9 1
2 BRIDGING TO FUTURE REFORMS
HSRA Monograph No. 9 3
BRIDGING TO
FUTURE REFORMS
DEPARTMENT OF HEALTH
Republic of the Philippines
4 BRIDGING TO FUTURE REFORMS
Published by the Department of Health-Health Policy Development and Planning Bureau (HPDPB)
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, 1003 Philippines.
TELEPHONE +632-781-4362 EMAIL healthmonographs@gmail.com. June 2010
The mention (if any) of specific companies or of certain manufacturer’s products does not imply that they are
endorsed or recommended by the DOH in preference over others of a similar nature. Articles may be reproduced
in full or in part for non-profit purposes without prior permission, provided credit is given to the DOH and/or
the individual authors for original pieces. A copy of the reprinted or adapted version will be appreciated.
Suggested Citation:
Bridging to Future Reforms. Health Sector Reform Agenda – Monographs. Manila, Republic of the Philippines -
Department of Health, 2010. (DOH HSRA Monograph No. 9).
Editorial assistance provided by Anna Cassandra S. Melendez, MA. Cover photograph by Paquito P. Repl ente.
The UPecon-Health Policy Development Program, a U.S. Agency for International Development Cooperating Agency (USAID CA),
provided technical assistance in the development of this document under the terms of Cooperative Agreement No. 492-A-00-06-
00031. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the UPecon-Health Policy
Development Program or the U.S. Agency for International Development.
HSRA Monograph No. 9 5
CONTENTS
Executive Summary 6
Health Financing 19
Health Regulation 22
Service Delivery 25
Good Governance 38
Appendix
Department of Health
Resolution No. 2009-03-01 44
References 47
6 BRIDGING TO FUTURE REFORMS
EXECUTIVE SUMMARY
OVERVIEW OF FIGURE 1
Projected Life Expectancy at Birth by Sex,
THE PHILIPPINE Philippines, 1995-2005 (Medium Assumption)
.1
73
.8
72
.5
72.0
.2
72
.1
72
.9
73
.8
71
.6
72
.5
72.0
71
.3
.2
72
71
.0
72
.9
.7
71
HEALTH STATUS OF THE FILIPINOS
71
.6
70
.4
70.0
.3
71
.1
70
71
.0
70
71
.7
70
.4
70.0
70
.1
70
68.0
LIFE EXPECTANCY AT BIRTH. Filipinos are living
.8
67
.5
68.0
67
.2
.9
67
.8
66
.6
67
.5
longer, with a projected life expectancy at birth of 66.0
66
.3
67
.2
66
.0
.9
67
66
.7
66
.6
.4
65
66.0
.3
66
65
.1
66
.0
73.08 years for females and 67.83 years for males
.8
65
66
.7
64
65
.4
64.0
65
.1
65
.8
64
64.0
(NSO, 2008a). This is an improvement from the 62.0
projected life expectancy of 70.1 for females and 62.0
60.0
64.1 for males in 2000 to 2005. The life expectancy 60.01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
of females has been consistently higher than males CalendarYears Male Female
FIGURE 2
Infant Mortality Rate
by Age and Causes
Maternal deaths account for 14 percent of all and Davao registered TFR, NMR, IMR, and U5MR
deaths in women aged 15-49 years. The country’s rates that were higher than the national average
Maternal Mortality Ratio (MMR) decreased from 209 (Table 1). In contrast, NCR, CALABARZON, and
per 100,000 live births between 1987 and 1993 Central Luzon registered rates which were equal to
(NSO, 1993b) to 162 per 100,000 live births in 2006 or lower than the national average. Regional
(NSO, 2006). As shown in figure 3, most maternal variations were also reported for MMR.
deaths occur within 0-1 day after delivery. Maternal
deaths are mainly due to complications occurring
TABLE 1. Total Fertility Rates for 3 Years
in the course of labor, delivery, puerperium,
Preceding the Survey, Early Childhood
hypertension, and postpartum hemorrhage. Mortality Rates for the 10-Year Period
Preceding the Survey, Philippines, 2006
FIGURE 3
Maternal Death After Delivery TFR NMR IMR UFMR
Philippine Average 3.2 13 23 31
2010 Target (NOH) 10 17 32
NCR 2.6 12 19 24
CAR 3.2 16 26 31
Reg. 1 3.0 15 26 30
Reg. 2 2.8 14 25 30
Reg. 3 2.7 13 19 22
Reg. 4A 2.9 13 19 24
Reg. 4B 4.1 19 34 45
Reg. 5 4.1 14 25 38
Reg. 6 3.3 11 18 25
0-1 2-7 8-14 15-21 22-30 31-42 Reg. 7 3.3 11 20 30
day days days days days days
Reg. 8 3.9 14 31 43
Source: X. F. Li et al., International Journal of Gynecology & Obstetrics Reg. 9 3.7 13 32 44
54 (1996): 1-10
Reg. 10 3.4 10 22 29
FIGURE 4 NCR
Attendance Ilocos
Cagayan Valley
2003
Central Luzon
2008
CA LABA RZON
M IM A ROPA
Bicol
Central V isayas
Eastern V isaya
Zamboanga Peninsula
Davao Region
SOCCSKSA RGEN
Caraga
A RM M
Source: NSO, 2008
0 10 20 30 40 50 60 70 80 90 100
P e rce nt
Zamboanga Peninsula, and MIMAROPA, on the This is particularly true in the case of low income
other hand, less than half of births had medical households. Affordability is the main reason for
attendance. going to a government medical facility, while
RESPONSIVENESS OF HEALTH SYSTEM. excellent service is the main reason for going to a
Responsiveness is somewhat difficult to measure, private medical facility (SWS, 2006).
since there is very limited data on Respect for The net satisfaction with services given by
Persons and Client Satisfaction on the health government hospitals has slightly improved from
system. The DOH is currently commissioning a +30 in 2005 to +37 in 2006. Excellent service and
survey similar to the 2003 World Health Survey to affordability are the main reasons for being satisfied
measure those indicators. whereas poor service is the main reason for being
The current available data is on the average dissatisfied with the services given by government
travel time to health facility, which is 39 minutes. hospitals (SWS 2006).
Travel time is longest in ARMM (83 minutes) and SATISFACTION WITH DOH AND PHILHEALTH.
shortest in NCR and Northern Mindanao (both 28 Surveys by the Social Weather Stations (SWS) from
minutes); longer in rural areas (45 minutes) than in 2005-2009, have revealed that net satisfaction
urban areas (32 minutes); and longest for persons ratings for both DOH and PhilHealth have been
in lowest wealth quintile (47 minutes) and shortest improving. There was a slight dip in net satisfaction
for those in the highest wealth quintile (35 in 2006, following a change in DOH and PhilHealth
minutes). Older persons seeking care (60+ years administrations, but ratings have improved steadily
old) have longer average travel times than younger in subsequent years.
persons (NSO, 2008).
In a 2006 survey by the SWS, 49 percent of the
SATISFACTION WITH HEALTH FACILITIES. The respondents rated the government as successful
Social Weather Station reported that a majority of in providing health care for the sick. This is higher
Filipinos prefers to seek treatment in a government than the average rating of 36 percent in other
hospital if a family member needs confinement. countries.
HSRA Monograph No. 9 13
GDP. The national health budget comprised only amount of P15,000 per year, which is a small amount
28.7 percent of total health expenditure in 2005. compared to their capacity to pay. This is also true
On the other hand, the health budget more than for the Overseas Filipino Workers program, which
doubled from P9.73 billion in 2005 to P24.65 billion requires members to pay a flat rate of P900 per year,
in 2010 (Figure 5). Perhaps even more impressively, regardless of actual income. The Individually Paying
the health budget increased by more than 100 Program and Sponsored Program members pay a
percent between 1999 and 2010. This significant flat rate of P1,200 per year. However, the Sponsored
increase in the health budget consequently Program can only promote fairness in revenue
increased resource allocation for public health collection if the members are correctly and
services (Figure 6). adequately selected.
