Research Locale

The study covers the Congressional Districts in the provinces of Aurora, Bataan, Bulacan, Nueva Ecija, Pampanga, Tarlac, and Zambales (Fig. 2).

The study surveyed 1,541 health service providers and program implementers (doctors, nurses, midwives, and auxiliary personnel) across Region III. Also, 450 vaccinated individuals (vaccinees) were surveyed and interviewed to triangulate the responses gathered from the primary respondents. The bases for the computation are the number of health service providers and program implementers in the region and the vaccination records of DOH CLCHD as of September 30, 2021, covering the periods from March 2021 to September 2021. The minimum accepted size was drawn for the sample population of vaccinated individuals.

The instrument was presented to subject matter experts and methods experts to ensure validity. The instrument also underwent statistical analysis which yield a mean rating of 4.306 verbally interpreted as Excellent. In terms of reliability, pilot testing was done on 27 respondents outside of the target population which yielded a Cronbach Alpha value of 0.947 which indicates the consistency of the items.

Respondents

The succeeding table (Table 1) illustrates the profile of the respondents segregated as to distribution per province.

Table 1

Distribution of Respondents by Province
	Implementers		Vaccine Recipients
	Frequency	Percent	Frequency	Percent
Aurora	124	8.0	57	12.7
Bataan	114	7.4	58	12.9
Bulacan	329	21.3	66	14.7
Nueva Ecija	348	22.6	61	13.6
Pampanga	253	16.4	81	18.0
Tarlac	182	11.8	62	13.8
Zambales	191	12.4	65	14.4
Total	1541	100.0	450	100.0

There was a total of 1,541 respondents for the implementers and 450 for the vaccine recipients or vaccinees respondents.

Profile of the Implementers

Profession.

Most of the implementers (619 or 40.2%) are Nurses who are mostly in charge with the Vaccination Administration, Health Screening and Assessment, Health Education and Informed Consent, Vaccination Administration, and Post Vaccination/ AEFI Monitoring Area. It is followed by Midwives (381 or 24.7%) who are usually assigned in the Health Screening and Assessment and Vaccination Administration. There are also 486 or 31.5% auxiliary personnel who are in-charge of the Registration, Waiting Area, Post Vaccination/AEFI Monitoring Area and they also sometimes perform the Health Screening and Assessment. There are other auxiliary personnel that were hired and trained specifically to carry out tasks for the vaccination program, such as documenting, encoding, administrative tasks, counselling, IT-related activities, health assessment, monitoring, report generation, and vaccine administration.

Human resource category.

The majority of the program's implementers (893 or 57.9%) work for the local government, while 498, or 32.3%, are DOH-augmented (HRH) to carry out their duties. The implementers claim that they have remained consistent from the start of the pandemic until now. Additionally, given the bulk of the barangay appointees work for the LGU, it may be deduced that the LGUs hired the barangay health workers to increase the demand for implementers to serve the recipients. Also apparent was the presence of volunteers, barangay officials, and government hospital staff.

Profile of the Vaccinees

Out of the 450 vaccinees, the majority had Sinovac Coronavac as their first dose (186 or 41.3%) followed by Oxford/Astrazeneca (101 or 22.4%), then 66 or 14.7% had Pfizer/BioNTech, and 61 or 13.6% were vaccinated with Janssen (Johnson & Johnson), a single dose vaccine. The majority of people received the Sinovac Coronavac for their second dose of vaccination (186 or 41.3%), followed by Oxford/Astrazeneca (103 or 22.9%), and Pfizer/BioNTech (65 or 14.4%) and Janssen (61 or 13.6%). There is also one vaccinated by Pfizer/BioNTech and Sinopharm on their first dose but took Oxford/AstraZeneca in their second dose. This might be due to the side effects experienced by the vaccinees on the first dose that led them to take other vaccines in their second dose or may also be due to the availability of the vaccine brand in their locality. The vaccine brand is mostly influenced by the quantity, variety, and type of vaccines that the government issues and purchases. Even while some respondents stated that they preferred particular brands, a lot depends on what the government has to give.

In terms of age the vaccinees are mostly between 41–50 years old (110 or 24.4%) followed by 51–60 (93 or 20.7%), 21–30 (87 or 19.3%), and 31–40 (78 or 17.3%). There are also 15 respondents or 3.3% who are around 71–80 years old and 17 or 3.8% who are 20 years of age and below. It can be construed that most of those who are vaccine recipients are older people.

In terms of sex 236 or 52.4% of vaccine recipients are female, whereas 214 or 47.6% are male. The statistics do not show that more females received vaccinations, but more females were available and willing to provide the information required for the study. The majority of vaccine recipients are workers in frontline health services (115 or 25.65%) and those belonging to other groups (259 or 57.6%). Only 70 respondents, or 15.6%, were older than 60 years old at the time of the vaccination, and 6 respondents, or 1.3%, are in the A3 group, or people with co-morbidities. Furthermore, the majority of the vaccinees are College graduates (131 or 29.1%) and High School graduates (131 or 29.1%) which shows the level of education of the vaccinees. This demonstrates that informed community members are more motivated to take part in the vaccination rollout because they are more aware of the goals and potential advantages of obtaining the COVID-19 vaccine.

Status of Implementation of COVID-19 Vaccination Program in Central Luzon

The following scale range and description were used in investigating the status of the implementation of the COVID-19 vaccination program in Central Luzon during the start of the pandemic.

Leadership and Governance.

The importance of governance in health is becoming recognized as a key development issue. Building a health system requires leadership and governance that ensures strategic policy frameworks are in place and combined with efficient oversight, partnership, regulation, system attention, and observance of accountability.

Based on the data, out of those who strongly agree majority of the implementers (960 or 62.3%) strongly agree on the policy on prioritizing vulnerable groups (such as frontline healthcare workers, the elderly, those with co-morbidities, and other vulnerable populations) especially when the supply was constrained were strictly enforced and implemented.

Moreover, the greatest number of implementers combining agree and strongly agree on a parameter of leadership and governance is on the availability of the COVID-19 Vaccination Operational Plan (e.g., Micro plan) (648 agree and 863 strongly agree). This is consistent with the other parameters of leadership and governance where the implementers agree that the LGU implements the vaccination operation plan.

