Impact Evaluation on Health-outcome of the

Essential Health Care Package (EHCP) in Public

Elementary Schools in the Philippines

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Impact Evaluation on Health-outcome of the Essential Health Care Package
(EHCP) in Public Elementary Schools in the Philippines
Study Protocol
I.

Research objective:

The objective of this research is to evaluate the efficacy of combined general

health and oral health interventions on the health status, academic performance
and school attendance of public elementary school children in the Philippines.
II.

Background/Introduction

The health status of the public elementary school population in the Philippines is
alarmingly poor. A recent report of the Department of Education revealed that 28
% of 12-year old children had a Body Mass Index (BMI) below normal (DepEd 2006).
A nation-wide study on pre-school children showed that 66% of the pre-school
children were infected with common intestinal helminths (de Leon and Lumampao,
2005). Another study on school age children in selected sites in Luzon, Visayas and
Mindanao showed that the cumulative prevalence of soil transmitted helminth
(STH) infections was 67% and was noted to be greater than 50% in all selected
areas (Belizario et al., 2005).
According to the recent National Oral Health Survey 97 % of first graders are
affected by dental caries (DepEd, 2008). The average 6 year old student was
shown to suffer from nine decayed teeth with three of the teeth having caries
reaching the pulp. In the 12 year olds the mean number of permanent teeth
affected by dental caries was 3, one with pulp involvement already. No teeth were
filled in both age groups. 20% of the 6-year old and 16% of the 12-year old children
reported to have actual pain in the moment they were questioned. Toothache is
the main reason for absenteeism from school in the Philippines.
All these diseases are not life- threatening but they are neglected and have a huge
impact on the physical and mental development of children, their school
attendance, productivity and quality of life. Worm infections cause anaemia,
reduced physical growth, delay motor activity and result in poor mental
development. Malnourished children become even more malnourished. Children
who suffer from toothache cannot eat, sleep or concentrate.
All these findings are strongly associated with poverty. Crowded living conditions,
overcrowded classrooms, lack of water, lack of sanitation facilities at home as well
as in the schools, lack of healthy and sufficient food are the root causes. The
social and the physical environment lead to diseases, which will keep the children
in the cycle of poverty. And even more important, all these diseases can be
controlled through relatively simple cost-effective interventions.
Current approaches by government agencies mandated with health of the child
population, focus on preventive health education and service delivery;
implementation however is noted to be generally poorly coordinated among

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implementing agencies like the Department of Health, the Department of
Education, and the Local Government Units.
The Health and Nutrition Centre (HNC) of the DepEd Central Office Manila has
taken these concerns into account and has developed in close cooperation with
CIM/GTZ and the WHO Collaborative Centre in Njimegen, Netherlands an
Essential Health Care Package for Filipino Children (EHCP) This program is being
implemented in pilot schools in all 16 F1 provinces of the Philippines, covering
100 000 students.
Cornerstone of the EHCP program is an intersectoral strategy that uses the
schools and day care centers as venues to reach the whole child population with
simple and proven evidence based preventive interventions. Implementation of
daily soap hand washing, daily fluoride toothbrushing and bi-annual de-worming
are the core interventions to improve health of the child population.
Evidence for daily soap hand-washing
Curtis V, Cairncross S (2003)
A systematic review with random effects meta-analysis on the impact of washing
hands with soap on the risk of diarrhoeal diseases in the community was carried
out. Seven intervention studies, six case-control, two cross-sectional, and two
cohort studies were located from electronic databases, hand searching, and the
authors' collections. On current evidence, washing hands with soap can reduce the
risk of diarrhoeal diseases by 42-47% and interventions to promote handwashing
might save a million lives caused by diarrhoea and acute respiratory infections in
developing countries.
Evidence of daily fluoride toothbrushing:
The decline in caries in the past 25 years seen with the widespread use of
fluoride toothpaste in many high income countries in spite of the high levels of
sugar consumption (Bratthall et al., 1996) warrants the promotion of daily tooth
brushing with fluoride toothpaste. According to WHO/IADR daily fluoride
toothbrushing is the only realistic measure to reduce the burden of dental caries
in populations. School based fluoride toothbrushing programs have shown
reduction in caries increment up to 58% in high risk population in Scotland
(Curnow et al, 2002, Pine et al 2007) and up to 40 % in a high caries risk public
elementary population in Indonesia( Adyatmaka A et al., 1998).
In the
Philippines, daily school based fluoride tooth brushing in pilot schools has
resulted in 40% reduction of caries increment which is in line with international
literature and even more important a 60% reduction of caries progression
measured as reduction in caries with pulp involvement was observed after 18
month of program. (Monse, unpublished data).
Evidence of self applied fluoride gel
Fluoride gels are available for professional application and for self applied use on
a toothbrush under supervision. Different fluoride concentration (0.5% - 1.25%
ppm Fluoride) and different formulation as Acidulated Phosphate Fluoride (APF),
Sodium fluoride and Amin fluoride are being used. The variety of frequency of