Social health insurance is another prepayment Another method of risk pooling would be
scheme that protects people against catastrophic through the general budget funnelled to the DOH
health expenditures. Social health insurance and the Local Government Units (LGUs). Direct taxes
provided by PhilHealth financed only 11 percent of are the most progressive way to finance health
the total health expenditure in 2005. However, spending since they are linked to income levels,
PhilHealth’s membership increased to 81 million, but inefficiency in tax collection still poses a major
covering 82 percent of the 2010 projected problem.
population. Premium collections have also shown RESOURCE ALLOCATION AND PURCHASING.
a steady increase from P18.7 billion in 2005 to P25.98 Data from the 2005 PNHA revealed that 78.4 percent
billion in 2009 (Figure 7). of total health expenditure was used for personal
Additional budgetary resources for DOH and health care, which were largely curative and
PhilHealth are earmarked by RA 9334 or the Sin Tax hospital based. Public health care, generally for
Law. The law provides that 2.5 percent of the preventive and promotive health services,
incremental revenues from excise taxes on alcohol accounted for 11.5 percent of total health
and tobacco products be allocated each to DOH and expenditure, while administration and
PhilHealth starting January 2005 for five years. In management support for health services accounted
2009, at least P50 million was given to each agency for 10 percent. To improve the allocative efficiency
that covers the period of 2005 to 2008. The of the DOH budget, the National Objectives for
PhilHealth share from the sin taxes revenues is for Health (NOH 2000-2005) targets 20 percent public
meeting and sustaining the universal coverage of health care expenditure for the year 2010.
the National Health Insurance Program. For DOH, PhilHealth’s most recent support value of 36.29
the revenues go to its disease prevention programs. percent (based on 2008 claims) falls considerably
RISK POOLING. Risk pooling is essential for short of the NOH’s target of 80 percent. The delivery
providing risk protection; it aims to manage of cost-effective and equitable PhilHealth benefit
revenues collected from taxes, health insurance, packages is hampered by the lack of accreditation
and other sources in order to pay for the care of in many rural health units (RHUs) which are more
those who become ill. Social health insurance is accessible to the communities. In 2009, only 1,301
one method of risk pooling. RHUs out of 2,226 (55 percent) were accredited,
Although increased enrolment in PhilHealth has while only 1,654 were accredited out of the 1,784
improved risk pooling, premium payments remain licensed hospitals (90 percent). Although the
highly regressive. Contributions of government and number of PhilHealth accredited health facilities is
private employees are set at 2.5 percent of the increasing, this is still below the NOH (2000-2005)
employee’s monthly salary. This premium payment targets of 80 percent for rural health units and 100
is progressive until it reaches a salary cap of P50,000. percent for hospitals.
This means that employed sector members earning
higher than the salary cap will still pay a fixed
HSRA Monograph No. 9 15
* Hot issues captured by national media. Selection was based on public impact and length of media co verage. List updated by HPDPB.
16 BRIDGING TO FUTURE REFORMS
public’s fear for the safety of farm workers. “Milk formula may contain pathogenic
Similarly, farm visits by both Departments were microorganisms”; (3) a ban on company
conducted to provide information to farm involvement in scientific research and policy
workers. A depopulation of affected pigs was making; (4) a ban on distributing company
done to assure that no further virus transfer information through health facilities; and (5) the
could occur. right to delete, reject, and prohibit false health
6. Milk Code/ Breastfeeding – In November 2006, and nutrition claims.
mothers and breast milk advocates were 7. Hospital Holiday/ Illegal Detention of Patients
outraged by the letter of Thomas Donahue, – In May 2007, the Pharmaceutical and
President and Chief Executive Officer of the USA Healthcare Association of the Philippines
Chamber of Commerce, warning President (PHAP) objected to a new law that penalizes
Arroyo on government’s position against infant hospital officials who refuse to release patients
formulas. “It has been brought to my attention due to unpaid bills. PHAP spokesman Dr. Rustico
that a recent regulatory decision by an agency Jimenez threatened that the group will push
of your government would have unintended through with hospital holidays, i.e., two to three
negative consequences for investors’ hospital holidays per month until December of
confidence in the predictability of business law that year, if talks with DOH officials prove to be
in the Philippines,” Donahue wrote in a note unproductive. Further, PHAP members
dated August 11, 2006. nationwide said that they will only attend to
Donahue was referring to the revised emergency cases to protest the implementation
implementing rules and regulations (IRR) of of the new law.
Executive Order No. 51, or the Milk Code, which The decision to defer the planned action of
limits the marketing of infant formulas and the PHAP came following a dialogue with Health
requires companies to put labels on their Undersecretary Alexander Padilla, who also
products warning the public of possible health invited the group to assist the DOH in drawing
hazards. Health Secretary Francisco T. Duque III up the rules and regulations governing the
described Donahue’s letter as a form of implementation of Republic Act 9439.
“pressure” and “subtle blackmail.” 8. Graphic Health Information on Tobacco
Malacañang stood its ground, not giving in Packaging – In May 2010, the DOH issued an
to international pressure. Words of Administrative Order (AO) requiring the use of
encouragement from all over the world poured graphic health warnings on tobacco product
as the Philippines, represented by its health packages despite strong lobbying from the
secretary, put up a brave front against bullying tobacco industry to derail or stop its issuance.
multinational pharmaceutical companies. Sec. The AO mandates all packages of tobacco
Duque stressed that the country, as a matter of products to bear large, clear, visible and legible
national policy, supports and promotes full-color graphic health information on the
breastfeeding and adheres to reasonably strict dangers of cigarette smoking on their front and
standards for the entry of infant milk formula bank panels. Medical and health groups, legal
products in the Philippines. The controversial experts, women’s groups, and other various
IRR underwent review by the Supreme Court civic organizations lauded the department’s
until the majority of the provisions of the IRR issuance of the AO citing that this would slow
was approved providing “broader” powers to down the increasing numbers of cigarette
DOH, which include (1) a wider scope of coverage smokers.
of regulated products to include those for older 9. Advocacy for Condom Use – The distribution of
children; (2) the right to specify warnings such condoms is part of the DOH program to counter
as “There is no substitute for breast milk” and the spread of STDs and the dreaded HIV/AIDS
HSRA Monograph No. 9 17
EXPANDING THE NATIONAL HEALTH INSURANCE flat-rate premium contribution of its members
PROGRAM. PhilHealth’s coverage has increased results in regressive risk pooling. Identifying,
steadily. The Employed Sector Program had the categorizing for appropriate premium payment
biggest slice of membership at 44 percent, with 8.91 scale, and enrolling them should be a challenge
million active members. The Individually Paying to PhilHealth.
Program (IPP), which includes self-earning For the sponsored program, there are 5.38
professionals and daily wage earners, had about million members in 2009. Budgetary constraints
3.33 million members. The Overseas Workers and the evolving priorities of the local
Program (OWP) had 2.10 million members while government affect enrolment of indigents to
the Non-Paying Program (Lifetime Members) had PhilHealth. As such, there is a need to intensify
0.46 million registered members. For the PhilHealth’s campaign to encourage LGUs to
Sponsored Program, 5.38 million members are earmark funds for premium payments for
currently enrolled (PhilHealth Stats and Charts indigents. There is also a need to explore other
2009). alternative sources of sustainable financing for
PhilHealth benefit packages continue to expand PhilHealth to expand the Program’s coverage,
to cover more services and increase benefits to including the enrolment of indigents as well as
members. An example of these are the expanded the poorest members of the informal sector.
coverage of normal spontaneous delivery of 2. Inadequate total health expenditure. The
maternity care packages, the outpatient malaria Philippines only spends 3.3 percent of its GDP
package, and voluntary surgical contraception on health in 2005. A provisional estimate from
procedures. WHO showed that in 2008 this slightly increased
PhilHealth accreditation of health facilities also to 3.8 percent (WHO, 2010). Although there are
continues to increase. As of 2009, 55 percent of RHUs no guidelines on how much a country should
and 90 percent of DOH licensed hospitals were spend on health, WHO recommends a 5 percent
accredited. PhilHealth likewise expanded the spending on health as most countries that have
accreditation of facilities from hospitals and RHUs achieved universal coverage spend at least this
to other health facilities such as Maternity Care much.