Although there is only 40 or 2.6% of the implementers strongly disagree it is notable that these implementers believe that there are no available policy/ies (either issued/adopted/localized) that support the COVID-19 vaccination program implementation in the LGU during the start of the roll-out. This might be due to the limited number of people that can be catered to during the start of the roll-out.

According to the three vaccinees in a Focus Group Discussion dated August 21, 2022, during the start of the vaccination program, people line up from dawn till noon just to be vaccinated.

Based on the vaccinees’ responses, the majority strongly agree (250 or 55.6%) that the policies/protocols on the observance of Minimum Public Health Standards (MPHS) and Infection Prevention and Control (IPC) measures in the vaccination sites were strictly enforced/implemented. The parameter with the greatest number of agree and strongly agree responses combined is the presence of representatives from other organizations/partners (e.g., DOH, PHO, WHO, UNICEF) in the vaccination sites. This shows how the government agencies, local chief executives, and local officials are being hands-on with the implementation of the vaccination program in their area.

However, it can be noticed that most of the vaccinees disagree (118 or 26.2%), strongly disagree (39 or 8.7%), or are unaware (18 or 4.0%) that there are malls, cinemas, and private properties that were utilized in their locality during the start of the roll-out. Most of the roll-out occurs in the barangay health centers and municipal halls as mentioned in the FGD. Malls and private properties were only recently added as vaccination sites.

It can also be observed that across the provinces, Tarlac has the greatest number of implementers who Strongly Agree (135 or 74.2%) that policy on prioritizing vulnerable and priority groups were strictly enforced and implemented during the initial vaccine roll-out. While the highest proportion of implementers with combined Strongly Agree (124 or 68.1%) and Agree (58 or 31.9%) is also in Tarlac, where the respondents believe that policies/guidelines on COVID-19 vaccination program implementation as well as LGU-level target immunization coverage from the Department of Health was clear, consistent, and cascaded on a timely manner, it can also be noted that although it is minimal, the greatest number of respondents who Strongly Disagree (14 or 5.5%) is on Pampanga where they perceived that there are no available policies that support the COVID-19 Vaccination Program implementation in the LGU.

Moreover, the responses suggest that 100% of the implementers from Bataan (44.7% Agree and 55.3% Strongly Agree) affirmed the presence of external monitors (e.g., DOH CLCHD/PDOH/PHO personnel, WHO, UNICEF) who regularly visited/assessed the program implementation of the LGUs and provided necessary technical assistance.

Investigating the mean response of the implementers by the province in Leadership and Governance, the overall mean response shows that implementers of Central Luzon believe that the COVID-19 Vaccination program initial roll-out has been Fully Implemented by the provinces (Mean Response = 3.48).

The data show that all provinces are fully implementing the vaccination program in terms of prioritizing the vulnerable and priority groups; visibility of the Local Chief Executives, responsible agencies, NGOs, and other support agencies; enforcing of policies and protocols on COVID-19; the presence of Vaccination Operation Plan and its implementation; cascading of policies related to the vaccination program, and active involvement of LCEs in the implementation of the Vaccination Operation Plan. The highest mean was reflected by the implementers of Tarlac (Mean = 3.62) while the least was under the province of Bulacan (Mean = 3.42) and Pampanga (Mean = 3.43) which are also consistent with the distribution of response per province.

Financing.

In assessing the financing aspect of the implementation of the COVID-19 vaccination program at the start of its roll-out, the majority of the implementers either strongly agree (666 or 43.2%) or agree (797 or 51.7%) that their LGU allocated and/or re-aligned its funds for COVID-19 vaccination program implementation. This is to adjust their fund based on the priorities of the local chief executives as mentioned by an implementer during the FGD. However, there were 186, or 12.1% implementers who strongly disagree, and 362, or 23.5% who disagree that the LGU provided incentives (e.g., grocery/food pack, rice pack, cash, etc.) to clients who had been vaccinated. Consistent with the response of the implementers, the vaccinees strongly disagree (133 or 29.6%) or disagree (219 or 48.7%) that the LGU provided incentives (e.g., grocery/food pack, rice pack, cash, etc.) to clients who had been vaccinated.

The survey responses were reaffirmed by the vaccinees during the FGD as all of them mentioned that at the start of the vaccine roll-out, there were no incentives for the vaccine recipients. This might be due to the high demand and low supply of vaccines during the start of the roll-out. It was only recent that LGUs provide relief goods and rewards for those who would want to be vaccinated.

It can be observed that across the parameters in Financing, the highest number of implementers who Strongly Agree is on Tarlac (93 or 51.1%). The respondents perceive that the LGU allocated and/or re-aligned its funds for COVID-19 vaccination program implementation. While the greatest proportion who Strongly Agree (52 or 45.6%) and Agree (59 or 51.8%) are in Bataan where implementers also believe that the LGU allocated and/or re-aligned its funds for COVID-19 vaccination program implementation. However, it was in Zambales where the greatest number of those who Strongly Disagree (38 or 19.9%) and Disagree (53 or 27.7%) can be noticed. They do not believe that the LGU provided incentives (eg. grocery/food pack, rice pack, cash, etc.) to clients who had been vaccinated. Across the parameters, it can also be noted that the respondents gave a much lower response in Financing compared to other building blocks of Health.

Only Bataan with a Mean response of 3.27 is fully implementing their initial vaccination program roll-out with extra efforts to their fund allocation towards the program and provision of incentives for vaccinees and implementers compared to other provinces. The least Mean (2.99) can be seen in Zambales which is consistent with the distribution of response of the implementers. In general, the respondents perceived that the Central Luzon LGUs are implementing the COVID-19 Vaccination program but not fully.

Health Workforce

When it comes to the health workforce during the start of the vaccination program, implementers strongly agree (774 or 50.2%) and agree (730 or 47.4%) that the roles and responsibilities among the program implementers/vaccination team were clearly defined and delineated.

The implementers strongly agree (750 or 48.7%) that the program implementers received appropriate and adequate training for the implementation of the COVID-19 vaccination program. Likewise, they agreed that assessments of staffing status and needs were regularly conducted. The implementers even recalled that they need to conduct several meetings in a day to assess the needs and issues which helped them improve the implementation of the program.