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application is varying from weekly to bi-annual depending on the risk of the
patient, the formulation of the gel and the intervention concept. Most common is
the Acidulate Phosphate Fluoride (APF) where the effectiveness has been firmly
established by research for more than 30 years.
Evidence of the effectiveness of fluoride gel has been provided by Cochrane
review. (Marinho V et al., 2003)
28% pooled preventive fraction in caries increment was shown for all
different application forms, different frequency and different baseline
caries data.
Significantly greater treatment effect was observed with increased
frequency and intensity (frequency x concentration) of gel application with
self-applied compared with operator-applied gel treatment
Encouraging results from school based programs in Argentina showed
results of to 81% reduction in caries increment after 2 years of weekly self
application 0.5% APF (Bardoni et al 1995)
Evidence for Oral Urgent Treatment (OUT)
WHO recommends a Basic Package of Oral Care (BPOC) that includes Oral Urgent
Treatment (OUT) as an on demand treatment for the relief of oral pain and
trauma. (Frencken et al., 2002).
According to the NOHS in the Philippines, the child population is suffering from
high prevalence and experience of odontogenic infection. Review of possible
effects of caries on failure to thrive (FTT) found, in otherwise healthy children.
(Elice CE et Fields HW. ,1990) that severe dental caries (caries with pulp
involvement) contributed to FTT. In North American 3.2 year-olds with severe
dental caries weighed 1kg less than controls; 8.7% with caries weighed less than
80% of ideal weight compared to 1.7% of comparison group (Acs G et al., 1992).
Turkish children with caries weighed between 25th and 50th percentiles whereas
controls weighed between 50th and 75th percentiles; 7% of cases and 0.7% controls
weighed less than 20th percentile (Ayhan H. et al., 1996). In the Philippines the
average 6 year-old has 4 caries teeth with pulp involvement. That is much higher
than in USA and Turkey. So treatment may be even more beneficial.
Plausible mechanisms for severe caries and toothache being associated with
underweight and poor growth are:
1. Altered eating because of pain and discomfort.
2. Pain during night, irritability and disturbed sleeping habits that may affect
glucosteroid production and growth.
3. Dental sepsis and inflammation can affect growth through chronic
inflammation via a metabolic pathway where cytokines affects
erythropoiesis. Interleukin-1 (IL-1), which has a wide variety of actions in
inflammation, can induce inhibition of erythropoiesis. This suppression of

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haemoglobin can lead to anaemia of chronic disease from depressed
erythrocyte production (Means RT et Krantz SB, 1992).
Oral Urgent Treatment (OUT) may reverse these processes by eliminating pain and
inflammation.
According to research significant improvements in QoL can be expected
provision of oral urgent treatment.

