A 25-Year Assessment of Philippine Health Sector Performance

THE CHALLENGE OF REACHING THE POOR WITH A CONTINUUM OF CARE A 25-Year Assessment of Philippine Health Sector Performance

Carlo Irwin A. Panelo Orville Jose C. Solon Rebecca M. Ramos Alejandro N. Herrin Corresponding author: Carlo Irwin A. Panelo

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Suggested citation: Panelo, C. I .A., Solon, O. J. C., Ramos, R. M., Herrin, A. N. The Challenge of Reaching the Poor with a Continuum of Care: A 25-Year Assessment of Philippine Health Sector Performance. Quezon City, 2017.

This document is made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of Cooperative Agreement No. AID-492-A-12-00016. HPDP is a five- year USAID health policy project implemented by the UPecon Foundation, Inc. that supports the Department of Health (DOH)-led policy formulation process for scaling up Universal Health Care.

The contents are the sole responsibility of authors and do not necessarily reflect the views of HPDP, UPecon Foundation, Inc., USAID or the United States Government. The Challenge of Reaching the Poor with a Continuum of Care: A 25-year Assessment of Philippine Health Sector Performance

Carlo Irwin A. Panelo Orville Jose C. Solon Rebecca M. Ramos Alejandro N. Herrin

Includes a commentary by John Peabody, MD, PhD and Diana Tamondong-Lachica, MD, and insights from Manuel M. Dayrit, MD, MSc, and Paulyn Jean B. Rosell-Ubial, MD, MPH, CESO II

In memory of Mario M. Taguiwalo and Alberto G. Romualdez Jr.

Table of Contents

Acknowledgments i Foreword iii List of Tables v List of Figures viii Acronyms and Abbreviations ix Executive Summary xiii Overview xix

PART I: Challenges, Fundamental Weaknesses, and 1 Strategic Responses

1. The Challenge of Improving Health Outcomes of the Poor 3

2. Managing a Highly Decentralized Health Delivery and Financing System 11

3. Reducing Variations in Access and Quality of Care to Improve Health Outcomes 19

4. Consolidating Public Finances to Secure the Needs of the Poor 37

5. Reducing Fragmentation and Expanding Capacity to Implement Reforms 53

PART II: Fundamental Problems and Strategic 63 Responses to Specific Health Problems

6. Ensuring a Continuum of Care to Improve Maternal and Neonatal Health 65

7. Intensifying Tuberculosis Control in High Burden Areas 79

8. Adopting a Programmatic Approach to HIV and AIDS Prevention and Control 89

9. Adopting a Set of Cost-Effective Interventions to Reduce Mortality and Morbidity 97 from Non-Communicable Diseases

10. Investing in Capacity to Respond to Threat from Emerging and Re-Emerging 105 Infectious Diseases

11. Strengthening the Process of Accountability to Reduce the Burden of Vaccine- 111 Preventable Diseases

12. Investing in Inter-Jurisdictional Emergency Services for Injuries and Disasters 119

References 127

Commentaries and Insights A. “A Commentary on the Philippine Health Sector Review” by John W. Peabody 155 B. “Insights on Philippine Health Sector Performance” by Manuel M. Dayrit 157 C. " Insights on Strengthening the Continuum of Healthcare in the Philippines" 159 by Paulyn Jean B. Rosell-Ubial

Acknowledgments

The authors would like to acknowledge with gratitude the following people who made this Report possible.

Aleli D. Kraft, Ermi Amor T. Figueroa Yap, Carlos Antonio R. Tan, Jr., Maryann A. Evangelista, Jhiedon L. Florentino, Miharu M. Kimwell, Kathryn U. Roa, Maria Christina C. Langit-Bagro, Jan Aura Laurelle Llevado, Patricia B. Miranda, Faith Obach, Leanne Elaine L. Lu, and Xylee A. Javier, for writing drafts and providing data analysis.

The authors also acknowledge the excellent advice, comments, and information given by the following experts and resource persons: Department of Health current and former officials Francisco T. Duque III, Paulyn Jean Rosell-Ubial, Enrique T. Ona, Esperanza I. Cabral, Manuel M. Dayrit, Lilibeth C. David, Mario C. Villaverde, Roger P. Tong-an, Herminigildo V. Valle, Achilles Gerard C. Bravo, Vicente Y. Belizario Jr., Kenneth Y. Hartigan-Go, Teodoro J. Herbosa, Rhais M. Gamboa, Myrna C. Cabotaje, Enrique A. Tayag, Gloria J. Balboa, Elvira S.N. Dayrit, Crispinita A. Valdez, Socorro P. Lupisan, Joyce U. Ducusin, Anna Marie Celina G. Garfin, Ronald P. Law, and Jaime Y. Lagahid; Philippine Health Insurance Corporation officials Ramon F. Aristoza, Jr., Ruben John A. Basa, Johnny Y. Sychua, Francisco Z. Soria, Oscar B. Abadu, Jr., and Walter R. Bacareza; Juan Antonio A. Perez III (Commission on Population); Ella G. Naliponguit (Department of Education); University of the Philippines School of Economics professors Emmanuel S. De Dios, Toby Melissa C. Monsod, Joseph J. Capuno, Stella A. Quimbo, and Maria Socorro Gochoco-Bautista; University of the Philippines Manila College of Medicine professors Carmencita D. Padilla, Ernesto O. Domingo, Agnes D. Mejia, Mary Ann D. Lansang, Antonio L. Dans, Raul V. Destura, and Ma. Asuncion A. Silvestre; Ben S. Malayang III (Silliman University); Philip P. Padilla (University of the Philippines Visayas); Soonman Kwon (Seoul National University); Edwin M. Mercado (Qualimed Healthcare); Diana R. Tamondong-Lachica (QURE Healthcare); and John W. Peabody (University of California San Francisco and QURE Healthcare).

The Report likewise gained from the comments and suggestions from partners in the health sector: Susan P. Mercado, Ben Lane, and Lluis Vinyals Torres of the World Health Organization (WHO); Teresita Marie P. Bagasao (UNAIDS); Michael D. Singh (UNFPA); Raoul A. Bermejo III and Johanna S. Banzon (UNICEF); Eduardo P. Banzon (Asian Development Bank); Rouselle F. Lavado and Robert Oelrichs (World Bank); Loyd P. Norella (HIVOS Southeast Asia Hub); Thelma E. Tupasi (Tropical Disease Foundation); Daniel T. Tan (HealthJustice); Ann Claire K. Reyta and Von Ryan Ong (Philippine National Red Cross); Karen K. Klimowski, Bryn A. Sakagawa, Maria Paz G. de Sagun, Yolanda E. Oliveros, Belfrando Cangao Jr., Mariquita J. Mantala, and Maria Kathrina D. Olivarez of the USAID and Cooperating Agencies; and independent experts Gelia T. Castillo, Loraine Hawkins, Lorelie C. De Dios, Ricardo J. Mateo Jr., Maricar G. Bautista, Albert E. Domingo, Julie Marie Christi de la Gente, Ma. Victoria C. Villareal, and Oscar F. Picazo.

Technical notes were prepared by Gerry Lyn E. Alcantara, Riza Halili, Jason Alacapa, Consuelo D. Aranas, Bernardino M. Aldaba, Luis Aldaba, Ma. Caroline Belisario, Flory Ann Dycoco, Joyce Encluna, Napoleon S. Espiritu III, Jocelyn I. Ilagan, Maurice Liwag, Marvin Marquez, Allan O. Millar, Nathaniel Orillaza, Immanuel Razon, Dante Salvador, and Rhodora A. Tiongson. Research assistance was provided by Donna Faye Bajaro, Kaye De Ramos, Pamela Crosby, and Danica Galvan. Style and copy editing was done by Victoria V. Quimbo, and cover design and lay-out by Isobel Angelita F. Yap for earlier drafts, and Drink Editorial and Design, Inc. for the final version.

i The authors acknowledge the different institutions where parts of the Report were presented to the public:

Silliman University School of Public Affairs and Governance Seminar "25 Years of the Philippine Health Care and Delivery and Financing System: A Performance Review" on March 12, 2016 at Silliman University in Dumaguete City where Orville C. Solon presented the sections on Health Care Financing and Service Delivery;

Ayala-UPSE Economic Forum “Who Pays and Who Benefits From Health Care Reforms? (A quick look at the last 25 years)” on April 7, 2016 at The Mind Museum Auditorium in Taguig City where Alejandro N. Herrin and Orville C. Solon presented the summary of the section on Health Care Financing. A paper from this presentation was published in a special issue of the Public Policy Journal Volumes XVI and XVII of the University of the Philippines;

Pharmaceutical and Healthcare Association of the Philippines (PHAP) Forum “Health for Juan and Juana: Moving Forward with the Philippine Health Agenda” on May 4, 2016 at the Asian Institute of Management in Makati City where Rebecca M. Ramos and Carlo Irwin A. Panelo presented findings from the section on Maternal and Neonatal Health;

Philippine Institute for Development Studies 2nd Annual Public Policy Conference “Risks, Shocks, Building Resilience” on September 22, 2016 at the Marco Polo Hotel in Ortigas Center where Alejandro N. Herrin and Orville C. Solon presented the overview and highlights of the Fundamental Challenges and Strategic Responses section; and,

Series of Health Sector Review Discussion Fora were also held to consult and validate findings with various regional stakeholders. A total of nine fora were held in the following regions: Ilocos, Albay, Iloilo, Cebu, Leyte, Zamboanga, Northern Mindanao, and Davao. These events were organized in partnership with the UP Visayas Foundation, Inc. and the various Regional Health Research Development Councils supported by the DOH and DOST.

Earlier drafts were likewise presented to the USAID Office of Health and other Cooperating Agencies; the DOH Operations, Planning, and Health Services Cluster; and the PhilHealth Executive Committee.

The authors are grateful for the funding support of the Health Policy Development Program of the UPecon Foundation, Inc. and the USAID Philippines.

The contents of this Report are the sole responsibility of the authors. The Report does not necessarily reflect the views of the HPDP, the UPecon Foundation, Inc., the USAID or the US government and the American people.

ii ƌĂĨƚĂƐŽĨƉƌŝůϲ͕ϮϬϭϳ Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

FOREWORD

The Report entitled “The Challenge of Reaching the Poor with a Continuum of Care: A 25-Year Assessment of the Philippine Health Sector”, comes at a timely juncture after two decades since the devolution of the health system and the shift to social health insurance financing. This long-term assessment of the Philippine health sector provides the opportunity to celebrate gains from earlier health reforms. The Report is also a sobering reminder of how much better things could be. More importantly, the Report raises questions and offers bold solutions as we move towards the goal of universal health care for Filipinos.

The past 25 years of devolution has revealed the difficulties in implementing programs under a decentralized setting. For performance to improve, there is need for DOH to change the way it engages with local governments and the private sector in order to implement health programs at scale. This shift in the manner of engagement will also entail the need for harnessing new competencies that the DOH will have to invest in over the medium to long term. Lastly, this will also require more specific and accurate information and research to design implementation strategies, guide investments and strengthen regulatory mechanisms.

The DOH sees need for continuing discussion and debate on how the health sector can further improve its performance and what it will take to get there. This Report is an important reference to these ongoing discourses, especially in the light of broader social changes like the planned shift to federalism and pending legislation on universal health care. I strongly encourage both public and private stakeholders in health to read through the Report and engage the DOH as we jointly shape the Philippine health sector.

I wish to thank the United States Agency for International Development and the UPecon-Health Policy Development Program for coming up with this report. The contributions of various individuals and institutions who were instrumental in developing this report are also acknowledged.

Let us roll our sleeves as we boost Universal Health Care through the implementation of Fourmula 1 - Plus (F1Plus).

FRANCISCO T. DUQUE III, MD, MSc, Secretary of Health ǆǀ

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila • Trunk Line 651-7800 local 1113, 1108, 1135 Direct Line: 711-9502; 711-9503 Fax: 743-1829 • URL: http://www.doh.gov.ph; email: [email protected]

iii

List of Tables

Table 1.1 MDG Health Indicators 5 Table 1.2 MDG Poverty and Poverty-related Indicators 6 Table 1.3 Food Expense and Consumption of Rice, Sugar, and Salt by Wealth Quintile 7 Table 1.4 MDG Maternal and Child Health Care Utilization Indicators 8 Table 3.1 Utilization of Health Facilities by Wealth Quintile 20 Table 3.2 Quality of Care: CPV Scores of Doctors in Visayas, by Domain (in Percent) 31 Table 3.3 CPV Scores of Doctors for Pneumonia and Diarrhea, 2007 (in Percent) 32 Table 3.4 CPV Scores for ANPC and Labor and Delivery, 2014 (in Percent) 33 Table 3.5 Misdiagnosis among Obstetric Providers 34 Table 5.1 H Index of Core Medical Fields in Selected Countries from 1996 to 2015 57 Table 5.2 H Index of Fields Related to Effective Health Sector Management from 1996 60 to 2015 Table 6.1 Indicative Maternal and Neonatal Interventions in a Continuum of Care 69 Table 7.1 Informal Settlers and TB Prevalence 85 Table 12.1 Number of Cases of Injured and Deaths from Road Crashes, 2012 120

List of Figures

Figure 1.1 Life Expectancy at Birth, Both Sexes 4 Figure 1.2 Maternal Mortality Ratio (Per 100,000 Live Births) 5 Figure 2.1 Pre-Devolution Organizational Structure 12 Figure 2.2 Post-Devolution Organizational Structure 13 Figure 3.1 Hospital Beds per 100,000 Population, 1990 to 2014 21 Figure 3.2 Hospital Beds by Region per 100,000 population, 2015 23 Figure 3.3 Philippine College of Surgeons (PCS) Fellows by Region 24 Figure 3.4 Philippine Obstetrical and Gynecological Society (POGS) Members 24 by Chapter, 2017 Figure 3.5 LGU Hospitals with Surgeon and Obstetrician/Gynecologist by Region, 2014 26 (in Percent) Figure 3.6 LGU Hospitals with X-ray Services, 2014 (in Percent) 27 Figure 3.7 RHUs per 100,000 population by Region, 1995 and 2015 28 Figure 3.8 Proportion of RHUs with Trained Midwife in FP CBT1 and FP CBT2, 2014 29 Figure 3.9 RHUs with CBC Services, 2014 30 Figure 3.10 Probability of Various Outcomes for Mothers and Neonates (in Percent) 34 Figure 4.1 Per Capita Total Health Expenditures, 1991 to 2014 (in PHP at Constant 38 2000 Prices) Figure 4.2 Per Capita Total Health Expenditures and GDP Per Capita (in PHP at 38 Constant 2000 Prices) Figure 4.3 Philippines and Thailand: Per Capita Total Health Expenditures and GDP Per 39 Capita, 1991 to 2014 (in PHP at Constant 2000 Prices) Figure 4.4 Per Capita Total Health Expenditures and Per Capita Local Government Health 40 Expenditures, 1991 to 2014 (in PHP at Constant 2000 Prices) Figure 4.5 Per Capita Internal Revenue Allocation (IRA) and Per Capita Local 40 Government Health Expenditures, 1992 to 2013 (in PHP at Constant 2000 Prices) Figure 4.6 Per Capita Total Health Expenditures and Per Capita National Government 41 Health Expenditures, 1991 to 2014 (in PHP at Constant 2000 Prices) Figure 4.7 Utilization of DOH Budget Net of National Health Insurance Program, 1991 to 42 2015 (in PHP Billion, Current Prices) Figure 4.8 Per Capita Health Expenditures of Social Health Insurance, 1991 to 2014 (in 43 PHP at Constant 2000 Prices) Figure 4.9 Social Health Insurance Share in Total Health Expenditures, 1991 to 2014 43 (in Percent) Figure 4.10 Per Capita Total Health Expenditures and Per Capita Health Expenditures 45 of Private Insurance/HMO and Enterprises/Others, 1991 to 2014 (in PHP at Constant 2000 Prices) Figure 4.11 Per Capita Total Health Expenditures and Per Capita Out-of-Pocket Payments, 46 1991 to 2014 (in PHP at Constant 2000 Prices) Figure 4.12 Per Capita Total Health Expenditures by Financing Agent, 1991 to 2014 (in 47 PHP at Constant 2000 Prices)