Clinics, Ambulatory Surgical Clinics, and TB DOTS DOH can advocate for more resources through
Centers. Recently, midwives and dentists are also the HSEF and the PIPH by using its subsidies to
being accredited by PhilHealth. LGUs as leverage to encourage more local health
investments. PhilHealth, on the other hand, can
Challenges in Health Financing increase the salary cap for employed sector
1. Coverage of Vulnerable Population. Latest data members and implement a tiered premium
on PhilHealth’s coverage is reported at 82 contribution from the IPP and OWP members.
percent. However, the 2008 National 3. Limited financial risk protection. Financial
Demographic and Health Survey reported only protection is established when individuals or
38 percent of PhilHealth coverage. The households are prevented from becoming
discrepancy in the data suggests that a thorough impoverished by the costs of utilizing health
reassessment of the social health insurance care (WHO, 2000). In 2005, the prepayment
coverage is needed. scheme from taxation and social health
Considering the large number of informal insurance was only 39 percent of total health
workers in the country, membership to the spending while out-of-pocket expenditure
Individually Paying Program (IPP) is only at 3.33 (OOP) was at almost 50 percent. Although there
million members in 2009. Voluntary enrolment is no recent available data, several papers
contributes to the low enrolment rate and the estimate that OOP is still in this range or higher.
HSRA Monograph No. 9 21
and technical efficiency as this has implications expenditure especially for the poor. Shifting FFS
on the access, cost, quality, and consumer to case payment and diagnostic related group
satisfaction. Essential health care and desirable scheme, coupled with contracting with
health interventions can be delivered at the providers to limit balance billing and increase
primary level. Moving towards this path has the support value of PhilHealth benefits, will
potential for large savings and cost ensure financial risk protection.
effectiveness. This will also strengthen the 4. A package of essential health services. An
gatekeeping role of the primary health facilities essential health care package at each level of
which could improve referral system. care must be clearly defined, cost estimated,
6. Regressive Risk Pooling. PhilHealth’s premium and designed, including the source of financing
payment system is still regressive as members do and the provider payment mechanism. This
not pay premiums according to their capacity to must also identify the complementary health
pay (see discussion on risk pooling on page 14). care package that may be offered by PhilHealth.
However, without sufficient and well-
Recommendations distributed number of accredited health
facilities and health professionals to provide
1. Achieving universal health insurance coverage.
these, it will be useless. Therefore, increasing
Universal coverage goes beyond numbers.
and distributing equitably the number of
Extending social health protection to the
accredited health service providers are also
uninsured, increasing the range of services
essential.
under coverage, and reducing payment at the
point of service delivery are the three technical 5. Improving risk pooling from regressive to
challenges of moving towards universal progressive. Paying premiums based on
coverage. Addressing these three dimensions capacity to pay spreads the risks over all
will ensure health for all and health equity. members, consequently improving equity,
access, and financial protection. Premium
2. Increasing investment and public health
contribution of PhilHealth’s employed sector
spending. Allocation of 5 percent of GDP to
members is only progressive until it reaches
health will enable expansion of prepayment
the salary cap of P50,000. For IPP and OWP
schemes (to the insured and uninsured) and
members, premium payment is regressive as
increase safety nets for the poor and vulnerable.
they continue to pay a flat amount of P1,200
However, improving allocative efficiency
and P900 respectively per year regardless of
through a functioning performance-based
their capacity to pay.
budgeting and investing in primary health care
should also be done at the same time. Also,
external aid from development partners that
increases resources for health should be HEALTH REGULATION
sourced through alignment and harmonization Health regulation reforms aim to ensure access
of overseas development assistance with
to quality and affordable health products, devices,
national priorities. 100 percent of key facilities, and services, especially those commonly
stakeholders should therefore adopt SDAH. used by the poor.
3. Ensuring financial risk protection and improving HARMONIZATION AND STREAMLINING OF
provider payment mechanisms. The current REGULATORY PROCESSES. Strengthening
fee-for-service (FFS) for hospitals limits enforcement mechanisms and regulatory oversight
financial protection of members due to caps functions of the DOH were realized through the
that lead them to pay for “excess” fees which passage of RA 9711 or the Food and Drug
sometimes lead to catastrophic health
HSRA Monograph No. 9 23
Administration (FDA) Act of 2009 and the creation SEAL OF APPROVAL SYSTEM. To increase demand
of the National Center for Pharmaceutical Access for health care and influence consumer behavior,
and Management (NCPAM). FDA Act of 2009 creates the DOH has developed and implemented a unified
four centers for: drug regulation and research; food “seal of approval” system for health products,
regulation and research; cosmetic regulation and devices, facilities, and services. Technical assistance
research; and the device regulation, radiation for the development of an overall framework for
health, and research (formerly the Bureau of Health the seal of approval for the three regulatory
Devices and Technology). The NCPAM on the other bureaus of DOH (FDA, Bureau of Health Facilities
hand was created to further support the and Services or BHFS, and Bureau of Health Devices
implementation of the Universally Accessible and Technology or BHDT) was approved by the WHO
Cheaper and Quality Medicines Act. in the first quarter of 2008.
The Harmonization and Streamlining of the FDA developed a Seal of Approval System that
Licensure System for Hospitals in 2007 paved the combines the requirement for a license to operate
way for the simplification of the licensing system and certificate of current Good Manufacturing
for hospitals. Two policy directives were Practice (cGMP) for the production of
formulated to realize this: (1) establishment of a pharmaceutical products consistent with guidelines
one-stop-shop for the licensure of health facilities in the ASEAN region. In September 2008, twenty-
(its main feature is to issue a single license to eight (28) cGMP compliant companies were
operate to hospitals, including ancillary services and awarded quality seals or certificates proving that
other facilities in a shorter period of time, i.e., 30 they are of international standards.
days for new applications and 5 days for renewal); PhilHealth has also developed three new
and (2) decentralization of appropriate regulatory accreditation standards for health care
functions to regional offices and LGUs. organizations which serve as the basis for hospital
As part of the Department’s effort in accreditation starting 2010. These standards are the:
strengthening its enforcement mechanisms and Center of Safety, Center of Quality, and Center of
regulatory oversight functions, it recently issued Excellence.
Administrative Order (AO) 2010-0013 requiring INSTITUTIONALIZATION OF COST RECOVERY
graphic health information on tobacco packaging. AND REVENUE ENHANCEMENT MECHANISMS. The
This is part of the government’s efforts to curb Bureau of Quarantine is allowed to retain and
tobacco use and reduce its large socioeconomic utilize at least 50 percent of its income, by virtue of
costs from health care expenditures and RA 9271 of 2004. In 2006, the BHFS began
productivity losses which are estimated at P200 implementing a rationalized schedule of fees for
billion. The size of the graphic health information the regulation of health facilities. BHFS also
would occupy no less than 30 percent the upper continues to implement the provision of the
portions of each tobacco product packet of the front Hospital Licensure Act that allows it to retain funds
panel and 60 percent of the back panel. collected from permits to construct, register, and
AO 2010-0008 was also issued changing the use license to operate fees for hospitals and other
of the phrase “no approved therapeutic claim” in health facilities covered by the Act. The FDA and
all advertisement, promotional, and/or BHDT will also restructure their regulatory fees
sponsorship activities or materials concerning food/ based on actual administration costs. RA 9711 or
dietary supplements. All advertisements of food/ the FDA Act of 2009 seeks to make the FDA a
dietary supplements will now carry the message in financially autonomous institution, by giving it
Filipino stating: “Mahalagang Paalala: Ang (name authority to retain all its derived income, in
of product) ay hindi gamot at hindi dapat gamiting addition to its annual budget.
panggamot sa anumang uri ng sakit.”
24 BRIDGING TO FUTURE REFORMS
5. Enforcing the new provisions of the health of the one-stop-shop from the national to the
regulatory agencies. Regulation of health regional level should be regularly monitored for
facilities is currently limited to the licensing of its efficiency, user-friendliness, and the
individual facilities. As such, government is turnaround time for new applications and
unable to control the cost of health services renewals. Also, monitoring of the
provided by the private sector. This may lead to implementation of the cheaper medicines act,
spiraling health care costs, which would further the graphic health information on tobacco
compromise social protection. packaging, and the change in food/dietary
Limited funding and human resources have also supplements promotion should be regularly
made it difficult for the regulatory agencies to conducted and reported.
fulfill their functions. Quasi-judicial powers or The regulation of hospital and professional fees,
“police” powers to enforce laws are also lacking. health professionals, and regulation of the
This encourages hospitals or other health industry as a whole instead of regulating
facilities to operate without a license. individual health facilities should be
strengthened.