after

Evidence of Mass Drug Administration for De-worming

Ample evidence clearly demonstrates that regular treatment of soil transmitted
helminth (STH) infections produces immediate as well as long term benefits that
significantly contribute to the development of infected individuals particularly
schoolchildren (WHO: Geneva; 2005)
Anti helminthic drugs due to its safety and straightforward administration can be
included in large scale public interventions. (Urbani c. et. al, 2003)
School based approach is the best way to reach en masse, the infected child
population in the most cost effective and systematic manner. In such manner,
substantial return in terms of reduced morbidity, improved growth, and improved
educational outcomes can be achieved. (WHO Geneva, 2006)
Numerous researches clearly demonstrate how STH infections impair healthy
nutrition (Stephenson, LS et. al; 2000). Growth is affected through several
mechanisms, including reduced food intake due to malabsorption and poor
appetite, (Crompton, DWT, et. al., 2002) As a result, infected children, if not given
appropriate and timely intervention will show higher levels of stunting. (Stoltzfus,
R. et. al., 1997). Even light levels of infection may cause deleterious effects in
protein metabolism, appetite, and red blood cell production and development
(erythropoises). Such effects may be mediated by cytokines (IL1, IL6) that are
produced by the childs body immune response to the new helminth infection.
(Stoltzfus RJ, 2004)
STH also negatively impacts on the motor and language development of a child.
There is negative association between STH infection and cognitive performance.
(Ezeamama, AE et. al 2005) STH infections early in life may therefore affect the
cognitive indicators which are measured later in life.(Kwalsvig, J., 2002) The
negative correlation can be due to a variety of reasons, both direct and indirect,
including induced sleeplessness, micronutrient losses, and reduced absorption.
(Stoltzfus RJ et. al 2004) A possible cause may also be due to inflammatory and
cytokine responses triggered by the parasitic infection. (Dantzer R., 2001)
To date, two primary drugs most commonly used in the Philippines for soil
transmitted helminthiasis treatment are albendazole and mebendazole.
Albendazole, at the recommended dosage generally has low incidence of post
treatment side effect, as reported by literature, comprising of migration of A.
lumbricoides through the mouth, mild gastrointestinal symptoms, head ache,

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dizziness, and rare allergic reactions. All these are minor and transient and
generally recede within 48 hours. (Horton J.,2000)
Mebendazole treatment generally also has few instances of erratic migration, mild
gastro intestinal disturbances, and transient abdominal pain. Diarrhea has also
been reported post treatment. (Albonico, M. et.al., 1994)
It is substantial to recognize that in endemic areas where STH re infection is
definite, the objective of regular deworming is not to cure, but to reduce and
keep the worm burden of infected individuals below the threshold that cause
morbidity. ( Savioli, L., et. al., 1992)
Evidence of efficacy of biannual deworming
Provision of levamisole every six months to pre school age and school age children
infected with A. lumbricoides in Myanmar have been shown to drastically reduced
frequency of morbidity symptoms. (Thein-Hlaing, et. Al, 1990)
In Uganda, a randomized control study showed that weight of children receiving
albendazole every six months was 10% greater than in untreated control. (5%
greater when treatment was given annually) (Alderman, H., et; al.,2006)
In the slums of urban India, a series of studies has been conducted on the effect of
bi annual (every six months) deworming using albendazole. Evidence show that
infants and pre school age children had reduced stunting by 9.4% and improved
weight by 35% within two years. ( Awasthi, S. et.al, 2001)
III.

Objectives:

The objectives of this study are to determine the efficacy of different school based
health promotion interventions on health, school attendance and performance of
Filipino public elementary students. The study will look into the impact of the
different interventions on:
1.
2.
3.
4.
5.
6.
7.

Nutritional status
Parasitologic status
Oral health status
Self reported oral pain/problems
School attendance
School performance
Behavior change

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IV.

Materials and Methods:

Study Design
The research is a controlled clinical study with a longitudinal design to be
conducted in Philippine Public Elementary Schools of the Province of Camiguin and
the City of Gingeoog, in Northern Mindanao, Philippines.
School sites from the Divisions were selected for accessibility (within 5 kilometer
radius from the National Highway), security and safety of the project proponents
and strong administrative support from the local chief executives and the DepEd
School administrators.
Selected schools will be randomly assigned to any of the four study groups. Health
interventions will be implemented in the entire school.
Criteria for Inclusion of Schools into the Intervention Group
The selection of public elementary schools will be based on:
o 1st level selection:
Accessibility and safety
School size
Administrative Support
nd
o 2 Level Selection:
Prevalence of Below Normal Body Mass Index (DepEd Data)
o 3rd Level Selection
Pulp involvement, ulceration, fistula and abscess (PUFA) index
Intervention Groups
Group 1
Philippine public elementary schools that will fully implement the Essential
Health Care Package including daily fluoride tooth brushing using 0.3 ml. (pea
sized) fluoride toothpaste (1,450 fluoride ppm free available fluoride), daily
hand washing with soap done as a group activity prior to recess in the morning
in school and albendazole (400 mg tablet) or mebendazole (500 mg tablet)
single dose as mass drug administration (MDA) given every 6 months for soil
transmitted helminthiasis as per World Health Organization (WHO)
recommendations, starting July 2009.
Group 2
Philippine public elementary schools that will implement the War on Worms
Program consisting of either mebendazole 500 mg or albendazole (400 mg
tablet) mass drug administration (MDA) given every 6 months plus health
education, and distribution of one piece 10 ml commercial toothpaste sachet

