**1. Introduction**

Drowning in low- and middle-income countries has been identified as an issue requiring significant investment in order to reduce the burden to global public health [1]. Around the world, 295,000 people are estimated to die from unintentional drowning annually [2], with the true burden likely to be significantly higher when including transportation and disaster-related drowning [3]. The vast majority of drowning occurs in low- and middle-income countries and children are most at risk [1]. Fatal drowning ranks as the 13th leading cause of death among children under 15 years of age, with the 1–4 years age group at greatest risk [4]. Child drowning rates in low- and middle-income countries are six times higher than those in high-income countries [5].

Reducing child drowning is an area of key focus for the drowning prevention community. Across decades of research the risk factors for child drowning are reasonably well understood [5–7]. These include a lack of supervision when children are in or around water, unrestricted access to water through the absence of barriers or covers such as for wells, lack of awareness of dangers owing to their young age, and an inability to swim [8–10]. Quick rescue and resuscitation in instances of drowning are context dependent, with quick rescue and appropriate medical care a significant factor in survival [11]. What is less well understood is what influences the uptake of these strategies given that drowning often impacts those from low socio-economic backgrounds [1].

The Philippines is a developing country in the Western Pacific region that has made progress in reducing child mortality over past decades. Between 1990 and 2015, deaths of infants under one year decreased from 41 to 21 per 1000 live births, while the number of children who died before the age of five dropped from 59 to 27 per 1000 live births. However, determinants of health impact progress. Childhood immunization rates are low and in some cases declining, leading to increased incidence of vaccine-preventable diseases [12]. Children and adolescents in the Philippines have limited access to sexual and reproductive health services, with recent teen fertility rates now at levels comparable to the 1960s [12]. Children and youth aged 13–24 years in the Philippines experience high levels of physical (64%), psychological (62%), sexual (22%), and peer (65%) violence [12].

Despite some encouraging progress in recent years, there are still limitations to children's access to education in the Philippines [12], a key determinant of health. As of 2015, 83.4% (primary) and around 73.9% (secondary) of enrolled children actually completed their schooling. In its 3rd National Plan of Action for Children (2017–2022), the Council for the Welfare of Children outlined a plan for improving child health and well-being, including access to education [13]. Similarly, the Philippines Department of Health outlines a range of national objectives for improving the health for children that includes reducing infant mortality and reducing injury-related deaths, specifically road tra ffic deaths [14].

Drowning, another cause of injury-related death, is a significant issue in the Philippines [15]. As a nation, the Philippines is an archipelago made up of 7107 islands and has an estimated 2019 population of 108,116,615 [16]. Due to the country's geography, exposure to water, and thus risk of drowning, is a daily occurrence [17]. It is estimated that an average of 3276 deaths due to accidental drowning occurred in the Philippines between 2006 and 2013, a rate of 3.5 per 100,000 population [18]. Children aged 0–14 years are a leading age group for drowning, with children 1–4 years at most risk [18]. Population density, large average household size, increasing urbanization, and a lack of piped water are determinants of health that contribute to increased drowning risk in the Philippines [19,20].

Drowning in the Philippines, as it is in other nations, is a public health issue that crosses multiple policy areas and agendas [21]. This is both positive and negative as there are multiple opportunities for political engagemen<sup>t</sup> and ways of framing the issue of drowning prevention. However, this may also mean that there is no clear leadership on the issue and no governmen<sup>t</sup> ownership of the problem. As a means of gaining national traction on the issue of drowning prevention, the World Health Organization (WHO)

proposes the capture, collation, and analysis of quality data on drowning and the development of water safety plans (in this article referred to as a drowning prevention plan) as two key pillars [22]. In response to this call to action, this study presents the most recent estimates for child drowning-related mortality and morbidity in the Philippines, as well as an analysis of the recently developed multisector action plan on drowning prevention in the Philippines, with a specific focus on children and determinants of health.

### **2. Materials and Methods**

This study took a two-phase approach. Firstly, a retrospective study exploring unintentional drowning data for the Philippines for children 0–14 years of was accessed from the Global Burden of Disease (GBD) GBD Compare Viz Hub [23]. Within the context of the child drowning issue as depicted by the data, this study then aimed to document the process of, and results associated with, the development of a multisector action plan on drowning prevention in the Philippines.