vii Figure 4.13 Per Capita Current Health Expenditures by Disease Group and by Financing 48 Agent, 2014 (in PHP at Constant 2000 Prices) Figure 4.14 Per Capita Current Health Expenditures by Financing Agent and by Income 49 Quintile, 2014 (in PHP at Constant 2000 Prices) Figure 4.15 Possible Reallocation of Current Public Funds by Quintile 51 Figure 4.16 Possible Allocation of Additional Public Funds by Quintile 51 Figure 6.1 Maternal Mortality Ratio from the Surveys, Civil Registry, and DOH 66 (Per 100,000 Live Births Figure 6.2 Infant and Neonatal Mortality Rates, 1980 to 2014 (per 1,000 Live Births) 67 Figure 6.3 Counts of Age-Specific Causes of Maternal Deaths, 2012 67 Figure 6.4 Number of Neonatal Deaths by Cause, 2012 68 Figure 6.5 Cross Country Maternal Mortality Ratio (per 100,000 Live Births) 71 Figure 6.6 Deliveries Attended by a Doctor (Percent of Total) 73 Figure 6.7 Births Delivered in a Health Facility (Percent of Total) 74 Figure 7.1 Death Rates from Tuberculosis, 1980 to 2014 80 Figure 7.2 Undetected Prevalent Cases (Missed Cases) Based on TB Prevalence, 1991 81 to 2014 Figure 7.3 Tuberculosis Prevalence Rates (per 100,000 Population) 82 Figure 8.1 Actual Number of HIV/AIDS Reported Cases and Deaths, 1984 to 2016 90 Figure 8.2 Prevalence of HIV, Total (Percent of Population Ages 15 to 49), 1990 to 2015 91 Figure 8.3 HIV Modes of Transmission, 1984 to 2016 91 Figure 9.1 CVD Mortality (Rate per 100,000 Population) 98 Figure 11.1 Percentage of Children 12 to 23 Months who had Received All Vaccines by the 112 Time of the Survey, 2008 and 2013 Figure 11.2 Percentage of Children 12 to 23 Months who had Received Specific accinesV 113 by the Time of the Survey, 2008 to 2013 Figure 11.3 Measles Immunization Rates, Children Aged 12 to 23 months, 1982 to 2015 114 (in Percent) Figure 12.1 Deaths from Injuries and Transport Accidents 119 Figure 12.2 Major Disasters from 1970 to 2013 124

viii ACRONYMS AND Abbreviations

4Ps Pantawid Pamilyang Pilipino Program AFRIMS Armed Forces Research Institute of Medical Sciences AIDS Acquired Immunodeficiency Syndrome AMI acute myocardial infarction AMTSL active management of the third stage of labor ANPC antenatal and postpartum care AO Administrative Order APIS Annual Poverty Indicator Survey ARMM Autonomous Region in Muslim Mindanao ART antiretroviral therapy ARV antiretroviral drugs BDR benefit delivery rate BEmONC basic emergency obstetric and newborn care BHS barangay health station BHW barangay health worker CABG coronary artery bypass graft CALABARZON Cavite, Laguna, Batangas, Rizal, and Quezon CAR Cordillera Administrative Region CBC complete blood count CBT competency-based training CCT Conditional Cash Transfer CDR case detection rate CHCA Comprehensive Health Care Agreement COBAC Central Office Bids and Awards Committee COMPACK Complete Treatment Pack CPV Clinical Performance and Value CRVS civil registry and vital statistics CS caesarean section CSE comprehensive sexuality education CSR Contraceptive Self-Reliance CVD cardiovascular disease DepEd Department of Education DOF Department of Finance DOH Department of Health DOTS Directly Observed Treatment, Short-course DPT diphtheria, pertussis, and tetanus DSWD Department of Social Welfare and Development EINC essential intrapartum and newborn care

ix EMS emergency medical services EMSS Emergency Medical Service System EPI Expanded Program on Immunization ERD Emergency Response Department EREID emerging and re-emerging infectious diseases F1 FOURmula ONE for Health FDA Food and Drug Administration FDS Family Development Sessions FETP Field Epidemiology Training Program FHS Family Health Survey FIC fully immunized children FNRI Food and Nutrition Research Institute FP family planning FPS Family Planning Survey GAA General Appropriations Act GDD Global Disease Detection GDP gross domestic product GSRH general self-reported health HBC high-burden country HCT HIV counselling and testing HFEP Health Facilities Enhancement Program HIV human immunodeficiency virus HMO health maintenance organization HRW Human Rights Watch HSRA Health Sector Reform Agenda HST HIV self-testing ICU intensive care unit IHBSS Integrated HIV Behavioral and Serologic Surveillance ILHZ Inter-Local Heath Zone IMR infant mortality rate IRA Internal Revenue Allotment IRR Implementing Rules and Regulations ISO International Organization for Standardization IUD intrauterine device JCI Joint Commission International KP Kalusugan Pangkalahatan KP OM Kalusugan Pangkalahatan Operations Monitoring KP/UHC Kalusugan Pangkalahatan/Universal Health Care LGC Local Government Code LGU local government unit LTBI latent TB infection MBA Master of Business Administration

x MCHN maternal and child health and nutrition MCP Maternal Care Package MDG Millennium Development Goal MDR-TB multiple drug-resistant tuberculosis MERS-CoV Middle East respiratory syndrome coronavirus MMDA Metro Manila Development Authority MMR maternal mortality ratio MNCHN maternal, neonatal, and child health and nutrition MPH Master of Public Health MSM males who have sex with males MTB/RIF mycobacterium tuberculosis/resistance to rifampicin NCD non-communicable diseases NCR National Capital Region NDHS National Demographic and Health Survey NDRRM National Disaster Risk Reduction and Management NDRRMC National Disaster Risk Reduction and Management Council NGO non-governmental organization NHA National Health Accounts NHA National Housing Authority NHIA National Health Insurance Act NHIP National Health Insurance Program NHTS National Household Targeting System NHTS-PR National Household Targeting System for Poverty Reduction NIH National Institute of Health NLEX North Luzon Expressway NMR neonatal mortality rate NNS National Nutrition Survey NSCB National Statistical Coordination Board NTPS National TB Prevalence Survey NUS National University of Singapore OFW overseas Filipino worker OPB Out-Patient Benefit PAGCOR Philippine Amusement and Gaming Corporation PCB Primary Care Benefit PCS Philippine College of Surgeons PCSO Philippine Charity Sweepstakes Office PHIC Philippine Health Insurance Corporation PhilHealth Philippine Health Insurance Corporation Phil PEN Philippine Package of Essential Non-communicable Disease Interventions PIDS Philippine Institute for Development Studies PIPH Province-wide Investment Plan for Health PLHIV people living with HIV and AIDS

xi PNP Philippine National Police POGS Philippine Obstetrical and Gynecological Society PPMD public-private mix DOTS PSA Philippine Statistics Authority PSMID Philippine Society for Microbiology and Infectious Diseases PTB pulmonary tuberculosis Q@B Quality at Birthing Homes Study QIDS Quality Improvement Demonstration Study QRF quick response fund RA Republic Act RDT rapid diagnostic test RFO regional field office RGDP regional gross domestic product RHU rural health unit RITM Research Institute of Tropical Medicine RPRH Responsible Parenthood and Reproductive Health SARS Severe Acute Respiratory Syndrome SDRC Social Development Research Center SOCCSKSARGEN South Cotabato, Cotabato, Sultan Kudarat, Saranggani, and General Santos City SP Sponsored Program STD sexually transmitted disease STI Sexually Transmitted Infection TB tuberculosis TB-DOTS Tuberculosis - Directly Observed Treatment, Short-course UCSF University of California - San Francisco UK United Kingdom UN United Nations UP University of the Philippines UPCM UP College of Medicine UPPI UP Population Institute UPV UP Visayas US United States USAID United States Agency for International Development VPD vaccine-preventable disease WHO World Health Organization YAFS Young Adult Fertility Survey ZFF Zuellig Family Foundation Z-Package Case Type Z Benefit Package (PhilHealth)

xii EXECUTIVE SUMMARY

The Health Policy Development Program (HPDP) is a five-year health policy project of the United States Agency for International Development (USAID) implemented by the UPecon Foundation, Inc. (UPecon). The HPDP supports the Department of Health (DOH) in the policy formulation process for scaling up Kalusugan Pangkalahatan/Universal Health Care (KP/UHC).

In support of the DOH, the HPDP’s primary objective is to strengthen a supportive policy and financing environment for family planning and maternal, newborn, and child health and nutrition (FP/MNCHN) and tuberculosis (TB) to enable the Philippines to achieve its Millennium Development Goals (MDGs) in health, as well as expand and sustain its KP/UHC initiative.

As part of its mandate, the HPDP initiated the creation of this Report, the Health Sector Review (HSR), to assess the long-term impact on national health outcomes of health sector reforms that have been implemented in the Philippines over the past 25 years.

Objectives of the Report

This Report focuses on how the health sector, particularly the delivery and financing of health services, has affected national health outcomes, especially that of the poor. However, this Report has also been written with the recognition that a broader set of economic and social policies and programs implemented by various non-health agencies are also needed to further influence and improve the country’s national health outcomes.

While the Report touches on historical data, it is not intended to be a historical account of health reform initiatives or of the champions of specific health reform initiatives. It is also not meant to be a descriptive or exhaustive account of all the problems that plague the country’s health sector. Rather, the Report offers an analysis of how the devolution of health service delivery to the local government units (LGUs) reduced the effectiveness of the public health care delivery system to provide access to a continuum of health services to address the needs of poor Filipinos.

The establishment of the public health care delivery system is a policy intervention meant to address the failure of privately provided services to meet the needs of families with very limited abilities to pay for health care. The public health care delivery system was set up as a network of facilities and providers from rural health centers, provincial hospitals, and regional medical centers that would not only provide various levels of care but also guide families as they access the continuum of care. The analysis presented in this Report focuses on how the effectiveness of such a network survived the devolution of health service delivery in 1992.

Highlights of the Report

This Report is divided into two parts. Part I describes the progress in improving health outcomes during the past 25 years, as well as the progress in major social determinants. It then discusses major challenges to improving the performance of the health sector to produce greater health outcomes. These are: 1. The challenge of improving health outcomes of the poor; 2. Managing a highly decentralized health delivery and financing system; 3. Reducing variation in access and quality of care; and 4. Consolidating public finance to secure the needs of the poor.

xiii Part I ends with a discussion of the underlying and fundamental problems that have prevented reform initiatives to address the above challenges to produce greater health outcomes. A summary of the identified problems, proposed solutions, and challenges foreseen are detailed in the table below:

Part I: Challenges, Fundamental Weaknesses, and Strategic Responses Problems Identified Solutions Proposed Challenges Foreseen Improving health outcomes of the poor. Improving health service delivery and Prevailing economic and social Progress in improving health outcomes financing.There is a need to improve the problems of the poor. Having a for the past 25 years has been relatively capacity and effectiveness of the health large population of poor Filipinos with slow compared to neighboring countries care delivery and financing system to inadequate incomes, unhealthy diets, such as Thailand, Malaysia, Indonesia, ensure that poor Filipinos have access to poor living conditions, and low education and Vietnam, or to meeting the nation’s a continuum of care. remains the major contributor to poor Millennium Development Goal (MDG) national health outcomes. While these targets for maternal mortality, infant and prevailing problems of the poor are child mortality, child undernutrition, expected to be addressed by a broader and TB. set of economic and social policies and programs, the potential for the health sector to improve health outcomes remains large. Managing a highly decentralized Inter-LGU planning, and increasing Implementing and sustaining health health delivery and financing system. the role of the national government. programs. Under a devolved set- The passage of the Local Government Nationwide system reforms were up, health may not be a priority of Code (LGC) in 1991 devolved public implemented as a response to the autonomous local chief executives health service delivery to the local fragmentation: FOURmula ONE for Health compared to other local development government units (LGUs), resulting to the (F1), which promoted inter-LGU planning; concerns. Also, short term limits and fragmentation of a previously integrated and Kalusugan Pangkalahatan/Universal constant changes in administration can network of public health facilities, Health Care (KP/UHC), which increased affect the continuity of certain health personnel, and budget. the role of the national government in programs. health service delivery and financing. Reducing variations in access and Public investments to build health Population growth. Health infrastructure quality of care. The fragmentation of service delivery capacity. A package such as health facilities, diagnostic health service delivery has resulted to a of policy reforms has been proposed, equipment, and the number of clinically large variation in the range of available which is primarily hinged on making competent staff members generally have services and, where services are public investments to build health service a hard time keeping pace with population available, to a large variation in the quality delivery capacity based on the condition of growth. of care owing to the differing clinical sustained delivery of quality clinical care. competence of health providers. Consolidating public finances to Consolidating existing public financing The fragmentation of health budgets. secure the needs of the poor. Over the sources for the medium term. Existing There are enough public funds for health past 25 years, out-of-pocket payments public financing resources and subsidies care; however, public usage of such funds remained the major source of financing need to be consolidated, reallocated, and have been rendered ineffective due to the for the health expenditures of the poor. targeted in a way that would allow poor fragmentation of local and national health The contribution of organized public families to have better access to quality budgets, of which the DOH has the largest and private financing sources, such care, whether publicly or allocation. As such, the DOH also needs as PhilHealth and health maintenance privately provided. to improve its capacity to effectively utilize organizations (HMOs), have remained its budget. relatively small in part due to the fragmentation of health budgets. Reducing fragmentation and expanding Introducing legislation and using Renationalization and federalism. capacity to implement reforms. The public financing to contract service There are a number of issues regarding devolution of health care delivery to the delivery networks (SDNs). There is the renationalization of health care local government units (LGUs) weakened a need to introduce legislation that will delivery. Also, the Duterte administration’s the ability of the public health care delivery amend the Local Government Code discussions about shifting to a federal and financing system to secure access to (LGC) of 1992 to consolidate SDNs, and form of government raises questions on quality of care for poor Filipinos. to use public financing, such as through how best to transfer public health services PhilHealth, to contract SDNs rather than and financing to federal states. individual service providers. Pooling public financing. The challenge is how to pool the DOH budget, PHilHealth premiums, local government budgets, and state lotteries into a single fund that can be used to contract SDNs, and to also develop viable alternatives in places where SDNs cannot be contracted.

xiv Part II of this Report discusses specific health problems to examine how the structural weaknesses identified in Part I manifest themselves in preventing greater health sector performance in spite of numerous reform initiatives.

Eight specific health problems are chosen to represent a broad set of health concerns that affect Filipinos. Each of these problems actually represent a class of diseases and conditions. For example, maternal and neonatal mortality represents a broad set of problems around reproductive health. TB represents the class of infectious diseases that has persisted. Cardiovascular diseases represents a broader class of non-communicable diseases whose burden on the population has been rapidly increasing. Selecting these health concerns does not mean that other concerns that account for large disease burdens, such as child health and mental health, are less important and are not affected by the fundamental weaknesses of the health sector.

These specific health problems are: 1. Maternal and neonatal mortality; 2. Tuberculosis; 3. Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS); 4. Non-communicable diseases (NCDs); 5. Emerging and re-emerging infectious diseases (EREIDs); 6. Vaccine-preventable diseases (VPDs); and 7. Injuries and disasters.

A summary of the identified problems, proposed solutions, and challenges foreseen are detailed in the table below:

Part II: Fundamental Problems and Strategic Responses to Specific Health Problems Problems Identified Solutions Proposed Challenges Foreseen Improving maternal and neonatal Ensuring a continuum of care based There remains concerns about the health. Maternal and neonatal deaths on new technologies. The preventable capability of LGUs to invest in new and have not declined over the last 25 years, causes of maternal and neonatal death improved facilities, and to provide for the even though the main causes of deaths can be addressed by a continuum of care cost and manpower needed to operate are preventable. that represents a doctor/hospital-based these facilities. technology rather than the midwife/birthing facility-based technology that is currently available in the public health system. Controlling TB prevalence. Several Intensifying TB control efforts in The fragmentation of health service studies have reported a steady decline high-burden areas, such as urban poor delivery and financing owing to in TB prevalence over the past 25 communities. There has been a shift devolution prevents LGUs from years. However, the projected decline in of the TB burden towards urban areas. effectively controlling the spread of prevalence seems to be inconsistent with This intensified approach will require TB. Infected cases are highly mobile the high number of missed cases and the customized application of active and move across different jurisdictions. reported deaths. case finding approaches, the use of new However, resources such as manpower, diagnostic technology, and measures drugs, and equipment cannot be readily to ensure adequate case holding of TB shared across LGUs. cases.