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and tooth brush at the beginning of the school year as a preventive oral health
advocacy, starting July 2009.
Group 3
Philippine public elementary schools that will implement EHCP according to the
EHCP guidelines (annex 1) plus access to oral urgent treatment twice a year,
starting July 2009. Oral Urgent Treatment is defined as on demand treatment
for children suffering oral pain, mostly caused by advanced dental caries. (Ref.
Guidelines for OUT in public elementary schools in the Philippines, Annex 2)
The treatment includes tooth extractions, drainage of abscesses and drug
administration in selected cases.
Group 4
Philippine public elementary schools that will implement EHCP plus once
weekly use of 0.3 ml high fluoride concentration gel used as alternate to the
daily regular EHCP toothpaste. The high fluoride concentration gel contains
12,000 ppm fluoride.
Study population
The study population will be 6-7 years old school children attending grade one in
School Year 20092010. Students from this group will be followed up for the next 3
years. Evaluation will be carried out after 12 and 36 months, using the health and
child development indicators/parameters followed below.
Selection Criteria for inclusion of children:
1. Inclusion:
a. Age: 6 7 years old at baseline examination time.
2. Exclusion criteria:
a. Children with systemic medical conditions, and other chronic infectious
diseases
Control Group
Due to ethical considerations, the study has no true control group. A semi control
group therefore will be composed of randomly selected students from grades 2
and 4 within the intervention schools at baseline examination time (in July 2009).
These older students will come from the same communities as the intervention
children ensuring similar socioeconomic background.

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Selection criteria for inclusion of children to the semi control group:

1. Inclusion:
a. Age:
i.

7-8 year old school children (grade 2) in SY 2009210, for

comparison with the intervention group one year after the start of
the intervention.
ii. 09 10 year old school children (grade 4) in SY 20092010 for
comparison with the intervention group three years after the start
of intervention.

Sample Size
o An overall total of 800 schoolchildren will be the target group sample size
with 200 children assigned to each of the four intervention groups to allow
for drop outs, loss to follow up, and other issues that may confound
research health outcomes from baseline to final evaluation. ( 3years)
o Basis for computation for sample size
Length and Time of Study:
The study will be started with the beginning of the SY 2009-2010. It will be
conducted over 3year period.
Children will be assessed at baseline, after 1 and 3years following introduction of
the interventions.
Group 1
This is the group will receive EHCP. Baseline examinations of Grades 2 and 4 pupils
will serve as this groups control for respective outcome effects
Baseline

Grade 1

Grade 2

Grade 4

Number

200

120

100

Baseline

12 months

Test

Test

Test

Test

OUTCOME
Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, pain, School
Attendance, NAT
Performance
Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, pain, School
Attendance, NAT
Performance

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36 months

Test

Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, pain, School
Attendance,
NAT Performance

The 200 children at baseline in grade 1 are followed over the years. Due to drop
outs, the number is expected to decrease.
Group 2
Participants receive deworming, health education and one toothbrush with a sachet
of commercial toothpaste).Baseline examinations of Grades 2 and 4 pupils will
serve as this groups control for respective outcome effects.
Baseline

Grade 1

Grade 2

Grade 4

Number

200

120

100

Baseline

12 months

36 months

Test

Test

Test

Test

Test

OUTCOME
Helminth infection,
Type of worms,
Quantity, BMI,
Caries, PUFA, pain
School Attendance
NAT Performance
Helminth infection,
Type of worms,
Quantity, BMI,
Caries, PUFA, pain
School Attendance
NAT Performance
Helminth infection
Type of worms
Quantity
BMI
Caries, PUFA, pain
School Attendance
NAT Performance

The 200 children at baseline in grade 1 are followed over the years. Due to drop
outs, the number is expected to decrease

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Group 3
This is the group who receives EHCP + OUT. Baseline examinations of Grades 2 and
4 pupils will serve as this groups control for respective outcome effects .
Baseline