Recommendations
1. Increase acceptability and availability of quality
and cheaper medicines. BnBs, BNBs, and the SERVICE DELIVERY
P100 Project should be strategically expanded
The persistence of wide disparities in health
and their promotion to both doctors and outcomes across gender, age, regions, and income
consumers strengthened. groups underscores the remaining gaps in the
2. Curb irrational use of drug. A framework to curb availability and accessibility of health care services
irrational drug use needs to be institutionalized in the Philippines. For this reason, Health Service
and operationalized. Over-the-counter drugs in Delivery was highlighted as one of the key reform
sari-sari stores or small outlets and the sale of areas in F1. F1 seeks to improve the accessibility
non-essential drugs should be regulated. and availability of basic and essential health care,
Monitoring of doctors buying from medical particularly to the poor.
representatives and doctors dispensing drugs Substantial investments were provided for the
should be conducted. Service Delivery component of F1 to ensure the
3. Regulate non-essential health products. attainment of its objective. The budget allocation
Policies on the regulation of non-essential for service delivery more than doubled between
health products such as nutriceuticals are still 2005 and 2009.
wanting. Control of regulated product ENSURE THE AVAILABILITY OF BASIC AND
advertisements to reduce the risk of misleading ESSENTIAL HEALTH SERVICES. Service packages for
and biased promotional information reaching priority health programs such as Malaria Control;
consumers and professionals should be Maternal, Newborn, and Child Health; and the
tightened. An AO was recently issued to National Tuberculosis Program were developed.
regulate these products’ advertisements and Health services network were also established to
this should be strictly implemented and facilitate access to health facilities at different
monitored. levels of care. Some examples would be the
4. Enforce regulatory function guidelines of DOH Maternal, Newborn, and Child Health and Nutrition
agencies. Enforcing the implementation (MNCHN) health facility network which includes the
guidelines of the DOH regulatory agencies is Basic Emergency Obstetric and Newborn Care
critical and crucial in strengthening its functions. (BEmONC) and Comprehensive Emergency
Current initiatives such as the implementation Obstetric and Newborn Care (CEmONC), and the
26 BRIDGING TO FUTURE REFORMS
laboratory network for infectious diseases such as Meanwhile, trainings on service delivery (both for
TB and malaria. routine health care and emergency) have been
The rationalization of service delivery aims to conducted to improve the capacity of health
provide access to the right facilities in the right workers. The National Voluntary Blood Services
places with the right professionals, based on the Program (which regulates blood banks and ensures
health needs of the population. To rationalize an adequate supply of safe blood) closed all
health systems, provinces analyzed their health commercial blood banks in the country, and
needs and resources and are expected to deliver rationalized more than 200 blood service facilities.
ouputs that are benchmarked against DOH It also centralized the testing in selected blood
standards. All these must be reflected in each centers.
province’s health facility rationalization plan. Guided by the principles of F1, the Government
At present, sixteen F1 priority provinces, one Hospital Upgrading Project under the DOH’s Health
roll-out province (Albay) and one volunteer Facilities Enhancement Program (HFEP) is being
province (Occidental Mindoro) have completed pursued to rationalize and upgrade health facilities
their rationalization plans. The rationalization plans nationwide. Its objectives are to: (1) upgrade
are linked to the Province-Wide Investment Plans government hospitals from primary to secondary
for Health (PIPH) and the Annual Operations Plan level, thereby decongesting tertiary hospitals,
(AOP) and serve as a basis for the rational fund improving the gatekeeping function of primary care
allocation of the Health Facilities Enhancement facilities, and making them base hospitals for
Program. nursing students and nursing affiliation; (2) upgrade
secondary level hospitals to tertiary level, to make
There is a 38% increase in the number of them referral hospitals in their catchment area; (3)
PhilHealth accredited health facilities from 2005 to provide BEmONC or CEmONC services, to further
the 1st quarter of 2009 while accredited health
reduce maternal and neonatal mortality rates; (4)
professionals increased by 7%. help government hospitals comply with DOH
Encouraging successes were observed at the first licensing and PhilHealth accreditation standards,
16 F1 provinces with high levels of PHIC to ensure that they provide quality and appropriate
accreditation which suggest adequacy in services that are responsive to the health needs of
infrastructure and competency of health human the catchment population; and (5) further upgrade
resources. Many health centers and RHUs are OPB selected DOH Medical Centers and Regional
and TB-DOTS accredited. Many are also preparing Hospitals for specialty/subspecialty services to
to have MCP and newborn package accreditation. become end referral regional specialty centers.
(EC Technical Assistance, 2009) Between 2007 and 2009, about Php4.5 Billion
ASSURE THE QUALITY OF BOTH BASIC AND was invested in upgrading national and local
SPECIALIZED HEALTH SERVICES. Patient Safety was government hospitals, Barangay Health Stations
institutionalized as a fundamental principle of the (BHS), and RHUs nationwide.
health care delivery system. Guidelines or The establishment of ILHZs is important for the
standards have been developed or updated to district health system to work in a devolved setup.
ensure the quality of diagnosis, case management, These ILHZs serve as the focal point in converging
and treatment. The Continuing Quality catchment areas, allowing them to participate in
Improvement (CQI) Program Committee was providing quality, equitable, and accessible health
established in DOH hospitals to sustain care though inter-LGU partnership and cooperation.
improvements in the quality of health care services.
To date, all DOH-retained hospitals have a
functional CQI Program and Committee.
HSRA Monograph No. 9 27
INTENSIFY EFFORTS TO REDUCE PUBLIC HEALTH methods, including NFP methods, remains a
THREATS, PREVENT AND CONTROL COMMUNICABLE major challenge in health service delivery.
AND NON-COMMUNICABLE DISEASES AND The government has been advocating the
MINIMIZE HEALTH RISK-TAKING BEHAVIORS. The enabling of couples and individuals to decide
DOH implemented disease-free zone initiatives, freely and responsibly for the number and
intensified disease prevention and control spacing of their children (Responsible
strategies, strengthened maternal and child health Parenthood) and to have the information and
programs, and enhanced health promotion and means to carry out their decision (Informed
disease surveillance activities. Choice). However, the equivocal support of the
a. Improving Reproductive Health Outcomes government for the population program and the
The Save the Children Report 2007 rated the non-appropriation of the national government
Philippines as having the best child health care for family planning commodities are proofs that
program out of 55 developing countries. Senate the issues of the role of population in
Resolution No. 77 dated 28 May 2008 development remain unresolved (Orbeta,
commended the Department of Health for its 2006). The government has focused on the
exemplary efforts in providing our country with promotion of natural family planning methods
the best child health care. through the Responsible Parenthood-Natural
Family Planning program (RP-NFP) of the
A recent UNICEF report states that the Commission on Population. The provision of
Philippines is among the 10 priority countries family planning commodities is left to the Local
making good progress towards the reduction of
Government Units through the Contraceptive
child and maternal mortality (UNICEF, 2008). Self-Reliance Strategy (AO No. 158 s. 2004).
Infant and under five mortality rates are MMR has slightly improved, but is still far
decreasing and have a high probability of from the 2015 target of 52 per 100,000 live births.
attaining the MDG targets by 2015. However, the The low CPR and high MMR indicate that there
reduction is decelerated by the very slow must be some ambiguities and deficiencies in
decline of the neonatal mortality rate. the reproductive health policy that must be
There has been a consistent decline in addressed.
fertility in the past 36 years. The total fertility b. Disease-Free Zone Initiatives
rate (TFR) declined from 6 children per woman
in 1970 to 3.3 children per woman in 2006. The number of malaria-free provinces has
However, this is still relatively high compared increased from 14 provinces in 2004 to 22
to other countries in Southeast Asia (NSO, 2008). provinces out of 58 endemic provinces in 2008.