During the FGD, an implementer from the province of Bataan did mention that the personnel from Provincial DOH Office, Provincial Health Office, and Municipal Health Office (MHO) visit the vaccination sites to personally assess the readiness of the venue and completeness of both material and human resources for the scheduled vaccination rollout. The response of the vaccinees also concurs with the response of the implementers as they strongly agree (271 or 60.2%) that staff was competent in providing COVID-19 vaccination-related services. Across all the parameters of the health workforce, the vaccinees agree to each statement.

Four FGD participants from the province of Bulacan, Tarlac, Zambales, and Bataan respectively narrated their experiences. According to a participant from Bulacan, the LGU pulled out doctors and nurses from the district hospitals. Participants from Tarlac and Bataan shared similar observations. Tarlac hired additional Job Orders (JO) healthcare workers while Bataan hired additional doctors and nurses. Bataan furthermore extended additional support such as the provision of free lunch and coffee to healthcare workers. To motivate the workers, ten thousand pesos (₱10,000.00) awaits the unit that will perform well and meet the target number of vaccinated individuals. The local health office and the LGU even provided overtime pay to eligible workers at the height of the pandemic.

As preventive measures against COVID-19, health workers used Personal Protective Equipment particularly face masks and disposable gloves when vaccinating individuals. The LGU provided additional support and a line of defense by enforcing limitations on movement by placing barriers in strategic areas in the barangay.

Particularly, the response of the provinces in the parameters of Health Workforce shows that the highest distribution of implementers answering Strongly Agree is in Zambales (122 or 63.9%) as well as the highest combined response of Strongly Agree and Agree are noted in Aurora and Bataan. It shows that respondents believe that the roles and responsibilities among the program implementers/vaccination team were clearly defined and delineated. Thus, reflecting the performance of the vaccine implementers. Across all the parameters, the majority of the implementers of Aurora either Strongly Agree or Agree that the LGUs are performing well in terms of the Health Workforce.

Meanwhile, the greatest numbers of implementers who Strongly Disagree (22 or 11.5%) and Disagree (53 or 27.7%) are also observed in Zambales where implementers do not agree that human resource/manpower for vaccination was focused on the vaccination program and do not have other intervening tasks.

In terms of Health Workforce, the findings denote that all provinces performed well in Health Workforce parameters. The majority perceive that LGUs fully implement the parameters measured in the study as reflected in the overall Mean Response of 3.35. The greatest Mean is shown in Aurora (3.45) followed by Tarlac (3.43), while the least Mean is in Bulacan (3.26).

Information system.

Most of the implementers who strongly agree (745 or 48.3%) believe that an information system on logistics management (e.g., expiration date monitoring, management of expired and near expiry, documentation of vaccine utilization, updated inventory, etc) is available and functional. Yet the greatest number of combined agree (804 or 52.2%) and strongly agree (702 or 45.6%) of the implementers’ response is on the availability and functionality of the information system/mechanism to identify, track, and report COVID-19 vaccine-related adverse events.

The implementers have a positive response to the Data Quality Check/Validation and Analysis that are regularly conducted by external monitors (PHO/PDOH/DOH CLCHD/WHO/UNICEF). It shows that the implementers believe that the information system on vaccination implementation is in-place. However, it can be noticed that there are implementers who strongly disagree (63 or 4.1%) and disagree (175 or 11.4%) that the pre-registration process via an online platform where vaccine recipients are pre-registered/scheduled was established and functional. Although most of the implementers agree that they have online pre-registration and vaccination schedules, some still had a hard time scheduling for vaccination.

According to the vaccinees, they just go on-site or walk-in for them to be vaccinated. This reminds us that there is room for improvement when it comes to access to information, communication, and technology which is consistent with existing studies regarding the level of e-governance in the Philippines.

Consistent with the response of the implementers, the majority of the vaccinees, strongly agree (243 or 54.0%) that data management equipment (computers, tablets, pens and paper, QR scanner) was available in the vaccination sites. Vaccinees further agree (195 or 43.3%) and strongly agree (235 or 52.2%) that aside from the vaccination card, the LGU has an available and functional information system where clients’ information can be registered/encoded and validated. It can be said that the Information Technology equipment on the vaccination site is very prominent, and is being utilized for the implementation of the vaccination program even at the start of the roll-out.

Based on the response per province of Central Luzon with regards to the Information System during the COVID-19 vaccination program initial roll-out, the greatest distribution of implementers who Strongly Agree (132 or 69.1%) is in Zambales where the majority of the implementers believe that information system on logistics management is available and functional. This is the same parameter where the highest combined Strongly Agree (54 or 47.4%) and Agree (60 or 52.6%) are found in the province of Bataan and Aurora.

Meanwhile, the data reveals that there are 16 implementers, or 8.8% who Strongly Disagree, and 32, or 17.6% Disagree in the province of Tarlac that the pre-registration process via an online platform where vaccine recipients are pre-registered/scheduled was established and functional. It is also the parameter where there is a significant number of implementers in other provinces like Pampanga, Nueva Ecija, Zambales, Bulacan, and Aurora who also strongly disagree.

In terms of Information System, the provinces of Region III are fully implementing the information system during the start of the vaccination program of the government. The highest Mean can be seen in Zambales (3.53) which reflects the positive responses of the implementers on the parameters of the information system. The least is Bulacan (Mean = 3.29) where the majority of the implementers although they agree perceived that the implementation is not up to the full mark.

Medical products/vaccines.

During the start of the vaccination program, the majority of the implementers strongly agree (849 or 55.1%) and agree (669 or 43.4%) that appropriate storage and handling of COVID-19 vaccines, such as proper cold chain storage units, storage capacity, and temperature controls are ensured. They also agree that cold chain facilities and equipment and storage capacity are available and adequate (715 or 46.4% agree and 794 or 51.5% strongly agree). This indicates that the LGUs prioritize the equipment needed for the implementation of the program which is also verified by the implementers during the FGD.

Meanwhile, it can be noted that the vaccinees strongly agree (210 or 46.7%) and agree (215 or 47.8%) that the vaccine supply and logistics (e.g., syringe) of the LGU was adequate to cover the target population in our locality.

The vaccinees likewise, strongly agree (189 or 42.0%) and agree (230 or 51.1%) that appropriate storage and handling of COVID-19 vaccines, such as proper cold chain storage units and temperature controls were ensured although there are 20 respondents or 4.4% who are not aware of this.