Amending the Comprehensive TB Elimination Plan Act of 2016. The law specifically needs to mandate an intensified TB control effort in urban poor communities.

xv HIV and AIDS prevention and Adopting a programmatic approach to In addition to lack of information and control. The prevalence of human HIV and AIDS prevention and control restrictive legal provisions, the role of immunodeficiency virus (HIV) infection by implementing interventions directed LGUs in implementing a programmatic that causes acquired immunodeficiency at specific populations. Through the approach to HIV and AIDS prevention and syndrome (AIDS) remained low in the education system, the provision of HIV control needs to be re-examined owing to general population over the last 25 years, information and the promotion of condom differences in capacities in LGUs, highly but is increasing among key populations. use can reduce risky sexual behavior mobile key populations, and the need for among the youth. Providing cost-effective scale in delivering information. interventions, in turn, can prevent transmission and ensure continuity in the HIV treatment cascade among key populations. Reducing mortality and morbidity from Adopting a set of cost-effective The capacity to finance and deliver non-communicable diseases (NCDs). interventions focused on a smaller health services like those recommended Non-communicable diseases (NCDs) are package of interventions recommended in the Philippine Package of Essential now the leading causes of mortality and by the Copenhagen Consensus, with the Non-communicable Disease Interventions morbidity in the Philippines. About half of addition of intensive care and surgical (Phil PEN), vary across LGUs owing to deaths from NCDs are due to diseases management. These recommendations differences in priorities and capacities. of the heart and of the vascular system, are considered appropriate for middle- collectively known as cardiovascular income countries like the Philippines. diseases (CVDs). Threats from emerging and re- Investing in capacity to respond to Difficulties in coordinating investments emerging infectious diseases (EREIDs). threats. To mount an effective response from national and local governments Emerging and re-emerging infectious to EREIDs, there is a need to invest needed to build capacitites to respond diseases (EREIDs) are infections that in the following: a network of frontline to EREIDs. are “newly recognized, newly evolved, providers that can detect threats and or occurred previously but have shown deliver the appropriate response once an increase in incidence or expansion such threats have been identified; an of geographical, vector, or host range” effective surveillance system that is able (WHO, 2014). While the Philippines has to capture and analyze information coming yet to experience a widespread epidemic from the frontline; the scientific capacity to from more recent emerging infections, understand the nature of the disease; and the question remains as to whether the a network of specialists who can provide country can cope with a higher number of definitive care for EREIDs. cases that emerge either from within or from outside the country. Reducing the burden of vaccine- Strengthening the process of Problems with the DOH’s central preventable diseases (VPDs). An accountability. While the DOH is procurement and logistics system, and effective immunization program is ultimately accountable for the overall the large variation in the ability of LGUs expected to show high coverage rates performance of the vaccination program, to routinely administer vaccines (i.e., in the high 90s). But available it does not have the necessary sanctions data suggests that current levels of nor incentives to influence individual performance are way below standards. LGU performance. The law, Republic Act (RA) No. 10152 or “An Act Providing for Mandatory Basic Immunization Services for Infants and Children,” might have to be revised to introduce the appropriate “carrots and sticks.” Reducing deaths and injuries from Investing in inter-jurisdictional In a highly devolved setting, the cost accidents and disasters. These emergency services for injuries and of coordinating these overlapping but are two related problems that can be disasters. For both injuries from accidents ladderized authorities warrants the addressed with the proper assignment and disasters, the key recommendation is creation of a special body and funding and enforcement of accountability, as to review and amend existing mandates mechanism to manage disaster response. accidents and disasters often traverse so that it assigns accountabilities. local jurisdictions. For example, in the Moreover, it should provide for command case of a major disaster like Typhoon and control authority with the appropriate Haiyan, where the disaster affected more financial support. than one region, a national authority should have been assigned and made accountable.

xvi The Report also adopted a long-run perspective to allow for a better appreciation of how long-running fundamental structural weaknesses may prevent health care reforms from achieving their full impact on national health outcomes. By taking this long-term view, the Report argues that the health care reforms were essentially attempts to mitigate the potential adverse impacts of the devolution on the capacity of the public health care delivery system to protect and improve the health status of poor families. Through this long-term hindsight and analysis spanning 25 years, the Report hopes to contribute to new strategies that will address the fundamental weaknesses of the country’s health sector.

xvii

OVERVIEW

This Health Sector Review (HSR), initiated by the Health Policy Development Program (HPDP), assesses the long-term impact on health outcomes of health sector reforms that have been implemented in the Philippines over past 25 years. This Report focuses on how the health sector, particularly the delivery and financing of health services, has affected health outcomes, especially that of the poor. While this Report focuses on the health sector, it also recognizes that a broader set of economic and social policies and programs implemented by various non-health agencies are needed to influence health outcomes.

This Report adopted a long-run perspective to allow for a better appreciation of how long-running fundamental structural weaknesses might have prevented health care reforms to achieve their full impact on health outcomes. By taking a long-term view, the Report points out that the reforms were essentially attempts to mitigate the unintended adverse impacts of the devolution of health service delivery to the local government units (LGUs) on the capacity of the public health care delivery system to protect and improve the health status of poor families. With the benefit of long-term hindsight and analysis, the Report hopes to contribute to new strategies that address the fundamental weaknesses of the country’s health sector.

In the preparation of this Report, primary and secondary data were analyzed, scientific literature and program reports reviewed, and experts consulted. Portions of the preliminary version were presented at various fora to gather feedback. Finally, a draft Report was reviewed by local and international experts. Comments and suggestions were considered in the finalization of this Report.

1. The policy challenge of improving health outcomes of the poor. This section describes the progress in improving health outcomes in the Philippines over the past 25 years relative to its achievement of the Millennium Development Goals (MDGs) compared to neighboring countries. In addition, progress in the social determinants of health as measured by the MDGs, which include poverty reduction and health care utilization indicators, are examined.

2. Managing a highly decentralized health delivery and financing system. This section describes the unintended consequences of fragmentation on public health sector performance, which included the weakening of the implementation of national health programs due to the high transactions costs of engaging individual and autonomous LGUs; the reduction of the effectiveness of the public health delivery system as a regulatory instrument; and the widening of the variation in access and quality of public health care. This section also describes the two nationwide system-level reform initiatives implemented as responses to the fragmentation.

3. Reducing variations in access and quality of care. This section describes how weaknesses and gaps in the way health services are delivered contribute to poor health outcomes. The discussion focuses on two particular factors, namely: large variations in the range of available services and their accessibility, and, where services are available, there is large variation in the quality of care. In this section, key elements of access and quality, which contribute to poor health outcomes, are examined.

xix 4. Consolidating public finance to secure the needs of the poor. Using data from the National Health Accounts (NHA), the section describes the growth of per capita real health care expenditures over the past 25 years. It also describes the growth of per capita real expenditures of the different sources of financing, namely: the national government; local government units; social health insurance; private health insurance and health maintenance organizations (HMOs); and household out-of-pocket payments. Finally, this section analyzes beneficiaries of health spending.

5. Reducing fragmentation and expanding capacity to implement reforms. This section discusses suggested approaches to address the fragmentation of the public health system brought about by the devolution. Also, briefly discussed is the implication for health of a move to adopt a federal form of government. In addition to discussing approaches to address fragmentation, this section also describes approaches to build up the communities of health sector managers and health scientists.

Part I ends with a discussion of the underlying and fundamental problems that have prevented reform initiatives to address the above challenges to produce greater health outcomes.

Part II of the Report discusses specific health problems to examine how the structural weaknesses identified in Part I manifest themselves in preventing greater health sector performance in spite of numerous reform initiatives. Eight specific health problems are chosen to represent a broad set of health concerns that affect Filipinos. It should be noted that selecting these health concerns does not mean that other concerns that account for large disease burdens, such as child health and mental health, are less important and are not affected by the fundamental weaknesses of the health sector. These specific health problems are:

1. Maternal and neonatal mortality represent problems faced by families, reproductive issues being fundamental;

2. Reproductive issues, being fundamental, also require the Report to look at sexually transmitted diseases (STDs). Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are chosen to represent this class of diseases;

3. Tuberculosis not only represents the class of infectious diseases but is also one of those that has persisted for the longest time;

4. Non-communicable diseases (NCDs), specifically cardio-vascular diseases (CVDs), are discussed to represent that other class of diseases whose burden on the population have been rapidly increasing;

5. Injuries, specifically from road crashes, are also considered because its burden is also rapidly increasing;

6. Emerging and re-emerging infectious diseases (EREIDs) represent a class of infectious diseases that pose a continuous threat to the population, but whose nature, effects, and mitigating measures are hardly known and understood;

7. Vaccine-preventable diseases (VPDs) are included to address why disease outbreaks of measles and diphtheria persist despite the existence of cheap, cost-effective vaccines; and

8. Disasters and emergencies are discussed as a vulnerability that cannot be avoided, but the immediate health effects of which have to be addressed.

xx PART I: CHALLENGES, FUNDAMENTAL WEAKNESSES, AND STRATEGIC RESPONSES

The Challenge of Improving Health Outcomes of the Poor

Managing a Highly Decentralized Health Delivery and Financing System

Reducing Variations in Access and Quality of Care to Improve Health Outcomes

Consolidating Public Finances to Secure the Needs of the Poor

Reducing Fragmentation and Expanding Capacity to Implement Reforms 2 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

1. THE CHALLENGE OF IMPROVING HEALTH OUTCOMES OF THE POOR

This Report assesses the long-term impact on health outcomes of health sector reforms that have been implemented in the Philippines over the past 25 years. It is recognized that a broader set of economic and social policies and programs implemented by various non-health agencies are needed to influence health outcomes. However, this Report focuses on how the health sector, particularly the delivery and financing of health services, has affected health outcomes, especially that of the poor.

The Report is neither a historical account of reform initiatives nor does it focus on the champions of specific reform initiatives. It is also not a descriptive account of all the problems affecting the health sector. Rather, it offers an analysis of how the devolution of health services to local government units (LGUs) reduced the effectiveness of the public health care delivery system to provide access to a continuum of health services to address the needs of poor Filipinos. The establishment of the public health care delivery system must be recognized as a policy intervention to address the failure of privately-provided services to meet the needs of families with very limited abilities to pay for healthcare. Moreover, the public health care delivery system was set up as a network of facilities and providers from rural health centers, provincial hospitals, and regional medical centers that would not only provide various levels of care but also guide families as they access the continuum of care. The analysis here focuses on how the effectiveness of such a network survived the devolution of health services in 1992.

The long-run perspective adopted by the Report allows for a better appreciation of how long-running fundamental structural weaknesses may seem to have prevented health care reforms to achieve their full impact on health outcomes. By taking a long-term view, the Report points out that the reforms were essentially attempts to mitigate the unintended adverse impacts of the devolution on the capacity of the public health care delivery system to protect and improve the health status of poor families. With the benefit of long-term hindsight and analysis, the Report hopes to contribute to new strategies that address fundamental weaknesses.

Progress in Improving Health Outcomes Has Been Relatively Slow During the Past 25 Years

Progress in improving health outcomes in the Philippines over the past 25 years has been relatively slow compared either to neighboring countries in the region such as Thailand, Malaysia, Indonesia, and Vietnam, or to meeting the nation’s Millennium Development Goals (MDG) targets.

In the 1960’s, the Philippines ranked third highest among Indonesia, Vietnam, Malaysia, and Thailand in terms of life expectancy as shown in Figure 1.1. But while the life expectancy of Filipinos continued to increase, this secular trend is really an underachievement given what other countries have accomplished. This means that the life expectancy of Filipinos increased at a rate much slower than that of other countries. Moreover, the rate of increase of the life expectancy of Filipinos seem to have tapered off beginning 1999. Hence, by 2015, the Philippines has posted a life expectancy that is even lower than that of Indonesia.

Figure 1.1 Life Expectancy at Birth, Both Sexes 80

45 1 5 9 9 1 967 973 975 977 993 007 015 196 1963 196 1 1969 1971 1 1 1 197 1981 1983 1985 1987 1989 1991 1 1995 1997 199 200 2003 2005 2 2009 2011 2013 2

Indonesia Malaysia Philippines Vietnam Thailand

Source: : Countryeconomy.com, 2017

With respect to maternal mortality ratio (MMR), the MDG goal was to cut the 1990 MMR of 209 per 100,000 live births to 52 per 100,000 live births by 2015 (PSA, MDG Watch, 2015). However, by 2015, various sources of data on maternal deaths, which include the civil registry and population surveys using the sisterhood method, suggest that MMR has not changed. Because population-based surveys using the sisterhood method are not conducted regularly, we show in Figure 1.2 the long-term trend of MMR using data compiled by United Nations (UN) agencies based on adjusted civil registry data. To highlight the progress made by the Philippines, we compare it with the cases of Vietnam and Indonesia. Vietnam faced a similar challenge by having the same starting point, and was able to meet its MDG target by 2015. Indonesia, on the other hand, started with MMR three times higher than that of the Philippines and managed to reduce its MMR close to that for the Philippines in 2015. A fuller discussion on factors affecting the progress in reducing maternal mortality is provided in Section 6 of this Report, which is on maternal and neonatal health.

Looking at the progress in achieving other maternal and child care and related MDG targets, the data show that while MDG targets for infant and child mortality were barely achieved (PSA, MDG Watch, 2015), the progress has been slower in comparison with other countries in the region that had initially higher rates (United Nations, 2015). The nutritional status of children under five, measured as the prevalence of children under fivewho are underweight, has not significantly changed over the MDG period. Although not part of the MDG, fertility, as a factor in maternal and child health, has declined slowly compared to other countries in the region (United Nations, 2015).

The death rate from TB has also declined slowly, from 39 per 100,000 in 1990 to 24 per 100,000 in 2013 (PSA, MDG Watch, 2015). However, the targets for case detection rates and cure rates under directly observed treatment, short-course (TB-DOTS) have been achieved from 2001 to 2014. That program targets are achieved but death rates declined slowly, especially since 2007, suggests that there are still a large number of missed cases. Data on TB death rates are shown in Section 7.

4 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 1.2 Maternal Mortality Ratio (Per 100,000 Live Births)

500

450

400

350

300

250

200

150

100

0 1990 1995 2000 2005 2010 2015

Indonesia Philippines Thailand

Vietnam Malaysia

Source: WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division (2015)

Table 1.1 MDG Health Indicators Baseline Target Latest* Maternal mortality ratio 209.0 52.0 204.0 1990 2015 Under-five mortality rate 80.0 27.0 26.0 1990 2015 Infant mortality rate 57.0 19.0 20.0 1990 2015 Prevalence of underweight children under 5 years of 26.5 13.1 21.5 age 1992 2015 Death rate associated with TB 39.1 24.0 1990 2013 Proportion of TB cases detected under DOTS 53.0 70.0 83.0 2001 2015 2014 Proportion of TB cases cured under DOTS 73.0 85.0 90.0 2001 2015 2014 Source: PSA, MDG Watch as of September 2015 *Data based on FNRI, National Nutrition Survey 2015 except for tuberculosis indicators

Death rates from non-communicable diseases (see Section 9) and injuries (see Section 12) have been increasing. Both non-communicable diseases, especially cardiovascular diseases, and injuries are now the leading causes of death.

5 The Burden on the Health Sector has Increased, Owing to Slow Progress in Poverty Reduction

The non-healthcare factors affecting health are factors such as smoking, alcohol, physical activity, diet, and nutrition; physical and social environment including water and sanitation, housing conditions, and infrastructure, transport, and urban design; conditions at the workplace that reduce hazards and stress; and social inequities, particularly income and wealth, and education (WHO, 2008).

That the health status of Filipinos has barely improved in the last 25 years may be attributed partly to the lack of progress in poverty reduction. We show this by examining various MDG poverty indicators, as shown in Table 1.2. It is shown that the MDG target set in 1991 for poverty reduction was not achieved. The proportion of population below the poverty threshold of 34 percent in 1991 declined only to 22 percent in 2015, missing the target by as much as five percentage points (PSA, MDG Watch, 2015). Because of population growth, the actual numbers of families and individuals who remained poor increased between 1991 and 2015. In 1991, 3.6 million families and 21.7 million individuals were poor. In 2015, the corresponding numbers are 3.8 million and 22.6 million, respectively (PSA, 2017).1

Table 1.2 MDG Poverty and Poverty-related Indicators Baseline Target Latest* Proportion of population below national poverty 34.4 17.2 21.6 threshold 1991 2015 Percent of household with per capita energy less than 74.2 37.1 65.2 100 percent adequacy 1993 2015 Proportion of pupils starting grade 1 who reach grade 69.7 100.0 80.6 6 (cohort survival rate) 1990 2013 Proportion of families with access to safe water supply 73.0 86.5 85.5 1990 2014 Proportion of families with sanitary toilet facility 67.6 83.8 94.1 1990 2014

Source: PSA, MDG Watch as of September 2015

Other non-healthcare social determinants related to poverty such as nutrition and hunger and education have not fared well either. In nutrition and hunger, the percent of households with per capita energy less than 100 percent adequacy was 74 percent in 1993 and declined to 65 percent in 2013. The MDG target for 2015 was 37 percent. This means that only a third of Filipinos have adequate nutrition. Moreover, data from the National Nutrition Survey (NNS) reveal that, in 2013, the poorest quintile are the most food insecure (FNRI, 2015).2

Families belonging to the lowest quintile spend up to 70 percent of their income on food, and yet they continue to face food insecurity. The food expenditure pattern among Filipinos is shown in Table 1.3. It is alarming that the essentially rice-based diet of Filipinos puts them at risk for hypertension and diabetes. Rice is typically consumed with other high salt and high sugar foods. For table salt alone, the average Filipino already consumes five grams

1 Overall population growth remained high, declining only slowly since 1990. The average annual intercensal growth rate from 1990-2000 of 2.3 percent declined to only 1.9 percent in the period 2000-2010, and to 1.7 percent in the period 2010-2015 (PSA, 2016b). The population growth among the poor is expected to be much higher, as inferred from their total fertility rate, which in 2013 averaged five births per woman compared to the national average of three per woman (NDHS, 2013). 2 The FNRI in its 8th National Nutrition Survey gathered data on food security based on nine access indicators and frequency of occurrence of these indicators. The results show that overall only 34 percent of families are classified as food secure. However, only 11 percent of the poorest quintile are classified as food secure compared to 72 percent for the richest (FNRI, 2015).