The Philippines is the twelfth most-populous This surpasses the target of 18 provinces for
country in the world (PRB, 2008). 2010. The newly declared malaria-free provinces
are Albay, Marinduque, Sorsogon, Western
Knowledge of family planning is universal Samar, Eastern Samar, and Surigao del Norte.
since almost all women know at least one The other malaria-free provinces are Benguet,
method of family planning. However, it is not Cavite, Masbate, Catanduanes, Iloilo, Guimaras,
translated into high contraceptive use. The CPR Biliran, Capiz, Aklan, Cebu, Bohol, Siquijor,
has changed slightly over the last decade. The Northern Samar, Northern Leyte, Southern
use of both modern and traditional methods has Leyte, and Camiguin.
increased, although there has been no
improvement in modern contraceptive use in Although the country has generally attained
the last five years (NSO, 2008). Improving the leprosy elimination targets at the national and
availability and affordability of family planning regional levels, pockets of cases remain. Of the
28 BRIDGING TO FUTURE REFORMS
remaining endemic cities/municipalities, two prevalent among women in urban areas and in
highly prevalent cities (Osamis City and the National Capital Region; and increases
Oroquieta City) have achieved elimination directly with level of education and wealth
level. status (NDHS, 2008). The prohibition of national
In 2008, five out of 28 schistosomiasis- procurement of condoms, relatively high cost
endemic provinces achieved elimination level, of condoms, and other sociocultural factors
with prevalence below 1 percent for the past contribute in the only slight increase in the
five years. These are Bohol, Zamboanga del condom use, which is one of the effective
Norte, Davao del Sur, Surigao del Sur, and Sultan interventions against HIV.
Kudarat. Dengue has become a year-round threat,
Of the 42 provinces where filariasis is and cases continued to increase due to climate
endemic, Southern Leyte and Sorsogon were change, poor water disposal, and urbanization.
declared filariasis-free. The dengue mortality rate, however, has
remained low, since hospitals have the
Siquijor is the first province to be declared
capability to provide supportive treatment.
rabies-free.
The Philippines has remained bird-flu free,
c. Intensified Disease Prevention and while Influenza A(H1N1) cases have been
Control Program effectively controlled and managed. In a June
The Philippines performed well in terms 2009 SWS Survey, the DOH garnered a high
of TB case finding and case holding, compared satisfaction rating (78 percent) for its effective
to the average global performance in 2007. response against Influenza A(H1N1). It also
Deaths from all forms of TB have also decreased received a commendation from the WHO for its
by 40 percent in the last two decades. Over the “swift and tireless” efforts in responding to the
last six years, the TB case detection and cure emerging threat.
rates have increased. Based on the 2007 National
d. Healthy Lifestyle and Management of
TB Prevalence Survey, “the burden of the TB Health Risks
disease has declined over the past ten years
since the launching of the DOTS program.” The Philippines is one of 23 countries that
However, the 2010 targets for TB prevalence and account for around 80 percent of the total
mortality rate have yet to be achieved. The mortality burden attributable to chronic
increasing MDR-TB and XDR-TB cases were a diseases in developing countries and 50 percent
major challenge of the National TB Program. of the total disease burden caused by non-
communicable diseases worldwide (Abegunde
The Philippines is one of the few remaining et al., 2007). Morbidity and mortality rates from
countries in Asia with low HIV prevalence. At almost all non-communicable diseases have
present, HIV prevalence is already described as increased.
“expanding and growing” from the previous
“low and slow” and “hidden and growing” Access to safe water supply and sanitary
phases. According to a recent study, an HIV toilet facility has not improved; in 2008, there
epidemic is likely to emerge in the Philippines was a decline in the proprotion of households
(Farr and Wilson, 2010). One hundred twenty with access to safe water and sanitation.
(120) confirmed new cases were recorded in e. Enhancing Health Promotion and Surveillance
March 2010 alone which is roughly equivalent The Philippine Integrated Disease
to three to four cases per day. The prevalence Surveillance and Response (PIDSR) was
of higher-risk sexual intercourse is high among introduced as a strategy to harmonize all existing
young, sexually active women age 15-24; is more
HSRA Monograph No. 9 29
disease surveillance systems and strengthen diseases. Advocacy and social mobilization
LGUs’ capacity to perform disease surveillance involving various stakeholders included the
and response. This is in compliance with conduct of partners’ meetings and special
International Health Regulation 2005, which events for priority programs. The DOH began
requires the reporting of certain disease increasing investments in paid airtime for radio
outbreaks and public health events to help the and TV and space for print, to ensure that the
international community prevent and respond public is properly informed about important
to acute public health risks that have the DOH campaigns, programs, health emergencies,
potential to cross borders. The PIDSR includes and other health issues. The total budget for
reports from DOH, LGUs, and private health health promotion was dramatically increased by
facilities. 300 percent between 2005 and 2009.
The 2008 Revised List of Notifiable
Diseases, Syndromes, Health-Related Events,
and Conditions was adopted. The revised list
forms the basis for reporting not only notifiable
diseases but also syndromes, health-related
events, and conditions that are of public health
importance.
LGUs’ capacity for surveillance and
response was enhanced through capability
building on the Guidelines to Establishment of
Epidemiology and Surveillance Units and roll-
out trainings to all Regional Epidemiology
Surveillance Units (RESUs) in 2008. RESU
networks in 64 provinces were monitored and
assessed for functionality in 2009.
Health Promotion for Behavior Change was
developed as a new framework for advocacy. It
identified the three main audiences of the DOH,
namely: (1) legislators, policymakers, and Local
Chief Executives, to harness the necessary
support for priority health programs in terms of
policy and funding; (2) health workers,
professional organizations, and lobby/interest
groups and other partners, to influence some
decisions in favor of health beneficiaries and
clients; and (3) individuals and families, to adopt
healthy behaviors and participate in health
actions in their communities.
Health promotion and communication
plans for priority health programs were
developed and revised. The national risk
communication guidelines were also developed
for emerging and reemerging infectious
30 BRIDGING TO FUTURE REFORMS
Indicators 2010 Targets Baseline data and source Latest status and source
Number of provinces and Prevalence rate of Five provinces and eight Two cities with less than
cities with less than one case less than one case cities with prevalence of one case of leprosy per
of leprosy per 10,000 per 10,000 more than one case of 10,000 population.
population population in five leprosy per 10,000 Source: NCDPC, 2009
provinces and eight population
cities Source: NCDPC, 2004
LEGEND:
Indicators 2010 Targets Baseline data and source Latest status and source
Prevalence of HIV per 100,000 Less than one case 0.03 0.0168%
population per 100,000 Source: FHSIS 2003 Source: DOH-NEC
population estimates
Incidence rate of dengue Less than 10 DHF 13 DHF cases 14.5 DHF cases
hemorrhagic fever (DHF) cases cases Source: FHSIS 2004 Source: DOH, 2008
per 100,000 population 1.7%
Source: National
LEGEND:
Indicators 2010 Targets Baseline data and source Latest status and source
Mortality rate from COPD per Less than 20.8 20.8 24.58
100,000 population deaths Source: Philippine Health Source: : Philippine
Statistics 2004 Health Statistics 2005
Mortality rate from all forms Less than 47.7 47.7 48.92
of malignant neoplasm per deaths Source: Philippine Health Source: : Philippine
100,000 population Statistics 2004 Health Statistics 2005
Morbidity rate from heart and Less than 65.7 cases 65.7 36.4
vascular diseases per Source: FHSIS, 2006 Source: DOH, 2008
100,000 population
LEGEND:
Indicators 2010 Targets Baseline data and source Latest status and source
LEGEND:
Indicators 2010 Targets Baseline data and source Latest status and source
LEGEND:
of higher educational attainment tend to deliver in improve access of those special groups are few or
a health facility than women of lower educational even not yet in place.
backgrounds. The same observations are true for Substantial proportion of the population (26
the FIC. The contraceptive prevalence rate of non- percent) bypassed lower levels of care. Although
poor married women was higher by 5 percent than limited in number (half is located in NCR), tertiary
poor married women (FPS, 2006). level hospitals continue to admit and receive
Persistent gaps in the availability of quality referrals of primary cases. Data on PhilHealth
essential health services. Many regions and areas reimbursements of hospital admissions reveal
continue to have substandard health facilities and persistently high levels of ordinary cases treated
equipment. Almost 65 percent of hospital beds are by highly specialized health facilities (Caballes,
in Luzon but almost 50 percent of these are in NCR, 2009). As yet, there is no policy on the gatekeeping
the population of which comprises only 22 percent function of primary health care facilities which
of Luzon’s total population. ARMM, Region 6, and would ensure that primary cases are managed at
Region 7 are the top three regions with the fewest the lower level of care.