It can also be noted that 82 vaccinees or 18.2% disagree and 38 or 8.4% strongly disagree that their preferred COVID-19 vaccine brand was available and administered to them. The result is consistent with the earlier results that the vaccine brands depend on the availability and the type of vaccine procured or offered by the government.

According to the data per province, the highest distribution of implementers who answered Strongly Agree in terms of Medical Products/Vaccines is on Tarlac, 127 or 69.8%. It means that respondents perceive that appropriate storage and handling of COVID-19 vaccines, such as proper cold chain storage units, storage capacity, and temperature controls are ensured. While the highest combined distribution of Strongly Agree (80 or 64.5%) and Agree (44 or 35.5%) is in Aurora where implementers believe that different brands of vaccines were available hence, clients can choose which vaccine to receive.

The data, likewise, reveal that there 15, or 5.9% Strongly Disagree and 23, or 9.1% who Disagree in Pampanga that they have the availability of different brands and that the beneficiaries can choose which vaccine to receive contrary to the case of Aurora. This is the same with provinces like Zambales, Nueva Ecija, and Bulacan where there are implementers who do not support this statement.

As observed in the Mean Response for Medical Products/Vaccines, in general, the Region is Fully Implementing the vaccination program in terms of Medical Products/Vaccines with a Mean Response of 3.42. The highest Mean can be seen in Aurora (3.58) followed by Tarlac (3.53) and Zambales (3.52). The least Mean is noticed both in Bulacan and Pampanga (Mean = 3.33).

Service delivery.

The status of service delivery during the start of the vaccination roll-out in Region III according to the implementers is positive as reflected by the number of respondents who agree and strongly agree.

Most of the implementers strongly agree (852 or 55.3%) that the vaccine administration process (registration, health screening, health education and informed consent, vaccine administration, post-vaccination monitoring) were organized and well-implemented.

Moreover, the implementers strongly agree (831 or 53.9%) and agree (677 or 43.9%) that the minimum public health standards such as social distancing, wearing of face mask/face shield were strictly implemented in the vaccination sites. The implementers also have positive response that the vaccination site has adequate space for the number of currently scheduled eligible vaccine recipients and that risk communication and social preparation/mobilization activities were conducted prior to the vaccination activity. However, the data reveal that 39 implementers or 2.5% strongly disagree and 186 or 12.1% disagree that feedback mechanism (e.g., written/online survey, exit interview) on vaccination process experience was available. This issue was not confirmed by the implementers during the FGD as they mentioned that the access of the public to the social media accounts of the Local Government Units are available for them to post their comments, reactions, suggestions, and experience on the vaccination program.

The data revealed that the vaccinees response on all the parameters of service delivery are positive. Most of the respondents strongly agree (272 or 60.4%) and are consistent in the earlier results that the minimum public health standards such as social distancing, wearing of face mask/ face shield were consistently implemented in the vaccination sites. Further, 209 or 46.4% agree and 233 or 51.8% strongly agree that the necessary information about COVID-19 vaccination program (e.g., schedule, venue, target/priority recipients, etc.) in their locality was well disseminated. And that vaccine administration process (registration, health screening, health education and informed consent, vaccine administration, post-vaccination monitoring, etc.) were systematic/organized and well-implemented. This confirms that the implementers are well-trained to perform their function during the implementation of the vaccination program even at the start of the program.

Based on the data per province, implementers’ response across all the parameters of Service Delivery responded positively. The greatest distribution of respondents who answered Strongly Agree is on Zambales (133 or 69.6%) on the parameter of vaccine administration process where implementers believe that the vaccine administration process were organized and well-implemented. This is also the parameters where the highest combined Strongly Agree and Agree can be observed in the provinces of Bataan and Aurora.

Meanwhile, the greatest number of respondents who Strongly Disagree is in Pampanga (12 or 4.7%) whereas in terms of percentage, Tarlac recorded the highest on the parameter “Feedback mechanism (e.g., written/online survey, exit interview) on vaccination process experience was available”. This the same parameter where there are implementers from other provinces who also disagree with the statement.

Consistent with the response distribution per province, the Mean Response of the Region in Service Delivery is 3.42 denoting the full implementation of the vaccination program. The highest mean is also Zambales with Mean = 3.55 followed by Aurora (Mean = 3.52), while the least mean is observed in Bulacan (Mean = 3.33).

Across all the six pillars, the mean response of the region in the implementation status is Fully Implemented except in the pillar of Financing (Mean = 3.09) which is described as Implemented. Aside from it having the least mean response, it is also the pillar on which there is only one province where the respondents perceived that their Financing parameters are Fully Implemented. This most likely would be the case since the state of calamity has been declared due to the COVID-19 pandemic and LGUs have very limited amount of fund that could be re-aligned or utilize for the initial vaccination roll-out. It would only depend on the prioritization of the Local Chief Executives and their strategies to gather resources for its implementation. The highest mean response is also noticeable for the pillar of Leadership and Governance. It reflects that all LGUs and Local Chief Executives in the region have done well when it comes to managing their area of responsibility as much as the vaccination program is concern. They all showed their own management skills, and prioritization to best provide the service to the public.

In general, all the provinces in Region III have done their part to fully implement the COVID-19 vaccination program in its initial implementation. However, the challenge on the financial aspects still manifests in the response of the implementers.

Significant Difference in the Implementation Status of COVID-19 Vaccination Program among the Local Government Units in Central Luzon

The significant difference in the implementation status of COVID-19 vaccination program among the Local Government Units in Central Luzon was tested using the Analysis of Variance (ANOVA) through the use of IBM-SPSS 21.0. Results show that there were significant differences between the seven provinces of Central Luzon when it comes to the implementation status of the COVID-19 vaccination program across all the parameters of the six building blocks of health system resulting to p-value equal to or lower than .001. It means that among the seven provinces, their implementation of the vaccination program significantly differs compare to the other provinces. The specific provinces and the parameters of the building blocks of the health system on which the difference occurred would only be determined using Post Hoc test. Moreover, the reasons for differences may be based on different factors that may be room for further investigation on the topic.