6 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance per day, or more than twice the maximum suggested daily intake.3 In the case of sugar, nearly half of the suggested daily intake4, or roughly 20 grams per day (PSA, 2013), is provided by confectionery sugar alone. This pattern of salt and sugar consumption is observed for all income groups, implying that the poor are equally at risk.

Table 1.3 Food Expense and Consumption of Rice, Sugar, and Salt by Wealth Quintile Share of (in percent) Daily Per Capita Calories Per Capita Food on Total Rice on Food Rice Confectionery Grams Per Day Income Expenses sugar of Salt All 51.2 23.3 397.3 31.0 5.1 Poorest 64.8 33.8 340.1 29.8 4.9 Poor 58.6 28.6 396.0 25.4 5.2 Middle 52.8 23.1 402.3 29.4 4.9 Rich 45.6 18.2 425.8 27.2 4.9 Richest 34.1 12.8 422.0 43.1 5.3 Source: UPecon-HPDP calculations, 2012 FIES and 2013 Annual Poverty Indicator Survey (APIS)

The educational status of Filipinos, measured using such indicators as primary completion rate and cohort survival rate, have improved, but the actual levels remain low and failed to reach the MDG targets. The primary completion rate rose only from 64 percent in 1990 to 79 percent in 2013, still way below 100 percent target. The proportion of pupils starting Grade 1 who reached Grade 6 (cohort survival rate) rose only from 70 percent in 1990 to 81 percent in 2013, missing the MDG target by as much as 19 percentage points.

An important factor that affects health through multiple channels is the education of mothers. It is well-established that the education of mothers is an important determinant for children’s health (Desai & Alva, 1998; Becker, Peters, Gray, Gultiano, & Black, 1993). A good education, i.e., at least high school education, allows mothers to effectively access health information; understand basic sanitation, diet, and nutrition; detect early onset of illness; and know when and where to access appropriate care (LeVine & Rowe, 2009). Considering that only 63 percent of all Filipino mothers completed high school (PSA, 2014), public programs ensuring young women receive a high school education are expected to have large health dividends. It is, therefore, a great challenge to reach out to the poorest families, among whom only 27 percent of mothers complete high school.

Access to safe water among Filipino families improved from 73 percent in 1990 to 86 percent in 2014, just barely achieving its target of 87 percent. However, if a stricter standard for source of drinking water, i.e., pipe into dwelling and bottled water, is applied, the proportion of families having access to such facilities goes down to 57 percent (NDHS, 2013). For the poorest families, only 10 percent have access to water sources with higher safety standards.

The proportion of families with sanitary toilet facility rose from 68 percent in 1990 to 94 percent in 2014, exceeding the 2015 target of 84 percent. However, families with access to flush to piped sewer system, flush to septic tank, and flush to pit latrine only remain at 88 percent, but only half of the poorest families have access to similar facilities. Thus, by whatever standard used, it is always the poor who do not have access to water and sanitation facilities.

Another indicator that is important to health, but is not part of MDGs, is living space. The poor, especially those in highly urbanized cities, have limited living space. Based on the 2010 census, 38 percent of households lived in

3 The recommended daily intake of sodium is less than 2,000 mg (WHO, 2012). 4 The recommended daily intake of sugar is less than 10 percent of the total energy intake or roughly 50 grams, based on a 2,000 calories per day diet (WHO, 2015e).

7 homes with less than 20 square meters of floor area (PSA, 2010), and this group of households would have five members on average. These living conditions, living space, and access to safe water supply and sanitary toilets make the poor more vulnerable to TB, respiratory infections, and diarrhea, all of which are among the top five leading causes of morbidity (Ballesteros, 2010).

The Potential for the Health Sector to Improve Health Outcomes Remains Large

The channel through which healthcare affects health status is through the utilization of health services. Health utilization, in turn, is determined, for the most part, by how health services are delivered and financed. The extent to which Filipinos utilize essential health services may be best described in terms of the utilization of maternal and child health services, as shown in Table 1.4. These indicators are monitored as part of the MDGs, as these services are considered essential in preventing maternal and child deaths. It is shown that, for all indicators, the Philippines failed to achieve its MDG targets. Note that among these five services belonging to a continuum of care, the largest target versus accomplishment gap is in contraception and facility-based deliveries. As discussed in Section 6, access to more effective family planning methods, such as implants, and access to doctor-attended hospital-based delivery services have the largest potential in reducing maternal deaths.

Table 1.4 MDG Maternal and Child Health Care Utilization Indicators Baseline Target Latest* Antenatal care coverage (at least four visits) 52.1 90.0 84.3 1993 2013 Proportion of births attended by skilled health 58.5 90.0 72.8 personnel 1993 2013 Proportion of births delivered in health facilities** 28.2 90.0 61.1 1993 2013 Contraceptive prevalence rate (all methods) 40.0 65.0 55.1 1993 2013 Proportion of 1-year-olds children immunized against 77.9 95.0 83.9 measles 1993 2013

Source: PSA, MDG Watch as of September 2015, unless otherwise stated *Targets are based on DOH National Objectives for Health 2011-2016 **Not part of MDG indicators

Antenatal coverage (at least four visits) has increased from 52 percent in 1993 to 84 percent in 2013. However, data for 2013 reveal that only 62 percent of first antenatal visit was made during the first trimester (NDHS, 2013). Now that high utilization has been achieved, a key concern is the quality of antenatal care. A midwife doing routine antenatal care in a typical rural health unit (RHU) may not have the training and the equipment to diagnose life- threatening conditions such as gestational hypertension, pre-eclampsia, and eclampsia.

The proportion of births attended by skilled health personnel has increased from 59 in 1990 to 73 in 2013. However, progress has fallen short of the MDG target of 100 percent, as well as the DOH target of 90 percent as stated in the National Objectives for Health, 2011-2016 (DOH, 2011b). In 2013, the proportion among the poorest quintile was only 42 compared to 96 among the highest quintile.

Although not an MDG indicator, the percentage of births delivered in a health facility rose from 28 in 1993 to 61 in 2013. That maternal mortality ratio has remained unchanged over the period suggests that other factors are at

8 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance play, including delay in the management of complicated cases, which needs to be handled in hospitals, as will be discussed in Section 6. Note that, in 2013, the percentage is only 33 among the poorest quintile compared to 91 among the highest quintile.

Contraceptive prevalence rate for all methods increased from 40 percent in 1993 to 55 percent in 2013. In terms of modern methods, however, the increase was from 25 percent to 38 percent (NDHS, 1993 and 2013). Prevalence rate in other countries is much higher.

The percentage of one-year old children immunized against measles rose from 78 percent in 1990 to 84 percent in 2013, short of the target of 95 percent. Moreover, based on data from the National Demographic and Health Survey (NDHS), the percentage of one-year old children who were fully immunized (FIC) has remained low, from 72 percent in 1993 to 77 percent in 2013. This rate falls short of the 90 percent target of the DOH. In 2013, measles vaccination rate among the poorest quintile was 73 percent compared to 89 percent among the highest quintile.

That the Philippines has missed the MDG indicators for the utilization of essential health care suggests that the potential of the health sector to improve health outcomes remains large. Health care utilization reduces poverty or prevents families from becoming poor. Utilization of quality services reduces illness episodes, restores health stock, prevents early deaths, and improves productivity. Moreover, social insurance helps reduce the vulnerability of families to the financial burden of having to pay for essential health care. In a sense, the public delivery and financing services not only mitigate the effects of poverty on health care utilization but also contributes to poverty reduction.

In summary, while significant efforts have been introduced to reduce poverty, a considerable number of Filipino families remain poor. It is recognized that having a large population of poor Filipinos with inadequate incomes, unhealthy diets, poor living conditions, and low education is the major contributor to poor national health outcomes. In particular, poor families do not have the information, resources, and opportunities to access publicly and privately provided health services (Peters et al., 2008). The fundamental problems of the poor, therefore, should be addressed by a broader set of economic and social policies and programs to achieve inclusive and sustained growth in incomes, improved environmental and living conditions, and increased education. However, it is also recognized that poor health, owing to lack of access to quality care, could cause families to become more impoverished. Hence, this Report focuses on how the healthcare delivery and financing system is able to ensure access to the continuum of care needed by poor families. Of particular interest is the capacity and effectiveness of the public healthcare delivery system.

9 10 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

2. MANAGING A HIGHLY DECENTRALIZED HEALTH delIVERY AND FINANCING SYSTEM

The devolution of public health service delivery and financing had far-reaching unintended consequences on the performance of the health system. The devolution resulted in the fragmentation of service delivery and financing; weakened the implementation of the national programs due to high transactions costs of engaging individual and autonomous local government units (LGUs); reduced the effectiveness of the public health delivery system as a regulatory instrument; and widened the variation of access and quality of public and private health care. This wide variation, in turn, affected the capacity of the health system to influence health outcomes. Various health sector reforms were attempts to address the fragmentation emanating from devolution. However, outstanding issues remain.

Pre-Devolution Public Health Delivery and Financing System was Intended to Provide Services to the Poor

The establishment of a public health care delivery and financing system is a policy intervention to provide access to a large portion of the population that cannot be served by the fee-for-service private sector system. Widespread poverty and inequality left many families without the capacity and the willingness to pay for privately-provided medical care. Moreover, owing to lack of education, poverty also limits access to information about the nature of illnesses, how to prevent them, and how to access health care when needed. The public health care system addresses these by providing health information and by financing the cost of health services through direct public subsidies and social health insurance. In a sense, the public delivery and financing of services can be considered an intervention to alleviate poverty, since this intervention increases the consumption of health services by the poor.

In the pre-devolution era, the administration of the public health and financing system was centralized at the Department of Health (DOH). The DOH had command and control over public health facilities, health personnel, and the health budget. Drugs and supplies were centrally procured for the entire country, and were distributed to public health facilities through a national logistics system. A major feature of this system is that it offered open access to all users irrespective of income, so that no fees were charged at the point of care. The pre-devolution system was highly dependent on national government subsidies.

The typical public service delivery network that operated before the devolution is shown in Figure 2.1. At the frontline is the district health office, which manages a hospital; rural health units (RHUs), usually one per municipality; and barangay health stations (BHS). District health offices in a province report to a provincial health office. The provincial health offices, corresponding to provinces in the region, plus the regional and special hospitals, report to the regional health office, which, in turn, report to the DOH Central Office. Each unit exercised command and control over lower level units. Facilities at various levels, from the BHS all the way up to regional hospitals, operated as one referral system. This also implies that doctors, nurses, and other civil servants could be deployed anywhere in the system as needed.

11 Figure 2.1 Pre-Devolution Organizational Structure

DOH Central Office

Regional Health Office

Specialty Regional Provincial Hospital Hospital Health Office

District Health Office

Field Health Hospital Services

Rural Health Unit

Barangay Health Station

Source: DOH (2002)

Devolution Fragmented the Public Health Delivery and Financing System

The economic crisis in the mid-1980s created a large national budget deficit, which put into question the financial sustainability of an open-access public health care delivery system. Several solutions were recommended, including the introduction of user fees; the expansion of social health insurance coverage beyond the formal sector; encouraging non-government sector, such as private-for-profit and private non-profit institutions, to provide health services that consumers are willing to pay for; and decentralization (World Bank, 1987). Decentralization was considered an attractive compromise by letting LGUs finance devolved health services through local taxes and fees. Moreover, as in the case of the Philippines, decentralization “was not only a structural adjustment meant to arrest the deteriorating fiscal position of the national government, but more so a political move to insulate local government from the excesses of a strong central government” (Capuno & Solon, 1996).

In 1991, the Philippines embarked upon a major political reform through the enactment of the Local Government Code (LGC). This reform involved the devolution of a number of economic and social services, including the bulk of health services previously under the responsibility of the DOH. Under this reform, administrative and financial

12 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 2.2 Post-Devolution Organizational Structure

DOH Central Office

Regional DOH RETAINED Health Office

Regional Specialty Hospital Hospital

Provincial Health Office

independent provincial health systems District Health Office 81 provinces

Field Health Hospital Services

Rural Health Office CITY & MUNICIPAL health systems

143 cities 1,498 municipalities Barangay Health Station

control over health facilities, personnel, and governance for health was transferred from the DOH to the provinces, cities, and municipalities. Governors and mayors independently financed and administered devolved health facilities and personnel.

The fragmentation of the public health care delivery system into independent provincial, city, and municipal systems back in 1992 is illustrated in Figure 2.2. The bottom boxes represent the independent 66 city and 1,540 municipal health systems that operated RHUs and BHSs. The middle boxes represent the 76 independent provincial health systems that include the provincial and district hospitals. As of December 2015, this configuration has since changed to 81 provinces, 143 cities, and 1,489 municipalities. The creation of new cities is partly driven by the fact that the share of cities of national tax revenues is larger relative to devolved functions. The top-most boxes, representing regional offices and hospitals, were retained under the DOH.

13 The devolution that devolved about 39 percent of the health budget and 61 percent of health personnel by 1994 was seen as a political reform that conferred several advantages. This included better information about the preferences of the local population and, therefore, better matching of resources with local needs. It was also seen to engender greater accountability from the LGUs and greater local participation in collective decision-making (Diokno, 2003; Lakshminarayanan, 2003).

However, in the case of health services, concerns were raised on whether the devolution would indeed promote a more efficient and equitable allocation of resources and, thereby, generate greater health improvements than what could be realized under a centralized regime. Such concerns were based on problems arising from the way the devolution was designed, namely: 1) the inadequate funding of devolved health services; 2) the weakened linkages between the DOH and the LGUs, and among the LGUs themselves; 3) the uneven capacities of the LGUs to plan and manage the local health system; and 4) the limited ability of the DOH to reorganize itself to support LGUs in carrying out their devolved functions (Rama, 2003).

Fragmentation Hampered Improvements in Health Performance

Key to achieving national targets under a devolved set-up is the capacity of the entire system to implement health programs at scale. This requires coordinated efforts among the LGUs with the same energy and commitment. However, such coordinated efforts are not easy to achieve under a devolved set-up, seriously compromising the achievement of national targets. First, decision-making has now been devolved to local authorities. They can adopt their own health priorities and have wide discretion on how their Internal Revenue Allotment (IRA) shares can be spent (Capuno & Solon, 1996; Rama, 2003). In this case, health may not always be a top priority since health competes with other local development concerns that vary among LGUs. Moreover, even if health is a priority, LGUs may prefer certain health programs and withhold funding from others that are given lower priority or considered politically risky (e.g., family planning).5 Second, with short term limits, there is a tendency for local authorities to focus on short-term programs rather than long-term investments, particularly in upgrading health facilities. Moreover, constant changes in local administration can affect the continuity of certain programs whose national impact require a longer concerted implementation period.

Fragmentation contributed to a number of unfavorable consequences on the delivery of public health services that included weakened supervision systems; weakened health system information for local and national policy-making; and loss of career path for doctors and health workers. In addition, devolution altered the incentive structure faced by the LGUs in interacting with one another (Capuno & Solon, 1996). Factors such as spill-over effects (e.g., cross-border use of local health facilities) and the spatial bias of retained hospitals (i.e., facilities such as regional hospitals, which are still under the DOH after the devolution) also influenced the provision and financing of local health services.