PhilHealth accredited hospitals in relation to their According to Caballes (2009), “Hospital
population size, while Regions 3, 4A, and NCR have autonomy may have improved the fiscal status of
the highest number of PhilHealth accredited hospitals but its impact is not yet measured in
hospitals. The increase in the supply of health improving patient accessibility to hospital
professionals, particularly nurses, has no services.” Almost half of total health expenditures
corresponding plantilla positions in the LGUs. The come from out-of-pocket spending. PhilHealth only
maldistribution of health professionals is evident covers 11 percent of the total health expenditure
across regions since majority of health (NSCB, 2005). While there are different PhilHealth
professionals are in NCR, Central Luzon, and benefit packages, members have a low awareness
CALABARZON. There is a serious shortage of of these benefits. This is one of the main factors
specialists like anesthesiologists in many LGU leading to low utilization of the Out-Patient Benefit
hospitals (EC Technical Assistance, 2009). package. PhilHealth-accredited RHUs are still few
The monitoring of performance and capability and PhilHealth-accredited hospitals are
to ensure compliance by laboratory and health concentrated in economically progressive
provider networks are weak. Variations in the localities, depriving the poor from the far-flung
quality of diagnosis and treatment are still evident areas to access. The urban poor might have
in all levels of care. The rise in Influenza A H1N1 geographical advantage but financial capacity
and leptospirosis cases revealed inadequacies in remains the biggest barrier to access to health care.
most hospitals’ capacities to respond to health Cultural barriers to health care also persist. A
emergencies and outbreaks. This has also led to segment of the population still relies on untrained
congestion in a few capable hospitals. birth attendants or hilots and herbal doctors or
Challenges remain in achieving universal access albularyo for their health. More than a third of births
to health care. The distribution of available health are assisted by hilots. This is more evident in rural
resources contributed to inequitable access to areas than in urban areas (NSO, 2006).
health facilities, human resource, and health
services. The average time to reach a health facility
in ARMM is thrice that of the average time in NCR. 2. Issues On The Implementation Of Strategies
The isolated and displaced population and a. Varying LGU support and capacity to
indigenous groups still have poor access to health implement health policies and programs. The
services. While the segment of the population with implementation of national health programs
the worst health outcome has already been at the local level has become complex due to
identified, service packages and strategies to devolution. Although some LGUs have
36 BRIDGING TO FUTURE REFORMS
accepted the challenge with minimal health facilities for the most part were
assistance from the national government, a engaged in training and administrative work.
majority have limited financial and technical d. Public-private partnership is confined to a
capacity to manage health within their few programs and components in the health
catchment areas. Some local chief executives system. Efforts to harness the private sector
prioritize projects with results that can seen and strengthen performance and risk
by their constituents. Some LGUs are unaware management among private providers are
of the kind of health services that LGUs still deficient. This is reflected in the
should deliver. For instance, RHUs in Ilocos conspicuous lack of targeted subsidies and
Sur have not been providing communicable the absence of a system for monitoring the
and non-communicable control services performance of private providers. There
because health workers assumed that such have been no studies on the advantages and
programs were the responsibility of the DOH risks of private sector involvement in health
(Bueno, 2008). programs, and no plans have been laid out
b. Variations in treatment outcomes, such as to manage their involvement. As such, in
treatment failures and multi-drug resistant most cases, the private sector operates
cases, resulting from privately provided care independently of the public sector, once
and self-medication. About 40 percent of licensing, accreditation, and certifications
patients with TB symptoms consult private are dispensed (David and Geronimo, 2008).
physicians. As much as 19 percent self e. Current health promotion efforts seem to be
medicate and go directly to pharmacists. less effective. There is still a need to promote
Pharmacy personnel are typically untrained awareness on priority health programs. For
and unlicensed; as a first line of health care instance, 94 percent of Filipinos have heard
provision, they are therefore likely to of AIDS, but only 53 percent have adequate
mismanage diseases like TB, leading to drug knowledge of HIV prevention (NSO, 2008).
resistance, disability, or death. Many private Eighty-six percent have heard of TB, but of
sector providers do not comply with the NTP this number, almost 60 percent believed that
guidelines. They still rely on chest x-rays, TB was transmitted by ingestion; only 34
with inconsistent prescriptions among many percent knew that TB is transmitted by
outlets (David and Geronimo, 2008). inhalation (DOH and TDFI, 2008). The
c. Weaknesses in the design of health policies promotion of behavioral changes to
and programs: encourage the adoption of a healthy
Fragmented implementation of strategies. lifestyle must likewise be intensified.
Strategies tend to be developed and Majority of the Filipinos have unhealthy
implemented independently, without habits, and behaviors such as smoking have
establishing complementarities with other increased. The prevalence rate of tobacco
health programs. Planning, costing, data smoking among adolescents aged 13-15
collection, training, and monitoring are done years increased from 15 percent in 2003 to
programmatically, even though there are 22 percent in 2007 (DOH, 2007). Healthy
areas for collaboration and integration. behaviors, such as exclusive breastfeeding,
There are many capacity building activities are very low (34 percent) despite the
for implementing policy, but these are less existence of the strong policy (Executive
organized and systematic. Health workers Order 51 or Milk Code).
were taken away repeatedly from their One of the identified weaknesses in current
workstations to attend different kinds of health promotion efforts is the lack of a
training. Health providers in government mechanism for obtaining client feedback as
HSRA Monograph No. 9 37
input to the design and implementation of people, the elderly, people in difficult
health promotion activities. In addition, circumstances, and the urban and rural poor.
communication channels are sometimes 2. Sustain efforts to achieve the country’s MDG
inappropriate for reaching underserved commitments and ensure equity in the
communities; health messages sometimes availability of and access to health services. This
fail to adapt to local needs and culture, involves sustaining the MNCHN strategy,
because the messages are developed at the intensifying the implementation of the
national level by the DOH (David and strategies for nutrition, child health, TB, HIV,
Geronimo, 2008). Finally, a multitude of malaria, sanitation, and increasing access to low
stakeholders develop and disseminate cost quality drugs. More specifically:
health messages that are sometimes
inconsistent with DOH’s own policies, a. Push for MNCHN Policy localization, to
guidelines, and advocacy content. include facility upgrading/capacity/
functionality, skills development,
f. Information essential for decision-making appropriate staffing, adequate financing,
and policy-making is insufficient, caused by and demand generation. Explore the
either the lack of data or insufficient inclusion of reproductive health
processing or analysis. Knowledge-based commodities such as contraceptives as
decision-making at the subnational level is public health goods.
even weaker. While there is a huge amount
of data being generated at all levels, very b. Pursue disease-free zone initiatives and
strengthen disease surveillance
little is made accessible to the DOH. At the
same time, choosing data for decision- mechanisms. The national government must
making can be confusing, since one indicator invest in the MDA and treatment drugs.
can have several sources. This underscores c. Strengthen multiyear budgeting to pursue
the extent of fragmentation in health reduction of priority diseases such as TB and
information (David and Geronimo, 2008). HIV-AIDS. This will help identify financing
g. Current health system has failed to requirements and reduce procurement
effectively apply health interventions. delays.