With regard to the access of the ICCs/IPs and their participation to the vaccination program during the start of the roll-out, implementers from Aurora, Bataan, and Nueva Ecija mentioned in the interview that they even go down to the health centers and municipal hall to be vaccinated, while some of the Local Government Units reach out to the community through house-to-house activities. According to the implementers, there are cultural and religious communities that refuse being vaccinated but there are cultural communities that are open to this government activities especially those with regards to health.

Using a Tukey-Kramer Post Hoc test in account of unequal number of sample sizes per province, the test reveals that in Leadership and Governance parameters, the significant difference among the provinces lies between Tarlac and Aurora province, Tarlac and Bulacan, Zambales and Bulacan, Tarlac and Nueva Ecija, and Tarlac and Pampanga. The implementation of COVID-19 vaccination program is significantly higher when it comes to Leadership and Governance in Tarlac compared to Aurora. It means that implementers see that in terms of the parameters such as the active involvement of the LGUs and Local Chief Executives, COVID-related policies implemented, implementation of the Vaccination Operational Plan, and participation of other stakeholders, they are more prominent in Tarlac than in Aurora, Bulacan, Nueva Ecija and Pampanga.

Moreover, it is also significantly higher in Zambales than in Bulacan. These are all reflected in the perception of the implementers when it comes to their experience of the vaccination program during the start of the roll out. It shows that respondents of Tarlac and Zambales believe that their LGUs are doing better in their implementation of the vaccination program compared to the response of the implementers in other LGUs in terms of leadership of their LCEs’, participation of other stakeholders and implementation of the COVID-related policies and plans.

When it comes to Financing during vaccination program initial roll-out, Bataan performs well than Bulacan, Nueva Ecija, and Zambales, while Tarlac performs well compared to Bulacan and Zambales based on their mean differences as perceived by the implementers. It shows that during the initial roll-out of the program, implementers believe that Bataan and Tarlac LGUs implement it well when it comes to allocation of resources, incentives, and compensation compared to other provinces. It reflects the active participation of LGUs and the prioritization of the Local Chief Executives when it comes to health and the urgency of dealing with the COVID-19 crisis.

In the implementation of the vaccination program in terms of Health Workforce, it reveals that the implementers perceive that Aurora, Tarlac, and Zambales performs well compared to Bulacan. This is according the implementers’ response when it comes to the management of the capacity of the implementers, number of manpower, PPEs’ and procedures implemented during vaccination as well as assessment on the implementation of the program.

Although the respondents and participants of the FGD recall the challenges during the initial roll-out, LGUs from these three provinces have done well to address the challenges in the health workforce, given their situation and accessibility of their areas.

For the Information System during the initial roll-out of the COVID-19 vaccination program, Zambales performs well over Bulacan, Nueva Ecija, and Pampanga based on the mean response of the implementers. Thus, Zambales LGUs are seen to implement well the use of Information and Communications Technology and utilize it for the vaccination program through registration process, encoding, validation, report generation, recording, organizing of data, analysis of data, tracking, updating, and logistics management. Alhough all of the provinces have available hardware or ICT in the roll-out, the effective utilization and system are reflected on the response of the implementers of Zambales.

In terms of the Medical Products/Vaccines, Aurora, Tarlac, and Zambales perform well according to the implementers compared to Bulacan, Nueva Ecija, and Pampanga. It denotes that Aurora, Tarlac, and Zambales implemented their initial roll-out of the vaccination program well in terms of allocation of vaccines to cover the population, monitoring of supplies and logistics’ availability, provision of cold chain facilities and equipment for the vaccine storage, procurement of supplies and adequate PPEs, and management of resources and implementation of the COVID-19 vaccine plan.

Lastly, for the Service Delivery, Aurora is perceived to perform well over Bulacan, while Zambales is perceived to perform well compared to Bulacan, Nueva Ecija, and Pampanga. It means that according to the implementers, Aurora and Zambales are able to manage well the initial implementation of the program in terms of social preparation and communication, implementation of minimum public health standards, vaccine administration processing, feedback mechanism, and assessment of vaccination process/systems.

Although other provinces have good performance on their implementation of the program, implementers of Aurora and Zambales reflected a higher response than the other provinces.

The majority of responses concur with those from the survey questionnaire and the initial interview, but some do not, such as when it comes to the funding, procurement, and incentives which differ from province to province.

Challenges/Issues Encountered on the Implementation of the COVID-19 Vaccination Program During March-September 2021

The identified challenges manifest the areas needing improvement as they are seen to have significant effects on the attainment of the targets of the vaccination rollout.

To stop the transmission of the virus, avert hospitalizations, and stop deaths from the disease, efficient and secure COVID-19 vaccines have been created at a quick and unprecedented rate. However, vaccine reluctance and anti-vaccination views pose a challenge to the uptake of the COVID-19 vaccine.

Supply and demand issues are causing the region's fight against the COVID-19 pandemic to be difficult. Less respondents appear inclined to get vaccinated as vaccination becomes more likely, and the elevated safety concerns were connected to the scant information made available to the general public and target population. This was reinforced by the focus group discussion on August 21, when nearly every participant shared the same opinions on the rollout.

When deciding whether to vaccinate, individual perspectives are crucial. Misinformation exposure shapes these perceptions.

The region's vaccination rollout is further hampered by perceptions of the system's inflexibility and inefficiency, particularly among marginalized and vulnerable groups. To increase COVID-19 vaccination participation and reach, concerns must be identified and addressed at all levels. Increasing health literacy is a crucial strategy for combating false information that threatens vaccine confidence.

The Philippine "National Deployment and Vaccination Plan for COVID-19 Vaccines," established by the government, outlines population groups to be prioritized in order to maintain vaccination equity while taking into consideration various risks and needs.

Two respondents stated during the FGD that they need to line up early in order to get vaccinated, despite the fact that others were exploiting connections, commonly known as the "palakasan" method, to acquire the vaccination ahead of those on the priority list.

The following conclusions and recommendations were made in light of the study's findings. The six pillars of the public healthcare system are highlighted.

The Philippines is one of the countries greatly affected by the pandemic. Through the Department of Health (DOH) as the lead agency and with inputs from experts of various government agencies, the national government came up with the Philippine National Deployment and Vaccination Plan for COVID-19 Vaccines to synchronize and integrate efforts of the primary actors such as the Office of the President, Inter-Agency Task Force for Emerging Infectious Diseases, Department of Health, and Department of the Interior and Local Government as they play crucial roles in the exercise of command and control.