The change in political and administrative control brought about by the devolution broke the chain of supervision among the different levels of health care. As described by Taguiwalo (1993): “1) the Barangay Health Station (BHS), which is staffed by a midwife, continues to work under the supervision of the RHU physician and public health nurse based in the RHU, but the RHU is no longer supervised by the district hospital nor by the provincial health office; both the BHS and the RHU now become entirely part of the operations ofthe municipal government; 2) the city health department, including its component health centers, no longer report to the regional health office; they are now part of the city government and report directly to the citymayor;

5 With the gradual phase-out of externally donated contraceptives beginning 2004, the DOH adopted a strategy for an orderly distribution of remaining donated contraceptives to the LGUs and, at the same time, provided technical assistance to enable the LGUs to provide adequate contraceptive supplies to meet current and future users of modern methods. The strategy, referred to as the Contraceptive Self-Reliance (CSR) Strategy, is contained in DOH Administrative Order (AO) No. 158 s. 2004. An assessment of the LGU response to the phase-out showed that some LGUs were able to procure to compensate previously donated contraceptives, others procured but less than what was previously donated, while others did not procure at all (Cabigon, 2009).

14 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

3) the regional health offices of the DOH, which used to direct and administer all the provincial, city, district, and municipal health offices, have been changed to become regional field offices (RFOs), providing technical and logistical support to the devolved health units. Only the regional hospitals and medical centers remain under the direct supervision of the DOH.”

The lack of administrative control of the DOH meant that activities that required coordination among the different localities are difficult to undertake as a matter of routine. One such activity is the collection, aggregation, and transmission for program and policy analysis using the standard indicators of the utilization and coverage of different health services. After devolution, the collection and transmission of such information from the lowest level up to the DOH Central Office for consolidation and analysis were disrupted. Health personnel from lower- level facilities could not be compelled to submit reports that were previously routinely submitted to the DOH. This situation created gaps in health service data that made it difficult to get a nationally representative picture of the overall performance of different levels of health care.

Doctors and other health staff were locked into the LGUs where they were assigned. LGU doctors could no longer be automatically deployed to respond to the increased demand in other jurisdictions. Being locked into the LGUs also cut short their career paths to provincial, regional, and central positions. In the short run, this caused demoralization among the devolved workers, which, in turn, adversely affected the quality and effectiveness of service delivery (Rama, 2003). In the long run, it could reduce the ability of the LGUs to attract and retain young doctors.

With fragmentation, local health plans did not have to take into account natural and technical interactions among neighboring LGUs such as the cross-border use of local health facilities and the spatial bias of retained hospitals. Underinvestment in an LGU’s own facilities is expected if residents have access to health services provided by neighboring LGUs. In turn, localities at the receiving end of free-riding may be unable to expand their own capacity in order to accommodate cross-border users. The presence of DOH facilities could also lead to underinvestment. In particular, revenue-rich cities are able to spend less than their share in providing health care to their constituents because of the presence of DOH facilities.

With fragmentation, local health budgets, now independently determined by individual municipalities, cities, and provinces, do not typically include budgets for referrals, inter-jurisdictional health concerns, and complementarities. Local budgets, mainly financed by the LGU share of national revenues (IRA) on the basis of population size, land area, and an equity factor, have become less dependent on local taxes and revenues. Varying capacities to generate local taxes and revenues from enterprises due to differences in levels of development, managerial capacity, and political will eventually led to underspending in health.

What attracted the most attention in discussions on financing is that, while transfers to LGUs through the IRA were more than enough to support devolved functions, the LGUs continued to underspend for health. With devolution, the LGU share of national revenues increased from 20 percent to 40 percent. Such transfers were essentially implemented as unconditioned block grants. In effect, LGUs were able to freely allocate their IRA among competing local projects.

One explanation for underspending in health is the so-called mismatch between the IRA and the cost of devolved functions at the individual LGU level. The IRA was divided up among LGUs in two steps. First, the total IRA was cut up into four portions: 23 percent to provinces, 23 percent to cities, 34 percent to municipalities, and 20 percent to barangays. Second, within each portion, the individual LGU shares were determined using the following weights: 50 percent to population, 25 percent to land area, and 25 percent to equal sharing part. In contrast, the cost of devolved health functions was distributed as follows: 59.7 percent went to provinces; 37.7 percent went to municipalities; and 2.6 percent went to cities. Notice that while provinces had to support 60 percent of the cost of

15 devolved functions comprising mainly of hospitals, it only received 23 percent of the IRA. Meanwhile, cities which did not have any devolved health facilities got 23 percent of the IRA. As mentioned earlier, this led to the conversion of municipalities into cities, mainly via legislation.

Fragmentation raised the transactions costs of implementing the National Health Insurance Program (NHIP). In 1995, the National Health Insurance Act (NHIA) expanded social health insurance beyond the formal sector. The social health insurance was financed from premiums collected through payroll tax for the formal sector, individual premium contributions for individually paying members, and subsidies from national and local governments for indigents. Due to the differing local financing capacities and priorities of the LGUs, it was difficult to collect the LGU share of premium subsidies. Hence, enrollment of indigents varied across LGUs. LGUs had differing methods of identifying the poor. LGUs also varied in their priority to provide membership services and in accrediting their facilities, thereby affecting delivery of health insurance benefits to the poor. The high transactions costs of engaging LGUs made it harder to reach universal coverage.

Fragmentation also reduced the effectiveness of direct service delivery and bulk procurement as regulatory instruments. Reduced investments and the lack of upkeep among devolved hospitals reduced its ability to exert competitive pressure on private hospitals. Since LGUs independently determined and executed their own budgets, the government lost its power to leverage for quality and performance through bulk procurement.

Health Reforms were Initiated in Response to Fragmentation

An early response of the DOH to the mismatch between the IRA and the cost of devolved function was the introduction of the Comprehensive Health Care Agreement (CHCA) in 1993. With the CHCA, the DOH sought to ensure that the LGUs continued to provide basic health services at least at the same level before the devolution. Additional resources were provided through the CHCA to allow LGUs to implement national programs in exchange for LGU commitment to set aside an adequate portion of its IRA to fully support the cost of devolved health personnel and services.

A review of the CHCA revealed problems of implementation that led to its limited success. These problems included those that are related to fragmentation and to the management capacity of the DOH. Fragmentation made it difficult for the DOH to negotiate with all the LGUs within the province. Central government-LGU negotiations were conducted only at the province and city level, leaving out equally autonomous municipalities in the agreement. Moreover, it was difficult to sustain the effort since the LGUs can renege on their commitments without sanctions. The other problems are related to the capacity of the DOH. One was the difficulty of effectively monitoring its own commitments since financial resources were managed by different program offices within the DOH. Another was that the DOH cost-share did not vary with the income class of the province, and thus did not discriminate between rich and poor LGUs (Esguerra, 1996).

Almost 10 years after the implementation of the LGC in 1991, the DOH, in its analysis of the health sector towards the formulation of a health sector reform agenda, identified four major problems confronting the delivery and financing of health services (DOH HSRA, 1999). First, the access to and quality of publicly-provided health services varied widely across LGUs and by type of facility. Second, most LGUs failed to upgrade or even maintain devolved facilities. In some areas, devolved health workers were unable to receive mandated benefits. Third, technical coordination across levels of the previously centralized system was lacking under the devolved set-up. Whatever technical coordination that remained was driven by relations among health professionals. Moreover, the DOH lacked the capacity to lead and coordinate inter-local government health programs and activities. Fourth, the progress of building up PhilHealth into a social health insurance program, as mandated by the National Health Insurance Program (NHIP) Law of 1995, was slow. As indicated earlier, the law required that the premium subsidy for indigents be shared between the national government and the LGUs. The different LGU capacities to finance their share of the subsidy slowed down the enrollment of indigents. On the whole, the health sector was largely financed by out-of-pocket spending.

16 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Two nationwide system-level reform initiatives were implemented to address these problems. The first was a whole set of initiatives and innovations directed at addressing financial and service delivery fragmentation by promoting inter-LGU planning incentivized by centrally provided grants. This is essentially the DOH FOURmula ONE for Health (F1). Spelled out in the DOH AO No. 2005-0023 as the implementation framework of health sector reforms, the framework called for the implementation of critical health interventions as a single package, backed by effective management infrastructure and financing arrangements. These interventions are in the four areas of service delivery, financing, regulation, and governance at both local and national levels.

Specific activities under FOURmula ONE for Health (F1) included technical assistance to the LGUs to establish Inter-Local Health Zones (ILHZs) based on DOH AO No. 2006-0017 (Incentive Schemes Framework for Enhancing Inter-LGU Coordination in Health through Inter-Local Health Zones), and the promotion of inter-LGU planning through the development of the Province-wide Investment Plan for Health (PIPH) as the vehicle for determining the allocation of the DOH and donor financial support based on DOH AO No. 2007-0034 (Guidelines in the Development of the Province-wide Investment Plan for Health). The DOH also established central level grants as performance incentives, particularly in the area of maternal, neonatal, and child health and nutrition (MNCHN). Under the MNCHN grant facility, LGUs are expected to augment their regular local activities to make available a network of public and private providers to deliver the MNCHN package; secure supply of essential supplies of family planning and other MNCHN commodities; and undertake localized behavior change communication campaigns directed at improving MNCHN outcomes as part of the MNCHN strategy.6 In social insurance, LGU enrollment of indigents was encouraged by having tiered premium shares favoring poorer LGUs (PhilHealth Circular, 2000) that received capitation payments exceeding their actual premium remittances. While the outputs of these reforms were noted in the Annual DOH Reports, overall, the high transactions costs of engaging individual LGUs, especially the municipalities, either directly or through the provincial government, made it difficult to sustain these reform initiatives.

The second set of reforms recognized the enormous transaction costs involved in the approach proposed under FOURmula ONE for Health (F1). First, in order to accelerate the enrollment of indigents into PhilHealth, the full premium subsidy for the sponsored program was paid by the national government as provided for in the amended NHIA of 2013 (RA No. 7875, as emended by RA No. 10606). The beneficiaries of the sponsored program were identified using the National Household Targeting System (NHTS) of the Department of Social Welfare and Development (DSWD). The premium subsidy was financed mainly from the revenues earmarked for health collected from the expanded excise taxes on tobacco and alcohol (RA No. 10351 of 2012). This reform addressed two issues arising from fragmentation, namely: 1) the variation in the identification of indigents among the LGUs, and 2) the variation in LGU capacity to provide their share of the premium subsidy. This reform led to a rapid increase in enrollment of indigents equivalent to the number of poor households enumerated under the NHTS.

Second, to address investment gaps among local health facilities, the DOH created a centrally financed and managed fund under the Health Facilities Enhancement Program (HFEP). From 2010 to 2014, the HFEP supported the upgrading of more than 800 hospitals, close to 3,500 RHUs, and more than 2,500 barangay health stations (Picazo, et al., 2015)

Third, the DOH augmented local health inputs of personnel and commodities. To augment local health staff, the DOH deployed centrally contracted doctors, nurses, midwives, dentists, and medical technologists. The DOH also centrally procured previously local commodities like TB drugs, family planning (FP) commodities, selected maintenance drugs, antibiotics, and herbal medicines.

6 DOH AO 2008-0029: Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality; DOH, 2011c: MNCHN Strategy, Manual of Operation.

17 Fourth, the passage of the Responsible Parenthood and Reproductive Health (RPRH) program provided a fresh mandate to centrally finance and deliver family planning services (RA No. 10354 of 2012). The new law mandated the national government “to provide additional and necessary funding and other necessary assistance” to a number of LGU activities including: 1) hiring of skilled health professionals for maternal health care and skilled birth attendance; 2) establishment or upgrading of hospitals and facilities with adequate and quality personnel, equipment, and supplies to be able to provide obstetric and newborn care; and 3) procurement and distribution of family planning supplies.

In the last five years, this reform package has led to a significant increase DOH spending on priority national health programs. This package, popularly known as Kalusugan Pangkalahatan (KP), is provided in DOH AO No. 2010- 0036 - The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos (DOH, 2010) and in DOH DO No. 2011-0188 - Kalusugan Pangkalahatan Execution Plan and Implementation Arrangements (DOH, 2011a). The KP reforms managed to avoid large transactions costs of engaging LGUs by using centrally procured goods and services financed by “sin taxes” in the implementation of reforms.

That health outcomes have not deteriorated, and even slightly improved, over the last 25 years suggests that these two sets of reforms may have mitigated the adverse impact of the fragmentation of service delivery and financing on health outcomes. However, the expected health improvements from these two reform packages have failed to fully materialize. It may be the case that the effects, especially of the efforts in the last five years, are lagged. It may also be that system-level changes need to work through various channels and intermediate processes before they register changes in health outcomes like mortality and morbidity. However, one reason reform initiatives have not significantly affected health outcomes is that these reforms have not been implemented at scale with sufficient intensity and duration. In turn, this is due to the difficulties arising from fragmentation and the limited capacity of the DOH to coordinate inter-local government health activities. Further options to address these constraints will be discussed in Section 5.

18 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

3. REDUCING VARIATIONS IN ACCESS AND QUALITY OF CARE TO IMPROVE HEALTH OUTCOMES

The previous sections described how, despite the introduction of better policies, budget increases, and innovations at the operational level, health outcomes like maternal and neonatal mortality have not significantly improved. This section describes how weaknesses and gaps in the way health services are delivered contribute to poor health outcomes. The discussion here points to two particular factors, namely: 1) large variations in the range of available services and their accessibility; and 2) where services are available, there is a large variation in the quality of care. These variations in access and quality can be attributed to the effects of fragmentation that made it difficult to effectively respond to the need to expand and upgrade health infrastructure in the face of rapid population growth and, more importantly, to improve the clinical competence of health providers. The latter factor is particularly critical. This Report emphasizes that health infrastructure by themselves would not produce health outcomes unless assembled in a manner that actually produces improved health. This requires having clinically competent health providers. Thus, public investments to build service delivery capacity need to be conditioned on the sustained delivery of quality clinical care.

There were immediate problems encountered during the devolution that affected public health service delivery and financing. With devolution, facilities intended to function as part of a district system were relegated to serve a smaller jurisdiction. Such fragmentation cut the continuum of care delivered at different levels of care and the sharing of resources and personnel among LGUs. Another immediate problem was that financing did not follow devolved function. While the total Internal Revenue Allotment (IRA) was adequate to finance devolved functions, the distribution of the IRA to provinces, cities, and municipalities did not follow functions devolved to these LGUs. Provinces suffered the most, while cities gained. Some adjustments to the financing of devolved functions were done to mitigate the “mismatch between the IRA and the cost of devolved functions,” including the financing of national mandates (Magna Carta and salary standardization). Attempts were made to forge inter-LGU cooperation through the Inter-Local Health Zone (ILHZ) initiative to “re-integrate hospital and public health services for a holistic delivery of health services through, e.g., functioning two-way referral system” (DOH, AO No. 2006-0017). Moreover, with devolution, the traditional career paths of doctors and health staff were cut off, resulting in demoralization among medical doctors and difficulty for LGUs to attract and retain young doctors.

While attempts were made by the DOH to address some problems encountered in the early phase of the devolution, the overall effect was limited. The early efforts to address fragmentation and improve the capacities of the LGUs to upgrade services could not be implemented at scale and sustained. As a result, a number of problems persisted. One, the LGUs remained heavily dependent on the IRA and are either unable or unwilling to expand local revenues for investment in health. This differing financing capacities and priorities resulted in some LGUs making investments to upgrade health facilities and equipment while others failed to do so. Two, many local facilities, especially RHUs, do not have adequate number of doctors, have high turn-overs, and lack continuing training and supervision. Third, the DOH’s capacity to exercise technical leadership and provide incentives for performance remains mainly only on paper. In the meantime, the population continued to grow rapidly, outstripping existing capacity.

Underlying these persisting problems is the manner by which the devolution was implemented. Decision-making was devolved to autonomous LGUs that were provided with block grants with discretion to spend as they see fit. Thus, local authorities can adopt their own health priorities and have wide discretion on how their IRA shares can be spent. Health care may not be a priority for certain LGUs, given the wide range of competing local development

19 concerns. Moreover, LGUs had differing capacity and willingness to generate local revenues partly due to political factors, and instead continued to rely heavily on the IRA. Finally, given short term limits, there is an incentive to focus on short-term programs than long-run investments whose gains are reaped in the future.

The consequences of all the above contributed to variations in access and quality of care. In this section, we examine key elements of access and quality which contribute to poor health outcomes. We detail below the following observations: 1) hospital beds did not keep pace with population growth; 2) high-end care is available mainly in the National Capital Region (NCR) and highly urbanized cities; 3) the diagnostic and surgical capacity of LGU hospitals vary widely; 4) the number of RHUs did not keep pace with population growth; 5) RHUs lacked critical staff members, skills training, and diagnostic facility; and 6) clinical quality among public and private providers.