Grade 1

Grade 2

Grade 4

Number

200

120

100

Baseline

Test

12 months

Test

Test

Test

36 months

Test

OUTCOME

Helminth infection,
Type of worms,
Quantity, BMI,Caries,
PUFA, pain
Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, pain, School
Attendance, NAT
Performance
Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, pain, School
Attendance, NAT
Performance

The 200 children at baseline in grade 1 are followed over the years. Due to drop
outs, the number is expected to decrease.
Group 4
This is the group who receives EHCP + once a week tooth brushing with high
fluoride gel. Baseline examinations of Grades 2 and 4 pupils will serve as this
groups control for respective outcome effects.
Baseline

Grade 1

Grade 2

Grade 4

Number

200

120

100

Baseline

12 months

Test

Test

Test

Test

OUTCOME

Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, pain, School
Attendance, NAT
Performance
Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, pain, School

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Attendance, NAT
Performance

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36 months

Test

Helminth infection,
Type of worms,
Quantity, BMI, Caries,
PUFA, Pain, School
Attendance, NAT
Performance

The 200 children at baseline in grade 1 are followed over the years. Due to drop
outs, the number is expected to decrease.
Procedure:
o As baseline study, children with the respective age coming from Grades 1,
grade 2 and grade 4 pupils in the schools included in the study will be asked
to submit stool samples for laboratory examination. Children who submit
the required samples will be assessed for age, sex, height, and weight. Oral
health status will be assessed. Children will also answer to a quality of life
questionnaire.
o School attendance records and National Achievement Test (NAT)
Performance of the previous year (2008) will also be recorded for
participants from Grade 2 and Grade 4..
o Succeeding evaluations on anthropometry, dental status, stool parasitologic
evaluation, self reported oral pain, attendance and academic performance
among the target 6-7 year old grade 1 students of SY 2009-201009 will be
followed up in 2010 and 2012.
o Evaluation results of the target group with regards to child health and
development indicators will be compared to baseline data collected from
grades 2 and grade 4 from the same school (intra-school) and between and
among the 4 intervention groups (inter-group) in the study.
o After the second evaluation, a decision will be made, if there will still be a
re evaluation 5 years after baseline examination of the study group. At
this time, they will all be in their final year of elementary education (grade
6).
V.

Methods

1. Assessment of Nutritional Status (BMI)

Students age will be assessed in months.
Measurement will be done using the Users Manual of the Food and Nutrition
Research Institute (2003). Height and weight will be assessed to the nearest

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0.1 cm and 100 grams respectively using height and weight measurement of the
detecto weighing scale.
Z-scores of height for age and weight for age will be calculated using the NCHS
reference standards on Epi Info software (NutStat module) i.
Height will be measured using in the stadiometer without shoes. Children will be
measured with Frankfurt plane horizontal.
Weight will be measured using the detecto calibrated weighing scale on a firm flat
surface. Two sets of calibrated scales will be available to the research team. The
scales need to be checked every after 5 measurements for calibration purposes.
BMI will be calculated by weight (in kgs) for height (in meters) squared
[w(kg)/h(m)2]. The mean height for age Z score, the weight for age Z scores and
the BMI of groups will be expressed as arithmetic means and standard deviations.

2. Parasitologic Assessments
Stool cups will be given to the children targeted for monitoring with appropriate
collection instructions. Stool samples will be sent to the field laboratory for
analysis using Kato Katz method by the project team as described in the World
Health Organization Bench Aids for the Diagnosis of Intestinal Parasites (1998).
Data gathered will be used to derive the cumulative prevalence rates, prevalence
rates of individual Helminth infections and intensities of STH infections.
Assessments will be done pre-treatment at baseline (day 0 ), Years 1, and 3.
Provincial and City health office staff will be involved in parasitologic assessment
for capability building purposes.
Quality Control
The accuracy and reliability of parasitological assessment will be maintained
through strict quality assurance measures. This will involve proper collection of
specimens, availability of fresh reagents, appropriate laboratory technique,
meticulous examination of processed specimens and accurate reporting of
findings. Slides positive for STH will be referred to expert microscopists for crosschecking and validation. Ten percent of all negative slides will be re-examined
blindly by a reference microscopist to ensure accuracy of microscopic readings.
3. Oral Examination
All oral examinations of the schoolchildren will be carried out in the school
courtyard or in case there is rain under the covered court. Prior to examination,
trained parents will brush the teeth of the children. Students will be positioned
supine on a bench or table and examined by the gloved and masked dental
examiner using a battery powered headlamp to standardize examination
conditions. The teeth will be examined according to WHO basic methods (1997).
Mouth mirrors and cotton pellets held in tweezers to dry the teeth and sharp eyes
will be used. A CPI probe will be used gently to detect and confirm visual