Infectious disease interventions have been d. Implement the Water Roadmap, finalize the
hindered by (1) difficulties in procuring and Sanitation Roadmap, effectively utilize the
managing large volumes of public health Php1.5 Billion fund for waterless
goods to ensure access in peripheral outlets; municipalities, and revisit the Sanitation
and (2) the presence of private providers Code.
that remain unregulated and unmanaged 3. Intensify efforts to reduce the morbidity and
(David and Geronimo, 2008). mortality due to Non-Communicable Diseases
by developing a well-defined service delivery
Recommendations package per level of care; strengthening
1. The health system’s biggest priority should be regulatory mechanisms for tobacco, alcohol, fast
eliminating variations in performance. This is food, and food labeling as regards nutritional
crucial to attaining equity in health outcomes. content, and the implementation of the
There is a need to prioritize interventions and Executive Order 51 or the Milk Code; sustaining
to channel resources into remote areas that are registries in coordination with the appropriate
lagging behind the national average and are professional organizations; and intensifying
unable to meet health targets, and address the promotion of healthy lifestyle and supportive
needs of vulnerable populations such as the environment. The following unique features of
disabled, the adolescents, the indigenous NCDs must be addressed by the program: (1)
38 BRIDGING TO FUTURE REFORMS
support systems for procurement, finance and facilitate effective resource management at the
management information. provincial level. The SDAH principles have been
INTEGRATED IMPLEMENTATION OF F1 applied to: (1) the Joint Assessment and Planning
COMPONENTS. The establishment of four-in-one Initiative (JAPI), which assesses F1 implementation
convergence sites was done through the in convergence sites and identifies issues and
development and implementation of the Province- remaining gaps; (2) the creation of the Joint
wide Investment Plan for Health (PIPH) initially in Appraisal Committee (JAC) to review and appraise
16 sites, followed by 21 more sites in 2007 and a the PIPH, and Annual Operational Plans of all F1
nationwide roll-out in 2009. This partnership, convergence sites; and (3) the Health Partners
forged between the Secretary of Health and the Meeting (HPM), which appraises donors on the
governor of a province is meant to rationalize local SDAH and F1 implementation.
health systems and harmonize support from the A Technical Assistance Coordination Team (TACT)
National Government (NG) and development was created to harmonize technical assistance to
partners. It is accompanied by a Service Level DOH by various partners operating under the SDAH
Agreement (SLA), which sets the benchmark for thus, reducing duplication of efforts and enhancing
LGU achievements to guide the provision of grants complementarities among technical assistance
and variable tranche from the DOH. A total of groups by ensuring that technical assistance
Php1.6 Billion for the 16 initial PIPH implementation providers and their outputs are responsive to the
sites were allocated by the NG with the support needs of the health sector.
from the European Commission, 80 percent of Bilateral agreements have been undertaken
which have been given as fixed tranche and 20 with various countries to further strengthen
percent as performance grant under the SLA. cooperation. A computerized Project Tracking
The DOH also formalized its partnership with Management Information system funded by WHO
the Autonomous Region in Muslim Mindanao was also installed, to enhance DOH’s capacity to
(ARMM) through a Memorandum of Agreement implement the SDAH.
(MOA) signed on April 23, 2009, covering the IMPLEMENTED LGU SCORECARD. The LGU
allocation, release, and utilization of DOH resources scorecard is one of the components of the
which will be used by DOH-ARMM to implement Monitoring and Evaluation for Equity and
projects under ARMM’s five-year investment plan Effectiveness (ME3) which was developed to
for health (AIPH). This includes a Php17 Million measure the progress and contribution of reforms
start-up fund financed by the DOH, with an to health outcomes and goals. It is presented in a
estimated total cost of Php6.2 Billion. reader-friendly report which underscores
As of this writing, the rest of the provinces are accountability and performance. Scorecards for
already developing their PIPH. Eight cities are also 2007 and 2008 have been issued. The 2008
preparing their own citywide investment plans for scorecards were supplemented by region-wide
health (CIPH). scorecards and the MDG program scorecards.
IMPLEMENTATION OF SECTOR DEVELOPMENT INSTITUTIONALIZED HEALTH PROFESSIONAL
APPROACH FOR HEALTH. AO No. 2007-0038 sets the DEVELOPMENT AND CAREER TRACK. The Human
guidelines for implementing the Sector Resource for Health Network (HRHN), a multi-
Development Approach for Health (SDAH), a system sectoral organization led by DOH and composed of
for harmonizing and improving the government agencies and non-government
implementation of development assistance by organizations, was established in 2006 to address
strengthening donor coordination. It provides for the Health Human Resource issues and problems
the harmonization of donor agencies’ procedures in the country and ensure the achievement of the
with Philippine Government procedures, and goals and objectives of the Human Resources for
consolidates resources from various sources, to Health Master Plan (HRHMP). Various interventions
40 BRIDGING TO FUTURE REFORMS
were implemented to improve the distribution and The DOH adopted the Agency Procurement
retention of critical health personnel especially in Performance Indicators (APPI), which measures the
far-flung and underserved areas. These include: performance and adherence of government
scholarship programs like Pinoy MD, Residency agencies on the Government Procurement Law and
training, and scholarship for undergraduate includes the use of Standard Bidding Documents
personnel; institutionalization of HRH management and forms issued by the Government Procurement
and development systems; deployment programs Policy Board (GPPB), posting of invitations to apply
such as the Doctors to the Barrios Program, Leaders for eligibility and invitations to bid, and posting of
for Health Program, Medical Pool, Public Health procurement process results in the Philippine
Managers, and NARS; and institutionalization of Government Electronic Procurement systems.
capacity building activities in partnership with Alongside this, the Guidelines for Health
academic and partner institutions. Systems for Commodities Reference Information System
securing information on DOH employees and job (HCRIS) was developed to provide specifications
vacancies announcements are also being on the type of drugs and medicines to be procured
improved. The mushrooming of nursing schools in by government agencies. The Procurement
the country which are not at par with the standards Resource Center (PRC) systematically organizes all
required for nursing education is alarming. There available reference materials and pertinent
is a need to ensure the production of health documentation of procurement transactions, both
professionals to meet local needs and to contribute for the GOP and FAPs, and provides guidance on
to the global demand. pertinent procurement rules and regulations
IMPROVED PUBLIC FINANCE, PROCUREMENT relative to the package being evaluated. The
AND MANAGEMENT SYSTEMS. Public Finance Procurement Oversight Committee was also
Management (PFM) reform is geared towards created to settle issues on procurement in relation
improving budget credibility, budget execution, to other internal and external management
and internal controls. Several PFM-related reforms processes.
are being undertaken. Department Order 2009-0246 STRENGTHENING INFORMATION AND
was issued to set a common direction for all efforts COMMUNICATION TECHNOLOGY. Health
related to PFM reforms. Financial management information is important for health planning and
process was improved through the revision of decision-making. Among the initiatives
related issuances and delegation of authority for implemented to produce timely, quality and
various financial transactions, while operations relevant health information for health sector
were streamlined to allow for direct credit of development are: (1) the organization of the
salaries and other receivables to employees’ ATM Philippine Health Information Network (PHIN)
accounts. An electronic tracking system (ETS) was aimed at providing a harmonized framework for the
developed to track expenditures and correlate country’s HIS, strengthening our country’s health
them with planned activities, particularly the information system, and improving access to and
service delivery programs of DOH. Internal control use of health information through an inter-agency
system was upgraded from Internal Audit Division body responsible for the production and
to Internal Audit Service, allowing for improvement dissemination of timely and reliable health
in the existing systems and procedures as well as information; (2) the Philippine Local Health
to promote sustained transparency and Information System (PLHIS), a web-based
accountability in various aspects of operation as it monitoring and evaluation system that tracks
veers away from the traditional approach to one progress in local health systems development and
that is more risk-based, concentrating more on man- is integrated into the Local Health Information
hours and resources reviews. System or the LGU websites; (3) the development
and implementation of major registries and
HSRA Monograph No. 9 41
application systems supporting the specialized training and technical assistance, and
implementation of laws and disease prevention; the provision of financial grants to LGUs that have
and (4) Development of the National Health Data functional ILHZs and practice good inter-LGU
Dictionary (NHDD) and upgrading of ICT coordination. Intervention for Local Health Systems
infrastructure at the central office and field health Development in Far-flung Areas and Marginalized
facilities. Populations, also called geographically isolated and
MONITORING AND EVALUATION AND disadvantaged areas (GIDA), was developed to
STRENGTHENING RESEARCH AND KNOWLEDGE empower communities, LGUs, and key stakeholders
MANAGEMENT. A Knowledge Management Team for good governance in health which employs
was formed to develop the DOH KM Strategic Plan, collaborative partnerships and resource sharing
defining the KM framework, strategic direction, and through the Primary Health Care approach that
roadmap for implementation. The Philippine builds self-sufficiency and self-reliance.