While Most Filipinos Can Access Health Facilities, Most of the Poor Visit RHUs and BHSs

How easy is it for people to access health care facilities? The data in Table 3.1 is based on the 2013 National Demographic and Health Survey (NDHS), which covers 14,804 households, including over 71,000 individual members.

Table 3.1 Utilization of Health Facilities by Wealth Quintile PUBLIC DOH LGU RHU BHS PRIVATE Private Private Hospital Hospital Hospital Clinic ALL 67.1 5.1 11.1 18.7 32.2 32.9 20.3 12.7 Poorest 91.4 3.8 9.3 23.3 55.0 8.6 4.6 4.0 Poor 84.2 4.1 13.0 25.2 41.9 15.8 9.0 6.8 Middle 71.7 6.1 12.7 22.3 30.4 28.3 15.8 12.5 Rich 50.5 6.5 12.0 13.4 18.6 49.5 31.6 17.9 Richest 26.4 5.2 8.0 6.0 7.3 73.6 47.6 25.9 Source: UPecon-HPDP calculations from NDHS 2013

From the responses to the survey, only 10 percent of individual household members reported having visited a facility in the past 30 days, whether to seek treatment or advice. Of this number, 36.5 percent sought care from a public (16.2 percent) or private (20.3 percent) hospital facility. The rest visited outpatient facilities including RHUs, barangay health stations (BHSs), and private clinics. It is interesting that, while the reasons for such visits range from injuries all the way to medical check-ups, close to 40 percent of visits were made to a hospital facility. In the extreme case of the richest wealth quintile, where information and financing are less constrained, the proportion of visits made to a hospital goes up to 60 percent. One hypothesis is that families perceive services delivered in a hospital to be of relatively better quality than those delivered in outpatient clinics.

As if by design, public facilities are much more accessible to poorer families. For example, over 80 percent of the visits made by the poorest two wealth quintiles are in public facilities. However, it is important to note that over half of the visits to public facilities are in the BHSs, where there is no doctor, where a midwife rotates over several health stations, and where there are frequent reports of shortages of basic drugs and medicines (Lavado & Pantig, 2009). Moreover, as more and more programs are introduced, the expected load of the BHS piles up. The BHS is not only in charge of antenatal care, child immunization, nutrition counseling, family planning, and health promotion; it is also expected to collect and collate information on each of these programs for the national health information system.

20 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

After BHSs, RHUs and LGU hospitals are the facilities most accessible to the poor. The question is how well poor families are served in these facilities in terms of quality of clinical care. However, even families from the richest quintiles avail themselves of publicly provided services, especially from DOH-retained hospitals. This observation is key to the financing reforms proposed by this Report. Aside from additional public subsidies, it is recommended that existing public funds be targeted to the poor, possibly by introducing socialized pricing schemes.

Access to Hospital Services Remains Limited and Varies Widely Across Regions

Increase in hospital beds barely kept pace with population growth

A broad view of how the capacity of the sector has developed in the last 25 years can be provided by looking at the number of hospital beds as an indicator. As shown in Figure 3.1, the number of beds per 100,000 actually declined from 144 in 1990 to 99 in 2014. The decline is explained by the fact that the number of government beds essentially remained the same or, indeed, even declined despite population growth. The number of government hospital beds fell from 49,273 in 1990 to 48,384 in 2014. Private hospital beds, on the other hand, increased from 37,862 in 1990 to 50,045 in 2014.

Figure 3.1 Hospital Beds per 100,000 Population, 1990 to 2014

60,000 90.0

80.0 50,000 70.0

40,000 60.0

50.0 30,000 40.0

20,000 30.0 Number of Hospital Beds

20.0 Beds per 100,000 Population 10,000 10.0

0 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

Government hospital beds Private hospital beds

Beds per 100,000 population, government hospitals Beds per 100,000 population, private hospitals

Source: PSA, Philippine Statistical Yearbook 2015

It may be argued that even if bed capacity has not increased between 1990 and 2014, it could very well be the case that the quality of care delivered by each bed may have improved owing to advances in technology. Thus, there is a need to check if changes in the quality of care delivered per bed have indeed occurred. By quality, we refer to the quality of doctors, the availability of diagnostic facilities, the range of services being delivered, and the improvement in health outcomes, which are discussed later in this section. It is also important to see how these changes vary across the country. Furthermore, we need to check if the need for hospital beds have been effectively reduced owing to advances in preventive technology.

21 In the interest of public policy, Filipinos should have access to health services according to their needs, regardless of income. Using hospital beds per 100,000 population as a rough measure for access to a minimum standard of care, one should observe a more or less even distribution of hospital beds across the country, weighted by population. As a proxy, we use beds in its broadest definition, from a bed in a primary facility to a bed in a tertiary facility. The main policy instrument to address this concern is a public health delivery system, especially where the ability to pay for private services is low. Alternatively, instead of providing for public hospitals, one might consider delivering the same amount of subsidies to poor consumers by subsidizing social health insurance premiums. In this case, the instrument to even out access to quality care, using hospital beds as proxies, is to increase effective demand of poor families through insurance.

The public policy concern that hospital beds be equally accessible regardless of income is shown in Figure 3.2 where regions are ordered according to per capita regional gross domestic product (RGDP). Expectedly, NCR with the highest per capita RGDP also has the highest bed to population ratio, while the Autonomous Region in Muslim Mindanao (ARMM) with the lowest per capita RGDP has the least number of beds. But the ordering of regions between NCR and ARMM tells an interesting story about the use of public health policy and equity. The case of the Cordillera Administrative Region (CAR) would show a region that we would expect to have a successful public health policy. CAR is the fourth poorest but it has the second most number of beds per population. Moreover, the largest share is provided by the public sector. On the other hand, the case of ARMM shows the consequence of both market and public policy failures; being the poorest, it also has one of the least number of beds per population.

CALABARZON (Cavite, Laguna, Batangas, Rizal, and Quezon) and Central Luzon have the highest per capita RGDP after NCR, yet their respective number of beds are less than the national average of 107 beds per 100,000 population. However, it may be argued that these regions have access to facilities in the NCR. It is also worth pointing out that the middle-income regions like Northern Mindanao, Ilocos, and SOCCSKSARGEN (South Cotabato, Cotabato, Sultan Kudarat, Saranggani, and General Santos City) have a relatively large private sector presence.

Following the over-all trend shown in Figure 3.1, the number of public beds per 100,000 population declined in all regions from 1995 to 2015, except Caraga. The private sector was able to more than compensate for the decline in public sector capacity in Cagayan Valley, Central Luzon, and Western Visayas. Private sector growth in Ilocos, Central Visayas, and Eastern Visayas was insufficient to make up for what was lost in the public sector.

Tertiary level facilities and specialists are mainly located in NCR and the major cities

Questions about how public beds have been able to respond to address inequities across regions might have to be visited in later sections that discuss quality concerns in detail. People in poorer regions are more likely served by fewer beds in poorly staffed and equipped lower level facilities. Assuming that tertiary beds are a rough proxy for fully staffed and equipped hospital facilities, the extent of the inequitable access to quality care is shown by the fact that 61 percent of Level 3 beds are in NCR. The middle-income regions of Northern Mindanao, Ilocos, and SOCCSKSARGEN only account for 6 percent of such beds.

Another approach to describe quality of hospital care in the Philippines is to determine whether it would actually meet global standards. In particular, how many hospitals are compliant with the procedures and processes prescribed by the International Organization for Standardization (ISO), which provides specifications for products, services, and good practices for businesses and industries (Domittner, Kernstock, & Nowak, 2013)? Also, one can check how many hospitals are compliant with the Joint Commission International (JCI), an internationally recognized accreditation institution. JCI-accredited hospitals are examined for commitment to quality of care, patient safety, willingness to undertake rigorous preparation and survey, care delivery based on evidence-based practices, and continuous compliance (World Hospital Search, 2017).

22 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 3.2 Hospital Beds by Region per 100,000 Population, 2015

NCR CALABARZON Central Luzon Central Visayas Davao Western Visayas Northern Mindanao Ilocos SOCCSKSARGEN Bicol Zamboanga Peninsula Eastern Visayas Cagayan Valley CAR MIMAROPA Caraga ARMM

0 50 100 150 200 250

Public (LGU and DOH) Private

Source: UPecon-HPDP Facilities Database, 2015

After an intensive two-year campaign, 37 percent of DOH hospitals in 2015 became ISO-certified (DOH, 2015a). This means that these hospitals successfully met the prescribed standards and procedures for quality management, including management reviews, internal audits, procurement management, and customer feedback. In that same year, only two of 741 LGU hospitals were ISO-certified. In 2014, only six private hospitals met JCI standards, five from Manila and one from Cebu (Oxford Business Group, 2016). The emerging pattern indicates that the bulk of Philippine hospitals do not meet global standards. However, there are globally competitive hospitals serving market centers, especially NCR. This is true for both public and private hospitals that are compliant with these standards.

While tertiary facilities are highly concentrated in market centers, access to specialized care could be more accessible if specialists like surgeons and obstetricians were better distributed. Data from the Philippine College of Surgeons (PCS) and the Philippine Obstetrical and Gynecological Society (POGS) show the distribution of their members across the country.

Fellows of the PCS, shown in Figure 3.3, are used here as a rough measure of the distribution of trained surgeons. On the other hand, the number of trained surgeons increased four times in the last 25 years. The bad news is that half of them are practicing in Metro Manila, while another 30 percent practice in the city centers of Southern Tagalog, Central Luzon, and Central and Western Visayas. A similar pattern emerges for members of POGS, of whom half practice in NCR, while another 20 percent serve in adjacent regions (see Figure 3.4).

23 Figure 3.3 Philippine College of Surgeons (PCS) Fellows by Region

NCR 1295

CALABARZON 193

Central Luzon 192

Central Visayas 183 Davao 98

Western Visayas 146 Northern Mindanao 78

Ilocos 90 SOCCSKSARGEN 37 Bicol 52

Zamboanga Peninsula 29

Eastern Visayas 26 Cagayan Valley 31

CAR 66 MIMAROPA 17 Caraga 22 ARMM 1

0 200 400 600 800 1000 1200 1400

1990 2015

Source: Philippine College of Surgeons, 2017

Figure 3.4 Philippine Obstetrical and Gynecological Society (POGS) Members by Chapter, 2017

NCR 2227

Northern Luzon 229

Cagayan Valley 91

Central Luzon 336 Southern Luzon 427

Bicol 72 Western Visayas 243

Central Visayas 277 Eastern Visayas 59 Western Mindanao 40

Northern Mindanao 140

Southern Mindanao 220

0 500 1000 1500 2000 2500

Source: Philippine Obstetrical and Gynecological Society, 2017

24 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

That tertiary level facilities and specialists are mainly located in NCR and the major cities of the country may be explained by three inter-related factors: 1) the size of the population served in the catchment area; 2) the economic resources available in such centers; and 3) access to infrastructure. A large population base might actually be needed to have effective demand, especially for specialized services. Economic resources, particularly family income and public subsidies, determine the viability of such specialized and high quality care. Infrastructure is essential to operate and provide services. This raises a fundamental question on the viability of decentralized health systems. If the location of high-end hospital facilities and specialists indicates the apex, the earlier discussions concerning the distribution of hospital beds, surgeons, and obstetricians suggest that we can only be assured of the presence of a fully functional service delivery network for a wide range of conditions in the regions of NCR, CALABARZON, Central Luzon, and Central and Western Visayas. However, in the case of maternal care, which would involves clinics where prenatal care is provided all the way to a tertiary facility where neonatal intensive care is available, a service delivery network that can deliver essential services may be available in most provinces.

The above hypothesis about the Philippines having only a handful of service delivery networks would be falsified if it can be shown that LGU hospitals are capable of delivering care that requires the services of a surgeon or an obstetrician. Moreover, it should be shown that these trained physicians have adequate access to diagnostic facilities. The specific question is to determine if public health facilities and providers are present inareas where population is much less concentrated, where economic resources are wanting, and infrastructure is less than adequate.

Gaps in surgical capacity and diagnostic facilities prevent LGU hospitals from serving poor population

In 2012, the DOH issued AO No. 2012-0012 to reclassify hospital facilities. Under the new classification, Level 1 hospitals shall attend to surgical cases and complicated pregnancies. Public hospitals that cannot meet Level 1 standards are now reclassified as infirmaries. According to the DOH issuance, all hospitals must be able to perform surgeries done by a surgeon, obstetrician, or some other qualified specialist (DOH, 2012a).Figure 3.5 shows the level of compliance of LGU hospitals in 2014 in terms of the presence of a surgeon and an obstetrician who are either long-term staff members, visiting, or on-call.

LGU hospitals that did not have a surgeon were found in all regions. Even among the revenue-rich cities of NCR, one out of 14 hospitals sampled was found not to have a surgeon. The regions with the highest proportion of LGU hospitals without a surgeon are Cagayan Valley (62 percent), Bicol (56 percent), and Caraga (54 percent). The presence of an OB-Gyne follows a similar pattern except that compliance, on the whole, is much better. The same survey data (UPecon-HPDP, 2015a) show that private hospitals in all regions are found to have both a surgeon and OB-Gyne except for Davao and ARMM, and one in CAR without an OB-Gyne. However, while gaps remain, it should be noted that public facilities are able to operate where there is lack of resources, where populations are isolated, and infrastructure is wanting (e.g., ARMM).

Under the revised classification, all hospitals should have sufficient diagnostic capabilities, including the capacity to provide X-ray services. At this day and age, the provision of X-ray services is one of the most basic diagnostic tests. The expectation, therefore, is that all LGU hospitals are capable of providing these services. However, all regions, except for NCR, were found to have hospitals that were unable to provide X-ray services. Recall, from an early discussion of Figure 3.2, that CAR was identified as an interesting case of a region with high bed to population ratio despite lack of resources. It turns out, however, that this may not readily translate to effective delivery of services.

25 Recall from Figure 3.5, nine out of 18 hospitals sampled did not have a surgeon, and eight out of 18 did not have an obstetrician. In Figure 3.6, 10 out of 18 hospitals sampled were found to not provide X-ray services. CAR is an important case for providing public investments as an entire package effectively combining infrastructure, specialist care, diagnostic equipment, and drugs and medicines. In effect, the case of CAR is another manifestation of fragmentation. Putting the data of the presence of specialists and of diagnostic facilities together shows that gaps remain that prevent LGU hospitals from serving poor population not served by private providers.

Figure 3.5 LGU Hospitals with Surgeon and Obstetrician/Gynecologist by Region, 2014 (in Percent)

NCR CALABARZON CAR Central Visayas Davao Northern Mindanao Central Luzon Ilocos SOCCSKSARGEN Zamboanga Peninsula Western Visayas Cagayan Valley MIMAROPA Eastern Visayas CARAGA Bicol ARMM

0 20 40 60 80 100

with Surgeon with OB-Gyn

Source: UPecon-HPDP Kalusugan Pangkalahatan Operations Monitoring (KPOM) Survey, 2015

Gaps in RHU Service Capacity and Quality Prevent Delivery of Quality Primary Care

With the establishment of the public health delivery system in the 1950s, RHUs were built to serve communities with no ready access to hospitals. The demographics, as well as the health conditions at the time, dictated that one RHU be organized in each municipality. Two categories of RHUs were to be built during this period. A Category I RHU was designed to serve a community of not less than 5,000 members, and was supposed to have a staff complement composed of a doctor, a public health nurse, a midwife, and a sanitary inspector. On the other hand, in communities with more than 35,000 members, a Category II RHU should be established in addition. This type was designed to have a staff complement composed of two doctors, two public health nurses, a midwife, and a sanitary inspector (Congress of the Philippines, 1954).