Most of the implementers (619 or 40.2%) are Nurses who are mostly in charge of the Vaccination Administration, Health Screening and Assessment, Health Education and Informed Consent, Vaccination Administration, and Post Vaccination/ AEFI Monitoring Area. There are other professions besides medical allied professions that are hired and trained specifically to carry out tasks for the vaccination program, such as documenting, encoding, administrative tasks, counseling, IT-related activities, health assessment, monitoring, report generation, and vaccine administration.

The majority of those surveyed (186 or 41.3%) had Sinovac Coronavac as their first dose. The number, variety, and type of vaccines that the government distributes and purchases have a significant impact on vaccine brands. In terms of age, the vaccinees are mostly between 41–50 years old (110 or 24.4%). It could be assumed that elderly individuals make up the majority of vaccination recipients. The majority (236 or 52.4%) of vaccine recipients are females as compared to 214 (47.6%) males.

Status of Implementation of COVID-19 Vaccination Program in Central Luzon

Leadership and Governance.

According to the study's findings, policy implementers strongly agree that vulnerable groups (e.g., the elderly, people with co-morbidities) should be prioritized, especially when supply is limited. As a result, LGUs adhere to the vaccination operation plan (micro plan), but some implementers believe that there was no definite issuance or locally-adopted policy at the start of the roll-out due to the small population that could be accommodated and the limited supplies and equipment available at the time.

Meanwhile, many vaccine recipients strongly agree that the policies and procedures governing the observance of Minimum Public Health Standards (MPHS) and Infection Prevention and Control (IPC) measures in vaccination sites were followed correctly, despite the fact that the initial rollouts were plagued by issues such as a long queue or waiting time. Representatives from various organizations/partners such as DOH, PHO, WHO, and UNICEF were also present at the vaccination sites. This demonstrates how local chief executives, government organizations, and other local leaders are actively involved in implementing the vaccination program in their region. The roll-out, however, takes place at municipal halls and barangay health centers.

Tarlac has the highest percentage of implementers who strongly agree that the policy of prioritizing vulnerable and priority populations was strictly enforced and implemented throughout the initial vaccine roll-out. Respondents believe that the Department of Health's policies and guidelines on the implementation of the COVID-19 vaccination program and target immunization coverage at the LGU level were clear, consistent, and time-bound at the regional level, but not at the city/municipal and barangay levels due to differences in policies and information dissemination schemes. Some Pampanga vaccinees (5.5%) believe there are no policies in place to help the LGU carry out the COVID-19 Vaccination Program.

Despite lapses in systems and procedures during the initial roll-out of the COVID-19 Vaccination Program, all provinces fully implemented the vaccination program in terms of giving priority to vulnerable and priority groups, visibility of Local Chief Executives, responsible agencies, NGOs, and other support agencies, enforcement of COVID-19 policies and protocols, presence of the Vaccination Operation Plan and its implementation, cascading of policies related to the vaccination program, and cascading of policies related to the vaccination program.

Financing.

The LGUs had allocated and/or realigned funds for the implementation of the COVID-19 immunization program at the start of the rollout. This arrangement allowed some LGUs, including Bataan, Pampanga, Aurora, and Nueva Ecija, to provide incentives to vaccine recipients, such as grocery/food packs, rice packs, or cash. However, procurement of equipment and supplies was later delegated to the national government. This arrangement eventually impacted the availability of vaccines and the scheduling of LGUs while they waited for supplies.

Health Workforce.

When it comes to the health workforce, the implementers claim that the duties and responsibilities of the program implementers/vaccination team were properly defined and outlined at the start of the vaccination program.

The program implementers unanimously agree that they received adequate training for carrying out the COVID-19 immunization program. They also agreed on the importance of conducting regular assessments of workforce needs and status. The program implementers even remembered having to hold numerous meetings each day to assess needs and problems, which helped them improve how the program was implemented. The vaccinees' response is consistent with the implementers' response, as both agree that the personnel are capable of handling services associated with the COVID-19 vaccination.

Among the strategies used by the local governments of Bulacan, Tarlac, and Bataan was to pull out physicians and nurses from district hospitals. Tarlac hired more Job Order (JO) employees than Bataan. Bataan also provided additional assistance, such as free lunches and coffee for medical professionals. To motivate employees, the unit that performs well and achieves the target number of vaccinated individuals will be awarded ten thousand pesos (₱10,000.00).

During the peak of the pandemic, the local health office and the local government even paid qualified employees overtime. Aurora and Zambales implementers believe that the roles and responsibilities of program implementers and immunization teams were clearly defined. Some Zambales implementers, on the other hand, do not believe that the vaccine program's human resources and labor were solely focused on it, with no other tasks in the way.

As a COVID-19 prevention measure, health professionals used personal protective equipment, primarily face masks and disposable gloves, when administering vaccinations. The LGU provided an additional line of defense and support by enforcing movement restrictions in key locations throughout the barangays.

Information system.

The majority of implementers think that information systems on logistics management (e.g., monitoring expiration dates, managing expired and near-expiry items, documenting vaccine use, updating inventories, etc. are available and functional). Furthermore, implementers agree on the availability and functionality of the information system/mechanism to identify, track, and report adverse events connected to the COVID-19 vaccination.

The data quality checks, validations, and analyses that are routinely carried out by outside monitors (PHO/PDOH/DOH CLCHD/WHO/UNICEF) have received favorable feedback from the implementers. It demonstrates that those who are implementing vaccination programs think an information system is in place. Although pre-registration via an online platform where vaccine recipients are pre-registered/scheduled was built and functional. Most implementers concur that they have online pre-registration and vaccination scheduling, however some still found it difficult to arrange for vaccinations while other claims that walk-ins were later on allowed. This serves as a reminder that there is still potential for progress in terms of information, communication, and technological access, which is consistent with recent research on the state of e-governance in the Philippines.

Most vaccine recipients and implementers alike highly agree that data management tools (computers, tablets, pencils and paper, QR scanners) were available at the immunization sites and that all LGUs have functional information systems where clients' information can be registered, encoded, and validated in addition to the immunization card. Nonetheless, the pre-registration process and more systematic IT infrastructure at the vaccination sites became more noticeable as the rollout gets underway. However, for Bulacan, the majority of implementers feel that the implementation falls short of expectations because of inconsistent procedures and a lack of IT-related equipment.