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evidence of caries. All children will be examined on tooth level, only the first
molar will be assessed on surface level.
Teeth, with pulp involvement will be recorded in primary as well as in permanent
dentition according to PUFA /pufa index.(Monse et al. 2008, submitted for
publication)
A trained assistant will record the data on a standardized form.
Trained and calibrated dentists knowledgeable with the diagnostic criteria will
perform the examinations. Calibration will be conducted by comparing the results
of each examiner with the results of an experienced examiner. (gold standard)
Reexamination of 10% of the schoolchildren will be conducted by the examiners in
order to assess intra-examiner consistency and calculate the Kappa values. To
ensure consistency at least half of the examiners of the baseline examinations will
participate in the follow up evaluations.
4. Prevalence of oral pain / abdominal pain
Children will be questioned concerning experience of pain and impact of pain in
order to assess if the program could improve their quality of life.
The questionnaire to be used in the interview will be pre-tested. Children will be
given at least 10 seconds to answer.
5. Prevalence of abdominal pain
Children will be questioned concerning experience of pain or discomfort in
any part of the abdomen to assess if the program was able to improve the
quality of life of the school children. The questionnaire will be in the local
vernacular language and the question will be pre tested. Children will be
given appropriate time to answer.
6. Evaluation of school attendance
Information on school attendance of the students included in the examination will
be taken from teachers record books from beginning of school year to an agreed
cut off time (at the last day of the school year).
7. School performance
Information on school performance will be taken from the results of the ational
Achievement Test (NAT) for grades 3 and 6 on all subject levels.
7. Behaviour change
Change in behaviour of the study children with respect to personal hygiene in the
family environment will be researched by collection of dental plaque among study
children on a Monday morning and determining the fluoride concentration in the
dental plaque and measuring the bacterial colonization of hands. This will give
information about handwahing and toothbrushing activities in the natural family
environment during the week end.

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8. Statistical Analysis
The following information will be described at baseline, at each follow up
separately for each group.
1.

Prevalence of STH infections

2.

Severity of STH infection (geometric mean egg counts)

3.

Prevalence of dental caries

4.

Caries experience (mean dmfs/t, DMFS/T)

5.

Prevalence of dentogenic infection

6.

Dentogenic infection experience (Mean pufa/PUFA)

7.

Distribution of children according to BMI classification (%)

8.

Mean BMI

9.

Prevalence of children with self reported oral problem and/or abdominal

pain or discomfort

10. Average time of being absent from school (mean number of days being
absent)
11. School performance (mean % of National Achievement Test/ NAT)
12. Behavior change (Contact spotting for e coli colonization on hands and
fluoride concentration in dental plaque to evaluate behavior change with
respect to handwashing and toothbrushing in school and family
environment)

VI.

Reports to the funding agency:

Implementation reports have to be submitted September 15 in every research

year, while the scientific report containing the data analysis have to be submitted
at the end of October 2009, 2010 and 2012.

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62

Principal Investigator:
Ella Cecilia K. Gamolo Naliponguit, MD
Medical Officer V/ Health and Nutrition Division
Department of Education Regional Office X

Co- Investigators:
Gina A. Itchon, MD, MSc
Associate Professor, Preventive Community Medicine Department
Dr. Jose P. Rizal College of Medicine,
Xavier University Ateneo de Cagayan
Preventive Community Medicine Department
Vicente Belizario, MD, MPH
Deputy Director
National Institutes of Health
Manila, Philippines
Bella Monse, DDS, PhD
CIM-Consultant on School Health Promotion
DepEd City Division of Cagayan de Oro,
Cagayan de Oro, Philippines
Prof. Wim van Palenstein -Heldermann
WHO Collaborative Center Oral Health Care Planning and Future Scenarios,
Radboudt University, Njimegen, The Netherlands