26 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 3.6 LGU Hospitals with X-ray Services, 2014 (in Percent)

NCR

CALABARZON

CAR

Central Visayas

Davao

Northern Mindanao

Central Luzon

Ilocos

SOCCSKSARGEN

Zamboanga Peninsula

Western Visayas

Cagayan Valley

MIMAROPA

Eastern Visayas

CARAGA

Bicol

ARMM

020406080100

Source: UPecon-HPDP 2015 Kalusugan Pangkalahatan Operations Monitoring (KPOM) Survey

To respond to the growing range of health needs, increasing population, and changes in medical public health technology, the DOH introduced a new set of standards in 2012. RHUs would now have to be staffed and equipped to provide basic clinical, preventive, promotive, curative, and rehabilitative services for the municipality. Since RHUs are not licensed, the closest operational definition of what a modern RHU would be able to provide can be inferred from the PhilHealth Out-Patient Benefit (OPB) accreditation requirements (PHIC, 2000). An RHU would be accredited to deliver PhilHealth out-patient benefit package if it can provide medical consultation for pediatric, internal medicine, general surgery, and obstetric cases. It should be able to perform complete blood count (CBC), urinalysis, fecalysis, sputum microscopy, and chest X-ray. The minimum staffing requirement includes a physician, nurse, midwife, and a medical technologist. Furthermore, to address concerns about the slow progress in reducing maternal mortality, the same 2012 DOH Guideline set standards for RHUs to provide Basic Emergency Obstetrics and Newborn Care (BEmONC). Major investments were made to upgrade RHUs to have birthing facilities (Picazo et al., 2016). The following section discusses how the number of RHUs have changed between 1995 and 2015, and whether current RHUs are capable of delivering their mandates based on a number of indicators.

Increase in the number of RHUs has not kept pace with population growth

The number of RHUs increased from 2,335 to 2,642 between 1995 and 2015. This increase in the number of RHUs was insufficient, however, to keep pace with population growth. As a result, the RHU to population ratio fell

27 from 3.4 in 1995 to 2.6 per 100,000 persons in 2015. If the same ratio in 1995 were to be maintained, the number of RHUs in 2015 should have increased to 3,450. Even so, this figure still falls short of the standards set forth in RA No. 1082, which, if followed, should have raised the number of RHUs to at least 5,700 in 2015. Perhaps with new technology and better trained health staff, the actual number of RHUs may be able to serve a much larger population. It is, therefore, important to check if the current number of RHUs are appropriately staffed and equipped as in the case of the Malaysian community health center (Ariff & Teng, 2002) or the super health centers of Quezon City (Echeminada, 2004).

By design, the number of RHUs per region should be the same after controlling for differences in population. However, the number of RHUs should change over time to account for changes in the concentration of poor families, geography, and transportation networks. Figure 3.7 shows the number of RHUs per 100,000 population by region for 1995 and 2015. Regions are again ranked according to per capita RGDP. A number of regions have missing information for 1995 since data on selected provinces are still recorded under pre-ARMM regions.

Except for NCR and Region IV, the rest of the country saw a reduction in the ratio of RHUs to population. In 1995, Southern Tagalog, Bicol, Western Visayas, Central Visayas, and Davao fell below the national average of 3.4 in terms of the ratio of RHUs per 100,000 population. In 2015, the national average declined to 2.6. Bicol, Western and Central Visayas, Davao, and SOCCSKSARGEN were below the average. As with hospital beds, CAR had a higher RHU to population ratio despite low incomes.

Figure 3.7 RHUs per 100,000 Population by Region, 1995 and 2015

NCR CALABARZON & MIMAROPA CAR

Central Visayas

Davao

Northern Mindanao

Central Luzon

Ilocos

SOCCSKSARGEN

Zamboanga Peninsula

Western Visayas

Cagayan Valley

Eastern Visayas

CARAGA

Bicol

ARMM

0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0

1995 2015 Source: UPecon-HPDP Facilities Database, 2015

28 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Gaps in medical staff, skills training, and diagnostic facilities prevent RHUs from delivering quality primary care services to the poor

The existing capacities of RHUs in the country can first be described by checking compliance with the requirement that each RHU should have a doctor. In a 2015 survey of 342 RHUs across the regions, all RHUs, save for roughly 40 percent in ARMM, reported having a doctor, either engaged full-time or on a part-time basis. This is expected considering that, by law, municipalities are required to have a municipal health officer who, by default, also serves as the rural health doctor. A major concern is that a number of municipalities still do not have doctors. Such municipalities are then targeted for programs such as the Doctors to the Barrio. Municipalities with only one doctor also need special attention considering the competing demands of administrative duties, managing the rural health staff, implementing public health programs, and providing clinical care to a growing population (UPecon-HPDP, 2015).

Aside from the doctor, the midwife is key to the ability of the RHU to deliver primary care services, including family planning. To provide effective family planning services, a midwife needs to be trained in counselling, must be familiar with a wide range of methods, and perform special skills like the insertion of an intrauterine device (IUD). Ideally, each RHU should have at least one midwife that should have been trained in the competency-based training (CBT) for family planning, covering short-acting methods (CBT1), and long-acting and reversible methods (CBT2).

In the same 2015 survey of 342 RHUs, only 70 percent of RHUs had at least one midwife trained in CBT1 and CBT2. First of all, midwives who are trained do not seem to be determined by the economic status of a region. For example, as shown in Figure 3.8, NCR with the highest regional income only has up to 60 percent of health centers with trained midwives. On the other hand, a region like Caraga has trained midwives deployed to 90 percent of RHUs. The DOH provides the training for midwives; it is, therefore, possible that regional variation in RHUs having trained midwives is largely influenced by the efforts of DOH program managers to monitor family planning competency, identify training gaps, secure funds, and provide training.

Figure 3.8 Proportion of RHUs with Trained Midwife in FP CBT1 and FP CBT2, 2014

NCR CALABARZON Central Luzon Central Visayas Davao Western Visayas Northern Mindanao Ilocos SOCCSKSARGEN Bicol Zamboanga Peninsula Eastern Visayas Cagayan Valley CAR MIMAROPA Caraga ARMM

0 10 20 30 40 50 60 70 80 90 100 Source: UPecon-HPDP Kalusugan Pangkalahatan Operations Monitoring (KPOM) Survey, 2015 29 One of the functions of the RHU is to provide basic diagnostic services such as CBC examination. This test includes checking for hemoglobin levels that serve as the basis for diagnosing anemia. In addition, the test is used to detect and differentiate bacterial and viral infections. For the RHU to perform CBC, it would need at least a microscope, blood collection kit, centrifuge, and test reagents. While the test can be performed by a doctor, it is recommended that blood collection and CBC testing be performed by a medical technologist.

Of the RHUs surveyed in 2015, only 40 percent were able to perform CBC. This means that a large majority of RHUs are unable to evaluate overall health and screen for anemia and infections, which are very common in the communities they serve. The regional breakdown is shown in Figure 3.9. This inability to perform the test could be due to lack of staff, equipment, and supplies to perform the test.

Figure 3.9 RHUs with CBC Services, 2014

NCR CALABARZON Central Luzon Central Visayas Davao Western Visayas Northern Mindanao Ilocos SOCCSKSARGEN Bicol Zamboanga Peninsula Eastern Visayas Cagayan Valley CAR MIMAROPA Caraga ARMM

0 10 20 30 40 50 60 70 80 90 100 Source: UPecon-HPDP Kalusugan Pangkalahatan Operations Monitoring (KPOM) Survey, 2015

That the majority of RHUs lack trained personnel and basic diagnostic capabilities shows the extent to which LGUs have failed to fulfill their task of delivering primary care. The question is, what accounts for this failure? Is it because LGUs were given responsibility to provide health services without adequate financing, which is probably the case among provinces (Capuno, 2001)? Is it because health investments have gestation periods longer than term limits? Is it because health issues are not a priority for local officials, or do not matter during elections? Is it because for an individual LGU facility to perform well, it needs to be a part of a service delivery network that cuts across jurisdictions? Or is it because national agencies are unable to hold LGUs accountable?

These questions about the failure to provide the critical inputs for health care become important once linked with health outcomes. The concern is that public facilities are unable to assemble these inputs in a manner that complies with clinical standards so that services that improve health outcomes are actually delivered.

30 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Low Quality of Care Leads to Poor Health Outcomes

Health facilities, equipment, and staff members become linked to health outcomes of patients at the point of care. Several approaches have been developed to measure clinical quality during a doctor-patient encounter. The gold standard is to use standardized patient actors where specially-trained actors portray patients with particular health conditions or concerns. The patient actors record how the doctor takes history, conduct physical exam, order tests, make diagnosis, and prescribe a treatment plan. These records are then evaluated by a panel of clinical experts. A cheaper and more convenient alternative approach is to use Clinical Performance and Value (CPV) vignettes (Peabody et al., 2000).

A number of studies that measure the quality of clinical care have been conducted in the Philippines. Adherence to clinical practice guidelines in terms of history taking, physical examination, ordering tests, diagnosis, and prescription of a treatment plan for several conditions including pneumonia, diarrhea, prenatal care, and labor and delivery have been measured and scored. CPV scores are then assessed in relation to specific measurable health outcomes such as anthropometrics, biomarkers, and morbidity and mortality.

Low CPV scores raise questions on the quality of clinical care for common health conditions

In 2004, baseline data were collected for the Quality Improvement Demonstration Study (QIDS) from 145 doctors from public and private hospitals in ten provinces in the Visayas (Shimkhada et al., 2008). Most public doctors practiced in district and provincial hospitals, while private doctors served in facilities in the same district. The CPV scores of the sampled physicians are reported in Table 3.2. The first column shows the five domains being evaluated. The mean, high, and low scores are reported in the succeeding columns.

Table 3.2 Quality of Care: CPV Scores of Doctors in Visayas, by Domain (in Percent) Average High Low History taking 57 84 30 Physical exam 59 97 16 Tests 70 100 0 Diagnosis 47 100 17 Treatment 39 85 0 ALL 54 82 24 Source: Powerpoint presentation of Secretary of Health Francisco Duque III (2005) entitled "Challenges Ahead for Philhealth: Highlights from the QIDS Baseline Survey 2004."

The results of the QIDS baseline survey raised a number of policy questions about the poor level of quality of care (Duque, 2005). The average score barely met an arbitrary cut-off of 55 percent, meaning the average doctor in the Visayas was only able to answer half the questions correctly. Scores varied from a high of 82 percent to a low of 24 percent. It was a source of concern that doctors tended to score more poorly in the domains of diagnosis and treatment.7 This is quite dramatic considering how vignettes are administered. Questions on diagnosis and treatment are asked after the correct results of history-taking and physical examinations have already been given. This could mean that even with the right facilities, adequate diagnostic equipment, and drugs and medicines, doctors may still be wrong more than half the time. There were even doctors scoring zero for ordering tests and treatment.

7 The following examples illustrate the kind of responses that explain the low scores for CPVs: 1) 56 percent of doctors admit patients who needed to be admitted; 2) 42 percent of doctors administer the correct drug or class of drugs; 3) 58 percent of doctors actually recommend a drug that is contraindicated or unnecessary; and 4) 34 percent of doctors give appropriate follow-up advice.

31 In 2007, surveys were conducted to draw baseline for a new set of USAID projects supporting DOH reforms. CPV vignettes on pneumonia and diarrhea were administered to 134 doctors from various health facilities in 31 provinces. A summary of CPV scores is shown in Table 3.3. Overall scores are slightly higher than what were found in the Visayas using the QIDS survey. But the new information pertains to how quality varied across facilities. For both diarrhea and pneumonia, doctors in private hospital-based clinics scored better. On the other hand, doctors in free-standing clinics, whether public or private, tended to have the lowest scores. However, even a high mean score of 65 (i.e., answering 65 percent of the questions correctly) may be unacceptable, especially if low scores predict poor patient outcomes.

Table 3.3 CPV Scores for Pneumonia and Diarrhea, 2007 (in Percent) Pneumonia Diarrhea N (doctors) mean N (doctors) mean Public Hospital 53 59.4 50 60.4 Private Hospital 48 53.6* 45 56.1 RHU/CHC 10 56.6 9 54.7 Private Hospital- 16 65.4 20 60.7 based Clinic Free-standing Clinic 7 58.4 8 53.0 ALL 134 57.8 132 58.2 *Significantly different from public hospital at p=0.05 Source: USAID and UPecon-HPDP Operational Plan Baseline Survey Dataset, 2007

In 2013, data were collected from 171 midwives and doctors, practicing in 77 birthing facilities in Quezon City. In addition to CPVs, data on specific outcome measures concerning the condition of the mother and a newborn within a month after delivery were also collected. Maternal outcome measures include bleeding, perineal tear, dyspnea, prolonged labor, hypertension, and vaginal discharge. Neonatal outcomes include presumed sepsis, response to resuscitation, and birth trauma (UPecon-HPDP, 2014a). Table 3.4 shows the scores for the antenatal and postpartum care (ANPC) vignette. The same table also shows scores for labor and delivery. On average, doctors from both public and private facilities generally met the passing mark, but midwives did not. The passing mark was set arbitrarily at 55 percent. A modified test was administered to midwives to assess if they knew when to refer a complicated case that needed to be handled by a physician in a hospital.

Similar issues concerning the ability of doctors to properly diagnose and prescribe treatment can be raised with respect to labor and delivery. Of particular concern are the scores recorded for midwives, which suggest that midwives tend to treat complicated cases that they should instead have just promptly referred. CPV scores also suggest that many doctors and midwives may be able to identify. However, the scores in the treatment domain suggest that providers may be unable to intervene properly, thus raising the risk of complications during pregnancy and childbirth.

32 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Table 3.4 CPV Scores for ANPC and Labor and Delivery, 2014 (in Percent) ANPC Labor and Delivery Public Private Public Private MD Midwives MD Midwives MD Midwives MD Midwives N 2 40 13 86 2 40 13 86 Total 55 41 63 41 76 51* 60 48* History 50 27 55 33 71 35 47 39* PE 50 45 72 50 83 58 68 52* Test 100 73 59 52 50 43 69 35 Diagnosis 100 57 85 46* 100 71 92 67 Treatment 38 35 56 34 66 50 57 44 *Significantly different from CPV of public doctors for a specific condition Source: Estimated from CPV survey data of Q@B full report, 2014

Better quality clinical care produces better health outcomes

The main challenge of health care reforms is to build a service delivery system that is not only accessible but is instrumental in restoring, and improving, health status. But as reported in earlier sections, the overall health status of Filipinos, using maternal mortality as an indicator, has essentially remained the same in the last 25 years. The explanation being offered in this section is that the health infrastructure has barely kept up with population growth, and that it is unable to deliver quality clinical care. As suggested by the value chain framework, the lack of improvement in health status may be in large part due to the poor quality of care, especially that which is available to the poor.

Many of the studies using CPVs to measure quality were able to extend their analysis to how clinical quality affects health outcomes. The panel data collected in the QIDS study traces the link between quality of care and specific health outcomes. One result is that quality of care significantly predicts a lower likelihood of childhood death (Panelo et al., 2009). Interventions designed to improve quality of care have increased general self-reported health (GSRH) by seven percentage points, reduced wasting by nine to twelve percentage points, and reduced infections by about four to nine percentage points (Quimbo et al., 2010).

A more recent study on the quality of care provided by public and private birthing facilities finds that providers whose CPV scores met a 50 percent cut-off were less likely to have patient mothers and neonates experience bad outcomes, as shown in Figure 3.10. The specific result is that providers who are able to deliver higher quality clinical care seemed to be able to prevent bad outcomes affecting the neonate, and both the mother and neonate. Bad outcomes for neonates include presumed sepsis, cephalhematoma, extremity weakness, and umbilical redness and swelling. Bad outcomes affecting mothers include post-partum bleeding, urinary symptoms, and abnormal vaginal discharge. Results also suggest that providers who were unable to be tested had patients with the same outcome profile as those providers who had low scores.

A follow-up study was conducted tracing all mothers from the Quality at Birthing Homes (Q@B) study within six months of delivery. The study examined whether the final health outcomes after six months were influenced by having been misdiagnosed earlier. The results are shown in Table 3.The prevalence of misdiagnosis among obstetric providers was 29.8 percent overall, 25.2 percent for cephalopelvic disproportion, 33 percent for postpartum hemorrhage, and 31 percent for pre-eclampsia. It was found that those who misdiagnosed were more likely

33 Figure 3.10 Probability of Various Outcomes for Mothers and Neonates (in Percent)

100

90 86.07 86.07 86.07 80

20 10.19 10.19 10.19 10 3.12 0.62 3.12 0.62 0 No CPV CPV<50% CPV>=50%

No bad outcome Bad outcome for mother only

Bad outcome for neonate only Bad outcome for both mother and neonate

Source: Estimated from the 2014 Q@B Survey Data

Table 3.5 Misdiagnosis among Obstetric Providers CPV case (a) % of providers who misdiagnosed cases (b) Total misdiagnosis rate 29.8 Individual case types Cephalopelvic disproportion 25.2 Post-partum hemorrhage 33.0 Pre-eclampsia 31.0 CPV, Clinical Performance and Value. (a) Total misdiagnosis rate based on 309 CPV vignettes, individual case type misdiagnosis based on 103 vignettes for each case type; (b) misdiagnosis defined as missing primary diagnosis by the physician who took the CPV vignette and non-referral of the patient by the midwife who took the CPV vignette. Source: Shimkhada et al., 2016

to have patients with a complication compared to those who did not misdiagnose. The patients with complications were more likely to be readmitted to a hospital after delivery, had significantly higher medical costs, and lost more income (Shimkhada et al., 2016).