Medical products/vaccines.

At the beginning of the immunization program, COVID-19 vaccines are handled and stored properly using cold chain storage units with capacity and temperature controls, and there are readily available cold chain facilities, tools, and supply of syringes although these are limited during the first months of the rollout. Nonetheless, this shows that the LGUs give the program's equipment a high priority although the vaccine brands provided to the public depend on the kind of vaccines the government buys or distributed by manufacturers.

According to the data per province, respondents from Tarlac believe that proper cold chain storage units, storage capacity, and temperature controls are in place for the handling and storage of COVID-19 vaccines. This allowed them to accommodate multiple brands of vaccines so that residents can choose which vaccine to receive. This situation is in contrast with the experiences of Pampanga, Zambales, Nueva Ecija, and Bulacan at the beginning of the roll-out.

Service delivery.

Registration, health screening, health education, informed consent, vaccine administration, and post-vaccination monitoring processes were planned and carried out based on the majority (55.3%) of implementers although on a trial-and-error basis.

Social distance and the wearing of a face mask or shield were also observed. The vaccination location has enough room for the scheduled eligible vaccine recipients, and that risk communication and social preparation/mobilization activities were done prior to the vaccination activity. However, the findings show that feedback mechanisms (such as a written/online survey, or exit interview) on the experience of the vaccination procedure are not usually practiced.

Accordingly, the procedures involved in administering vaccines (registration, health screening, health education, informed consent, vaccination, post-vaccination monitoring, etc.) were structured and methodical. This demonstrates that even at the beginning of the immunization program, implementers were properly trained to carry out their duties.

Combating the COVID-19 pandemic in the region is challenging because to supply and demand difficulties. As vaccination becomes more likely, fewer respondents seem to be eager to obtain it, and safety concerns were linked to the lack of information provided to the general public and target demographic.

The deployment of vaccinations in the region is further delayed by beliefs about the rigidity and inefficiency of the system, particularly among vulnerable and marginalized communities. In order to boost COVID-19 immunization coverage and participation, issues must be recognized and resolved on all fronts. A key tactic for preventing incorrect information that jeopardizes vaccine confidence is raising health literacy.

For all six pillars, the region's mean response in terms of implementation status is Fully Implemented, with the exception of the financing pillar, which is characterized as Implemented. In addition to having the lowest mean response, this pillar is the only one where respondents believe their financing parameters have been fully implemented. This is most likely the case because the COVID-19 pandemic has caused a state of catastrophe, and LGUs have very little money that might be reallocated or used for the initial vaccination roll-out. It would solely depend on the Local Chief Executives' prioritizing and tactics for securing funding for implementation.

The pillar of Leadership and Governance likewise has the highest mean response. It shows that, in terms of administering their respective spheres of authority with regard to the immunization program, all LGUs and Local Chief Executives in the area have performed admirably. To provide the finest service to the public, they all displayed their management abilities and prioritization talents.

In general, every province in Region III has contributed to the initial execution of the COVID-19 vaccination program in full. However, the implementers' response continues to reflect the financial difficulty.

The results likewise indicate that there are significant differences between the seven provinces of Central Luzon in terms of the COVID-19 vaccination program's implementation status across all parameters of the six components of the health system, with p-values equal to or less than .001. In other words, the seven provinces' approaches to implementing the immunization program are very different from those of the other provinces. Hence, there may be an opportunity for additional research on the topic as the causes of the variances could be dependent on a variety of factors.

Implementers from Aurora, Bataan, and Nueva Ecija even go down to the health centers and municipal hall to be vaccinated, while some Local Government Units reach out to the community through house-to-house activities. This is in relation to the access of the ICCs/IPs and their participation in the vaccination program during the start of the roll-out. While certain religious and cultural groups oppose vaccination, others are amenable to government initiatives, particularly those that have to do with health.

The results of the Tukey-Kramer Post Hoc test, which took into account the different sample sizes for each province indicate that active involvement of the LGUs and Local Chief Executives, implementation of COVID-related policies, implementation of the Vaccination Operational Plan, and participation of other stakeholders is more observable in Tarlac than Aurora, Bulacan, Nueva Ecija, and Pampanga.

In terms of the leadership of their LCEs, involvement of other stakeholders, and the implementation of COVID-related policies and plans, LGUs of Tarlac and Zambales are perceived to be performing better than other LGUs. During the program's first roll-out, implementers perceived that Bataan and Tarlac LGUs have better resource allocation, incentives, and remuneration when compared to other provinces. It demonstrates the LGUs' active involvement, as well as the Local Chief Executives' prioritizing of health and the urgency of resolving the COVID-19 situation.

The vaccination program's implementation in terms of the health workforce reveals that Aurora, Tarlac, and Zambales performed better than other LGUs. This is in accordance with the management of the implementers' capacity, amount of manpower, the PPEs, and procedures used during vaccination, as well as appraisal of the program's implementation. Given their circumstances and the accessibility of their regions, LGUs from these three provinces have done well in addressing the obstacles in the health workforce.

Based on the average response of the implementers, Zambales outperforms Bulacan, Nueva Ecija, and Pampanga for the information system during the initial roll-out of the COVID-19 immunization program. As a result, it is evident that Zambales LGUs effectively use the information and communications technology for the immunization program, using it for the registration process, encoding, validation, report generation, recording, organizing of data, analysis of data, tracking, updating, and logistics management. Even though all of the provinces have hardware or ICT available for the roll-out, Zambales' implementers' responses show how effectively they are using the system.

The initial roll-out of the vaccination program in Aurora, Tarlac, and Zambales was successfully carried out in terms of the distribution of vaccines to cover the population, the monitoring of supplies and logistics availability, the provision of cold chain facilities and equipment for the vaccine storage, the procurement of supplies and adequate PPEs, and the management of resources and implementation of the COVID-19 vaccine plan.

When it comes to service delivery, Aurora and Zambales are seen as performing better than other LGUs in terms of managing the program's initial implementation in terms of social planning and communication, the implementation of minimal public health standards, the processing of vaccine administration, a feedback mechanism, and an assessment of the vaccination process and systems.

Recommendations

Leadership and Governance.