### *2.1. Fatal and Non-Fatal Drowning Data in the Philippines*

Data on unintentional drowning as a cause of death (C.2.2. Drowning derived from International Classification of Diseases [ICD] 9 and ICD10 code W65-74) were sourced from the GBD Compare Viz Hub for the Philippines. Data were accessed for children aged 0–14 years (age groups < 5 years and 5–14 years) between 2008 and 2017 (the latest publicly available data). Incidence and rates per 100,000 population were reported with a 95% uncertainty interval (UI). Trends over time were explored using a linear trend as calculated in Microsoft Excel. Data were explored by sex, age group, and by year of drowning fatality. Non-fatal drowning data were reported using Years Lost due to Disability (YLDs). The overall burden of child drowning in the Philippines is expressed through disability adjusted life years (DALYs). DALYs can be considered as 'one lost year of healthy life' and are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the YLD for people living with the health condition or its consequences [24].

### *2.2. Multisector Action Plan on Drowning Prevention*

Recognizing that drowning is also one of the health issues that the Philippines needs to address, the country started working on the multisector action plan on drowning prevention in 2016.

### 2.2.1. Development of the Plan

The process of developing the action plan was guided by the global public health documents and commitments and by the Philippine health policies. [1,25–28]. The Department of Health, in collaboration with various institutions led by the World Health Organization and with support from the Bloomberg Philanthropies, developed the Multisector Action Plan on Drowning Prevention in the Philippines, 2016–2026.

Core group meetings, attended by representatives from the Department of Health of the Philippines, World Health Organization, and College of Public Health—University of the Philippines Manila, were held in preparation for conducting consultative meetings (Figure 1).

**Figure 1.** Core group meetings among the representatives of the University of the Philippines College of Public Health Foundation, Inc. [UP-CPHFI], Department of Health (DOH), and World Health Organization (WHO): (**a**) Initial planning on how to conduct the multisector action plan development; (**b**) discussion of the agenda and activities for the multi action plan development; (**c**) discussion on the proceedings of the multisector action plan development.

Five consultative meetings with various stakeholders were held. The participants in the consultative meetings were from Department of Health (DOH), World Health Organization (WHO), National Economic and Development Authority (NEDA), Department of Education (DepEd), Philippine Coast Guard (PCG), Maritime Industry Authority (MARINA), Philippine Red Cross (PRC), Safe Kids Worldwide Philippines, National Youth Commission (NYC), National Council for Disability Affairs (NCDA), Office of Civil Defense (OCD), Department of Interior and Local Government (DILG), Department of Tourism (DOT), Philippine College of Emergency Medicine (PCEM), University of the Philippines College of Public Health Foundation, Inc. (UP-CPHFI), Council for the Welfare of Children (CWC), Philippine National Police (PNP), Philippine Statistics Authority (PSA), Philippine Information Agency (PIA), and the Philippine Lifesaving Society (PLS) (Figure 2).

**Figure 2.** Consultative meetings: (**a**) Multisector action plan meeting with Dr. David Meddings of the WHO; (**b**) presentation of drowning prevention activities being implemented by one agency; (**c**) discussion on the contents of the Multisector Action Plan on Drowning Prevention.

The multisector action plan on drowning prevention was presented during the Violence and Injury Prevention Program (VIPP) Forum. This forum was attended by representatives from various organizations (government, non-government, and civil society organizations). This forum also served as a public hearing on the multisector action plan (Figure 3). Finally, the plan was presented in a "Partners' Meeting on Drowning Prevention in the Philippines" in February 2017.

**Figure 3.** Public hearing on the Multisector Action Plan on Drowning Prevention in the Philippines: (**a**) presentation of the Multisector Plan on Drowning Prevention in the Philippines, 2016–2026; (**b**) panel addressing questions from the participants; (**c**) group photo of the participants who attended the public hearing.

### 2.2.2. Analysis of the Plan

The activities of the multisector action plan on drowning prevention in the Philippines were analyzed to identify those activities relevant to child or youth drowning prevention and to identify activities where social determinants of health need to be considered when delivering the activity. Analyses were performed by consensus among the authors. Each author coded the activities separately and disagreements were discussed until consensus was achieved.

### *2.3. Ethics Approvals*

This study used publicly accessible, de-identified data and as such did not require institutional ethics board approval. Similarly, the process of developing the multisector action plan on drowning was also deemed exempt from requiring ethics approval.