National Health Research System (PNHRS) Strategic The Department of Health adopted the Urban
Plan for 2006-2010 was developed and the National health equity and response tool (HEART),
Unified Health Research Agenda (NUHRA) was developed and launched by the WHO, to address
implemented in collaboration with other unfair health conditions and inequity in urban areas.
stakeholders. The annual National Forum on Health HEART is designed to help countries systematically
Research for Action translates health research generate evidence to identify, assess, and respond
findings into policies and program interventions. to urban health equity concerns. It also seeks to
The Resource Center for Health Systems generate intersectoral action, promote social
Development (RCHSD) was made operational as cohesion, community participation, and
the repository of various knowledge resources on empowerment of the poor.
health systems development. Documentation of
best practices was conducted for possible adoption Challenges in Good Governance
by other LGUs. The conduct of the National Health
Sector Meetings was enhanced with the Addressing the inequity in health is a continuing
challenge for the health sector. Future reforms must
development of 24 Health Policy Notes (HPNs) since
focus on how to minimize the widening inequities
2008, summarizing critical health policy issues to
guide DOH policy makers, program managers, and in health outcomes. This would entail strengthening
the overall stewardship function at all levels of the
health partners in decision-making. A monitoring
system.
and evaluation system (i.e. ME3) has been put in
place to determine the achievements of the health 1. Addressing persistent disparities in
sector reforms. performance across provinces, municipalities
and population groups. Despite years of
DEVELOPMENT OF EFFICIENT NATIONAL AND
implementing reforms, wide disparities in
LOCAL HEALTH SYSTEMS. It has been recognized that
performance and outcomes continue to be a
the establishment of ILHZs at the district level is an
major challenge. While some provinces are
important strategy to make devolution work.
doing well and lead in reform implementation,
Currently, there are 274 ILHZs in 89 percent of the
others continue to struggle with improving the
provinces. To enhance inter-LGU coordination and
health status of their constituents.
sustainability, an incentive scheme has been
developed as reflected in AO No. 2006-0017 2. Harmonizing public and private sector gains to
entitled, “Incentive Scheme Framework for improve overall health sector performance.
Enhancing Inter-LGU Coordination in Health Public-private partnership in health service
through Interlocal Health Zones (ILHZ) and Ensuring delivery is easier to achieve in urban areas than
their Sustainable Operations.” This includes the in rural communities in remote areas, where it
provision of additional commodities, access to is often difficult to jumpstart partnership
42 BRIDGING TO FUTURE REFORMS
activities. However, this process can be 6. Implementing the eNGAS and eProcurement
facilitated if an external private organization systems. These are the main foci of reforms to
with resources and a vast network joins the improve the efficiency of financial transactions.
partnership, with the able management of the The eNGAS is fully operational at the DOH
DOH. The health sector needs private sector Central Office, and has been rolled out to five
data that will complement the existing database CHDs and seven hospitals. Trainings on eNGAS
on health information and statistics. (in eight CHDs and 50 DOH hospitals) and
3. Strengthening partnerships through the HRHN. monitoring of its implementation have also
As the inter-agency body responsible for been undertaken. However, its implementation
developing HR policies, the HRHN must be was deferred in other areas due to a directive
strengthened to ensure coherence in the from the Department of Budget and
mandates of all agencies managing HRH. The Management calling for further system
HRHN must pursue the development of improvements.
responsive policies to ensure financing for 7. Addressing delays in procurement. For the
human resources for health, creating Calendar Year (CY) 2008 ODA, the performance
opportunities for people to work in the health of many projects in the DOH portfolio has been
sector and addressing the supply-demand slow, and implementation and achievement of
mismatch for Filipino health professionals. targets of many DOH FAPs have not been up to
4. Full blown implementation of the Sector Wide par. This could be attributed to various problems
Approach for Health. Although the policy for that are within DOH’s control, such as delays in
implementing the sector wide approach (SWAp) procurement and civil works, as well as external
for health has been issued, this has yet to be factors such as the increase in costs of
translated into an actual SWAp. The challenge construction material and the withdrawal of
is for DOH to develop a single sectoral program LGUs (NEDA, 2008).
with one basket of funds, where all donor 8. Reviewing government procurement law.
principals will be allowed flexible terms based Studies show that RA 9184 tends to compromise
on existing government procedures. quality of goods and services in favor of complex
5. Institutionalizing sound financial management bidding procedures. A procurement system that
to sustain budget increases and rationalize is slow and inefficient sends a strong signal to
spending. The creation of the Program Planning the business community that the government
and Budget Development Committee (PPBDC) is unable or unwilling to compete in today’s fast-
in 2006 is a big step towards sound Public paced economy. The drawn-out bidding process
Finance Management. It ensures the alignment takes about six months on average, even for a
of operational plans with DOH’s strategic thrust simple, low-budget contract. The performance
and policies, and synchronizes these to financial of government functions is further hampered
plans. The process of suballotment distorts by turnaround times for vendors to comply with
budget allocation and execution. In this regard, overly detailed terms of reference, and for
the DOH has sought to improve fund transfer procurement agencies to process voluminous
and suballotment by doing these on a quarterly bid documents. For those in court, this simply
basis. However, this process needs to be means that justice delayed is justice denied
strengthened and enhanced further. (Vilches, 2008).
HSRA Monograph No. 9 43
APPENDIX
Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
RESOLUTION
12th National Health Sector Meeting
Resolution No. 2009-03-01
COGNIZANT that while the health sector has pursued major reform initiatives in the past, from adopting
the Primary Health Care approach in the 1970s to implementing health-related legislations (like the Generics
Act of 1988, Local Government Code of 1991, National Health Insurance Law of 1995, Cheaper and Quality
Medicines Act of 2008 and the Food and Drug Administration Act of 2009) and to carrying out reforms through
the Health Sector Reform Agenda and FOURmula One for Health, implementing health reforms takes time
and is affected by political and policy environments;
COMMITTED to strengthen reform strategies and harmonize health sector efforts to achieve the health
system goals of better health outcomes, equitable health financing and responsiveness of health care system;
REALIZING that the Department of Health, as the leader in the health sector, must assess the progress of
the reform strategies, identify the implementation barriers, and propose appropriate intervention strategies
in preparation for the next Medium Term Philippine Development Plan and the next National Objectives for
Health;
CONSIDERING that continuing efforts to improve health system performance shall require the cooperation
and participation of all stakeholders in the health sector and effective governance at the national, subnational,
and local levels;
HEREBY RESOLVES to implement future reform strategies along the principles of:
Universal Coverage which shall ensure that essential health packages at all levels of care that may be
financed through social health insurance and subsidies from the national and local governments with
participation of the private sector shall be made available to all Filipinos, especially the poor.
Equity consideration in resource allocation to ensure access to health services of the marginalized (GIDA,
IPs, older persons, differently-abled persons, internally displaced population etc.) and people in conflict-
affected areas.
Effective governance that refers to the enhancement of the stewardship function and the improvement of
the management and internal support system both of the national, subnational, and local governments to
better respond to the needs of health service delivery, and monitor and evaluate the performance and
results of reforms.
HSRA Monograph No. 9 45
Broad and sustained participation among all stakeholders that is purposive, coordinative, harmonized and
productive.
Client-centeredness such that the health sector responds to the medical and social expectations of its
clients that are consistent with standards of care.
Building on the gains of reform efforts towards sustainable development.
THEREFORE:
The DOH and its attached agencies shall continue to:
Provide policy directions to strengthen and sustain health reforms particularly on regulation, servi ce
delivery, financing and governance;
Oversee the management and implementation of health reform strategies;
Mobilize and leverage resources to achieve the goals of health reforms;
Improve and develop performance indicators and activities to assess the progress of reform
implementation;
Engage partners in policy development and implementation of strategies
- Engage the media to echo the national health programs and policies across the population and provide
accurate and timely information to the public
- Advocate with the legislative bodies to enact laws that will support health reform priorities;
- Engage professional groups, the academe, and NGOs in establishing collaborative networks for service
provision, training, and advocacy.
Provide venues for consultation, information sharing, and research for effective policy and program
development.
The Development Partners within the context of Sector Development Approach for Health shall:
Provide official development assistance consistent with the national thrusts and directions for health;
Align and harmonize their systems and processes with government procedures to the best extent possible;
Cooperate in the establishment of mechanism to track development assistance;
Ensure the sustainability and institutionalization of projects to appropriate agencies/ offices.
The Sectoral Management and Coordinating Team (SMCT), as the lead in ensuring that the above are
carried out by the concerned offices, shall develop an action plan in coordination with concerned stakeholders
to be monitored on a quarterly basis by the Secretary of Health.
Be it resolved and approved this 5th day of November 2009 at the Diosdado Macapagal Auditorium, Land
Bank of the Philippines Main Office, Malate, Manila.
HSRA Monograph No. 9 47
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