To promote faith in the healthcare system and vaccination programs, policies should be effectively executed and applied equitably to all people, regardless of socioeconomic class or social position. In order to vaccinate as many people against COVID-19 as quickly and universally as possible, it is also necessary to study best practices in vaccine rollout. To do this, we must provide technological support, especially among older populations and bedridden, and allow other options for receiving the vaccine, such as house-to-house vaccination.

Given the limited resources available, expanding the private sector's involvement in the vaccination rollout and administration could also help. Access to communities can be made possible through the usage of malls and other huge public areas owned by commercial businesses. Even if COVID-19 infection becomes endemic, these facilities will be highly beneficial. For consultation and to co-create efficient and long-lasting solutions, the government and health organizations will need to communicate with people, communities, indigenous peoples, academe, and other institutions.

To stop the spread of the virus and ease public skepticism about the rollout, sharing of best practices on the procurement of supplies, localization of response, and distribution of incentives to healthcare workers and vaccine recipients would be beneficial.

Health Financing.

The government's top priority given the COVID-19 virus outbreak is to strengthen frontline services for pandemic response. To do this, supportive health financing policies are needed. The emphasis must be on generating sufficient funding for health systems, structuring that funding to optimize risk-sharing across the population, and using that funding most effectively to promote the health of all residents. It is also important to carefully simplify any immediate actions taken in response to COVID-19. Enhancing financial tracking for pandemic response would be crucial. To prevent frequent realignment of funds, local funds including the Disaster Risk Reduction and Management Fund must be well-allocated.

Health Workforce.

The health workforce is challenged by limited salary and incentive support which are not commensurate to the workload and risk of exposure to the virus, workforce shortages caused by financial constraints, and workforce resilience in the face of burnout.

The COVID-19 experiences have brought to light the urgent need for investments in the employment, education, and training of healthcare professionals. According to the respondents' experiences, there should be a strong emphasis on enhancing the governance of healthcare in the area by evenly distributing healthcare facilities between urban and rural areas, public and private facilities, increasing the recruitment of healthcare workers and their absorptive capacities, and concentrating on the provision of essential medical equipment.

The organizational structure of the Inter-Agency Task Force for Emerging Infectious Diseases needs to be reviewed to include representatives from vulnerable groups like Indigenous Peoples who can provide the necessary information about how modern medicine can support their cultural beliefs and practices. Additionally, by doing this, the health sector will be ready to respond to any upcoming pandemics in case COVID-19 becomes endemic.

Health Information System.

Although several laws and policies are developed at the national level and health workers frequently undergo training, it seems that cascading information down to the barangay is still a problem in the area of the health information system. This mismatch leads to misinformation and vaccination skepticism among the general people.

To boost confidence in the COVID-19 vaccine, the public has to be informed about the efficacy and safety of vaccines, independent of brand. Interpersonally, exposure to networks of anti-vaccine individuals increases public mistrust about vaccination. Political concerns and inadequate execution are just two structural hindrances that increase vaccine refusal. Therefore, health literacy is now a vital weapon in the fight against false information. Also, the Department of Information and Communications Technology (DICT) which is the partner of the DOH in the safekeeping of records must improve its system to address issues with unrecorded vaccination information and worries regarding the privacy of data shared.

Medical Products/Vaccines/Technology.

While behavioral treatments successfully slowed the virus in the short term, the only long-term method of managing the pandemic emerged as the distribution of potent vaccines. Despite the unprecedentedly rapid development, the supply of COVID-19 vaccines is insufficient to fulfill demand and will continue to be so for some time.

A system for long-term vaccine storage should be created, with the Department of Health and local government units providing the required infrastructure and transportation options to ensure vaccine potency while allowing vaccinations to reach isolated locations and other rural populations.

Service Delivery.

Client registration and other processes vary greatly between different locales. This emphasizes the necessity of identifying best practices in vaccine rollout systems to design an effective and inclusive system to guarantee that access to technology and mobility will not be a barrier to vaccination. The local government is in charge of the delivery and actual immunization at the barangays, municipalities, cities, and provinces, while the national government is in charge of acquiring, allocating, and distributing the vaccinations to the various provinces and municipalities.

A more accessible and quick response will be made possible by the barangay's active involvement in the vaccination program and training of more barangay employees in the correct handling of COVID-19 cases.

Ethics approval and Consent to Participate

The research study was submitted to and subsequently approved by the Institutional Ethics Review Committee (IERC) and the Accredited Ethics Review Committee of Dr. Paulino J. Garcia Memorial Research and Medical Center in the Philippines to effectively address the ethical considerations inherent in the research process. During the data collection phase, individuals identified as possible respondents were informed about the voluntary nature of their involvement in the study. Participants were provided with clear instructions that they had the opportunity to discontinue their involvement at any stage. Additionally, they were given the option to abstain from responding to any particular questions that they deemed to be invasive of their privacy. The researchers took measures to preserve the anonymity of all participants and followed full compliance with the Data Privacy Law when handling their responses. Informed consent was obtained from all the respondents. To ensure adherence to local legislation and protocol, an act of courtesy was undertaken by initiating correspondence with the Local Government Units (LGUs) in order to solicit guidance.

Availability of Data and Materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Consent for Publication

The authors give their permission for the material to be published in the Journal.

Competing Interests

The authors have no competing interests or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Funding

The authors acknowledge the Department of Health-Central Luzon Center for Health Development and Nueva Ecija University of Science and Technology for their financial support.

Authors' Contribution

All of the authors contributed to the data collection, analysis, and manuscript development.

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No competing interests reported.

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We Prevent and Recover as One: Local Responses to Ramp up COVID-19 Vaccination Efforts in the Philippines

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Abstract

Figures

INTRODUCTION

Theoretical Framework

Research Paradigm

Statement of the Problem

Hypothesis

METHODS

Research Locale

RESULTS AND DISCUSSION

Respondents

Profile of the Implementers

Profile of the Vaccinees

Status of Implementation of COVID-19 Vaccination Program in Central Luzon

Health Workforce

Challenges/Issues Encountered on the Implementation of the COVID-19 Vaccination Program During March-September 2021

CONCLUSIONS AND RECOMMENDATIONS

Status of Implementation of COVID-19 Vaccination Program in Central Luzon

Recommendations

Declarations

References

Additional Declarations

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