The take away from these studies is that quality of clinical care determines outcomes. It is not merely the presence of a doctor, availability of diagnostic equipment, and ready supply of medicines that produce health, but rather how these inputs are combined at the point of care. Poor quality clinical care not only leads to inferior outcomes; it also increases the financial burden on families as well as the health sector.

Several policy interventions have been proposed to address the problem of quality. The most common and perhaps least effective are recommendations requiring providers to meet certain staffing patterns, bed-to-patient ratios, and

34 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance organization of committees. But the studies described here invariably suggest that inputs in themselves do not produce health unless assembled in a manner that actually restores, if not improves, health. But doing so requires having clinically competent providers.

The same set of studies advocates a package of policy reforms based on direct evidence (Peabody et al., 2017). One proposal is to explicitly link payments to providers with the quality of care they deliver. A second is to use the cost of the clinical gold standard to determine the amount of insurance payments. A third is to continue to collect and measure quality of clinical care, and to offer to the public clear signals regarding the quality offered by all providers in the community. Finally, public investments to build service delivery capacity need to be conditioned on the sustained delivery of quality clinical care.

35 36 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

4. CONSOLIDATING PUBLIC FINANCES TO SECURE THE NEEDS OF THE POOR

Data from the National Health Accounts (NHA) show that per capita health care expenditures have grown in real terms over the past 25 years.8 Among the sources of financing, the out-of-pocket payments to total health care expenditures were the largest while organized public and private financing sources remained relatively small. Several innovations were introduced to raise the impact of public health budgets and improve the performance of the national health insurance program. But difficulties have been met in trying to scale up these innovations, largely owing to the transaction costs of dealing with a highly fragmented system.

The analysis further finds that health care expenditures by and for the poorest 40 percent of the population are the lowest. This pattern is consistent with a system that relies heavily reliant on a fee-for-service system paid from out- of-pocket. This Report recommends that for the medium-term, existing resources and subsidies be consolidated, reallocated, and targeted to allow poor families to have better access to quality care, whether publicly or privately provided.

Health Care Expenditures Have Risen in Line with Economic Growth

Real per capita health expenditures grew from 1991 to 2014 but the growth has been uneven

A summary of how much is spent on health is shown in Figure 4.1. Real per capita health expenditures grew from PHP1,219 in 1991 to PHP3,528 in 2014, an increase of almost 200 percent in 24 years. However, the growth has been uneven. For the period 1991-2004, real per capita health expenditures were basically flat, on average. The increases in spending from 1991 to 1997 were followed by declines from 1998 to 2004 owing to the effects of the Asian financial crisis (UNFPA & ANU, 1998). From 2005 to 2014, on the other hand, real per capita health expenditures grew, with faster growth observed during the period 2010 to 2014.

Health spending moved with economic growth and recovery from crisis raised health spending

The trend in real per capita total health expenditures can be examined in relation to the trend in real per capita gross domestic product (GDP), as shown in Figure 4.2. The real per capita GDP growth over the 24-year period was interrupted by the Asian financial crisis of 1997 to 1998 (UNFPA & ANU, 1998). The average real per capita GDP growth in 1991-2004 was 1.4 percent and 3.6 percent from 2005 onwards. In comparison, the growth in real health spending per capita averaged 2.6 percent from 1991-2004 and 8.2 percent from 2005 onwards. Over the entire period, it rose much faster at five percent than real GDP per capita growth at 2.4 percent.

8 The main source of data for the analysis is the National Health Accounts (NHA) produced by the then National Statistical Coordination Board (NSCB) and now under the Philippine Statistics Authority (PSA). The NHA provides information on the sources and uses of total health expenditures of a given year. The data used to estimate the NHA comes from various sources that include national income accounts, national surveys and financial records of public and private institutions. The data available is from 1991 to 2014. An earlier analysis of the NHA data from 1991 to 1997 (Solon et al., 1999) provided the basis for the formulation of the Department of Health’s Health Sector Reform Agenda in 1999 (DOH, 1999). This section expands the analysis to cover the 25-year period 1991 to 2014.

37 Figure 4.1 Per Capita Total Health Expenditures, 1991 to 2014 (in PHP at Constant 2000 Prices)

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0 1991 1995 2000 2005 2010 2014

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

Figure 4.2 Per Capita Total Health Expenditures and GDP Per Capita (in PHP at Constant 2000 Prices)

4,000 80,000

3,500 70,000

3,000 60,000

2,500 50,000

2,000 40,000

1,500 30,000 GDP per Capita GDP

1,000 20,000

500 10,000 per Capita Total Health Expenditures Total per Capita

0 0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Per Capita Total Health Expenditures GDP per Capita

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

But health spending is lower relative to countries with higher economic growth

Real health spending per capita as a share of GDP per capita averaged 3.2 percent from 1991 to 1994. This share increased to four percent in 2005 to 2013. Levels of health spending per capita as a share of GDP in Thailand are comparable at 4.1 percent from 2005 to 2013. However, real health spending per capita in the Philippines is less than half of that in Thailand which has a much higher GDP per capita, as shown in Figure 4.3.

38 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 4.3 Philippines and Thailand: Per Capita Total Health Expenditures and GDP Per Capita, 1991 to 2014 (in PHP at Constant 2000 Prices)

8,000 160,000

7,000 140,000

6,000 120,000

5,000 100,000

4,000 80,000

3,000 60,000 x x per Capita GDP x x x 2,000 x x x 40,000 Health expenditures per capita x x 1,000 x x x x x x x x x 20,000 0 0 1995 1998 2001 2004 2007 2010 2013

x Health expenditure per capita Philippines Health expenditures per capita Thailand GDP per capita Philippines GDP per capita Thailand

Note: GDP per capita for Thailand converted to 2000 Philippine pesos. Conversion factor estimated using GDP deflator. Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016; Authors’ calculation using World Bank, International Comparison Program database

Among Sources of Funds, Out-of-pocket Payments Grew Fastest while Organized Sources Remained Relatively Small

The question of how finances for health are being raised will be discussed by type of financing agents: 1) LGUs; 2) national government agencies; 3) social health insurance; 4) private insurance, including health maintenance organizations (HMOs) and establishment-based health programs; and 5) family out-of-pocket spending.

Local Government Spending remained flat and did not rise with IRA

With the implementation of the Local Government Code (LGC) of 1991, local per capita spending increased from PHP166 in 1993 to PHP444 in 2014, as shown in Figure 4.4. During the period from 1993 to 1997, real per capita local government health expenditures rose owing to devolution. From 1998 onward, real local government health expenditures per capita were relatively flat, with a net increase of only PHP150 over 16 years. From 1992 to 2013, the average increase in real per capita LGU spending for health was only PHP12 per year. Meanwhile, the average increase in real per capita Internal Revenue Allotment (IRA) was about PHP36.

Local health spending did not rise as fast as the rise in IRA. During the same period, i.e., 1993 to 2014, there were rapid increases in IRA as shown in Figure 4.5. Data from 1992 to 2013 show that for every one peso increase in real per capita IRA, only 33 centavos went to health. Moreover, local health spending did not make use of other local revenues. It appears that the LGUs have not been an active financing source for health despite many attempts to leverage such spending, and despite health being one of the largest devolved sectors.

But to put these increases in perspective, it should be noted that in 1992 the average real per capita health expenditure by LGUs was PHP53, which then increased up to PHP449 in 2013, although not as much considering

39 Figure 4.4 Per Capita Total Health Expenditures and Per Capita Local Government Health Expenditures, 1991 to 2014 (in PHP at Constant 2000 Prices)

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Local Government Total Health Expenditures

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

Figure 4.5 Per Capita Internal Revenue Allocation (IRA) and Per Capita Local Government Health Expenditures, 1992 to 2013 (in PHP at Constant 2000 Prices)

1,600 x 1,400 x x x x x 1,200 x x x x x x x 1,000 x x x x x x x 800 x 600

400 x

200

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

x Per Capita IRA Local Government Per Capita Health Expenditures

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

that per capita out-of-pocket spending was already at PHP1,777 in 2013. Moreover, while the bulk of government health facilities and health workers were devolved to LGUs after 1992, the share of LGU spending on health to total health expenditure increased from the pre-devolution level of four percent to 19 percent in 2000, only to decline to 13 percent in 2014.

40 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

National government spending recovered pre-devolution budget levels but utilization is a challenge

With devolution, real per capita health expenditures by the national government declined from PHP421 in 1991 to PHP187 in 2002. It was around 2002 when the lowest post devolution per capita LGU spending was observed. However, beginning 2008, the national health budget increased such that by 2014 it almost equalled its pre- devolution per capita spending levels (see Figure 4.6). This rise in national spending corresponded to the set of reforms where national government began to compensate for gaps and weaknesses in local health systems.

Figure 4.6 Per Capita Total Health Expenditures and Per Capita National Government Health Expenditures, 1991 to 2014 (in PHP at Constant 2000 Prices)

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0 1991 1995 2000 2005 2010 2014

National Government Total Health Expenditures

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

A closer examination of the DOH budget reveals that the levels were relatively low and flat from 1991 to 2007, but that these increased steadily thereafter so that the 2010 budget was twice that of 2007 (Figure 4.7). By 2015, the DOH budget had grown to more than three times that of 2007 levels. In 2016, the DOH budget even rose higher to PHP122.6 billion, or five times the 2010 budget. These increases in the budget may be attributed to the expanded fiscal space and priority given to social services. Beginning 2014, around PHP40 billion a year has been attributed to proceeds from “sin taxes9” (DOH, 2015d).

However, as Figure 4.7 also shows, while these substantial increases in the DOH budget led to the increased scale and scope of programs, the capacity of DOH to effectively utilize its budget has become strained. DOH was able to obligate only about 80 percent of its budget for each cycle although at larger allocations over time. Unobligated funds were then passed on as continuing appropriations to the following budget year. These unobligated budgets further added to the increasing amount that DOH had to utilize the following year. More importantly, unutilized funds represented missed opportunities to provide health services.

9 The Sin Tax Reform Law (RA No. 10351) titled “An Act Restructuring the Excise Tax on Alcohol and Tobacco Products by Amending Sections 141, 142, 143, 144, 145, 8, 131, and 288 of Republic Act No. 8424. Otherwise known as the National Internal Revenue Code of 1997, as amended by Republic Act No. 9334, and for other purposes” took effect on January 1, 2013. The Law restructures the tax on the production, sale or consumption of alcohol and tobacco products by increasing the tax rates and shifting to a unitary tax system by 2017. The Law was intended to generate revenues to fund the government’s Universal Health Program and reduce consumption of tobacco (NTRC, 2014).

41 Figure 4.7 Utilization of DOH Budget Net of National Health Insurance Program, 1991 to 2015 (in PHP Billion, Current Prices)

0 1991 1995 2000 2005 2010 2015

DOH Budget Net of NHIP Obligated Net of NHIP Expenditures

Sources: General Appropriations Act from 1991 to 2015; Commission on Audit Reports for DOH from 2008 up to 2014; Department of Health Fund Utilization Reports from 2010 to 2015 (DOH, 2015e)

Difficulties in fully utilizing the budget reflected the limited capacity of the DOH to address procurement bottlenecks. In the case of the Health Facilities Enhancement Program (HFEP), there were not enough engineers and architects to design facility upgrading, and not enough Central Office Bids and Awards Committees (COBAC) could be created to bid out and award civil works contracts. Moreover, there were insufficient technical personnel available to monitor the pace of facility upgrading. It has been observed that limited in-house capacity could have been addressed by pooling multiple projects into large packages that could then have been outsourced (Picazo, Pantig, & dela Cruz, 2015).

The data on expenditures indicate actual spending for the year for both the current allocation and any continuing appropriations from previous years. As such, the amounts spent do not necessarily reflect the spending for the corresponding budget year. Continuing appropriations that lapse are eventually returned to the National Treasury. The DOH had to return to the National Treasury an average of PHP1 billion a year from 2011 to 2013. In 2014, the DOH returned PHP400 million (UPecon-HPDP, 2014b).

Social health insurance coverage reached universal levels, but share to total spending remains low

Social health insurance benefit spending grew fastest among public sources, as shown in Figure 4.8. From 1991 to 1998, health expenditures represent the expenditures of the Medicare Program and the early years of PhilHealth. Average real per capita health spending was PHP73, which represented 5.2 percent of total per capita health spending.

PhilHealth spending increased during the period 1999-2008 with the introduction of the Sponsored Program (SP). During this time, the average per capita spending was PHP136 (7.8 percent of total health spending), representing an 86 percent increase over the previous period. However, further increases were constrained by the cost of negotiating and collecting premium counterparts from 81 provinces, 143 cities, and 1,459 municipalities yearly (UPecon-HPDP, 2013a; 2013b).

42 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 4.8 Per Capita Health Expenditures of Social Health Insurance, 1991 to 2014 (in PHP at Constant 2000 Prices)

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0 1991 1995 2000 2005 2010 2014

Social Health Insurance Total Health Expenditures

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

Subsequently, with the introduction of new benefits and assumption by the national government of the full cost of premiums for the poor as identified by the National Household Targeting System for Poverty Reduction (NHTS- PR), PhilHealth per capita spending for the period 2009-2014 rose to PHP309, representing 10 percent of total health spending per capita. By 2014, PhilHealth was spending PHP476 per capita or 14 percent of total health spending. However, this amount could have been much larger given its claim to have covered 87 percent of all Filipinos in 2014 and that nearly all conditions have a corresponding benefit package. What PhilHealth has in fact managed to do is to pay a little bit of everything for all Filipinos.

While PhilHealth has enrolled 87 percent of Filipinos as of 2014, its share in total health spending remains relatively low. The share of PhilHealth in total health spending in real per capita terms increased from five percent in 1991, to nine percent in 2002, and to 14 percent in 2014, as shown in Figure 4.9. This, however, falls short of the national target of 30 percent set in the 1999 DOH Health Sector Reform Agenda (HSRA).

Figure 4.9 Social Health Insurance Share in Total Health Expenditures, 1991 to 2014 (in Percent)

16 14 14

12 10 10 9

8 5 6 7

0 1991 1995 2000 2005 2010 2014

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority 2015; Racelis et al., 2016

43 The challenges facing the National Health Insurance Program (NHIP) were already described in 1999 by the DOH HSRA, which pointed out the following: 1) an increase in the PhilHealth share in total health spending from 15 percent to 30 percent; 2) the enrollment of the poorest 25 percent of Filipinos; 3) linking PhilHealth payments to quality care; 4) coverage of out-patient benefits; and 5) accreditation of public and private facilities. In response to these challenges, innovations were introduced including the introduction of the out-patient benefit package paid through a capitation scheme, TB-DOTS package, and Maternal Care Package (MCP), among others. It should be noted that these additional out-patient packages were introduced without the accompanying premium increases.

The next wave of reforms (under DOH FOURmula One for Health) focused on enrolling the poorest 25 percent of Filipinos in PhilHealth. Regional offices of PhilHealth were strengthened and given the autonomy to negotiate with LGUs. PHIC undertook the following to encourage enrollment and remittances of LGU premium counterparts: 1) it paid capitation (PhilHealth Circular 40, s. 2000) without clear accountabilities regarding benefits to be delivered and members to be served (capitation payments were essentially used as rebates for enrollment); 2) LGUs to determine who the poor are in their jurisdictions, allowing local chief executives to use enrollment to enhance political patronage; 3) it waived accreditation requirement for RHUs and LGU hospitals, creating a double standard between public and private facilities; and 4) it set aside the mandated gradual reduction of national subsidy share premiums despite this being provided by law.

A host of “novelty” benefit packages were also introduced in response to popular demand, including packages for malaria, influenza, HIV, and AIDS. Again, these packages were introduced without corresponding adjustments in premiums.

The NHIP Law of 1995 allows for premiums to be collected in a progressive manner. The implementing rules provide for a contribution rate of no more than three percent of salaries as premium payment for regular members. However, only a 2.5 percent contribution rate has been applied. In addition, salary caps have been set too low with infrequent adjustments, preventing PhilHealth from collecting sufficient and progressive premiums. For example, in the year 2000, members with monthly salaries of PHP7,500 and above only contributed PHP187 per month to cover a family, i.e., the principal member and qualified dependents. In the same year, the salary cap was below the average family income of PHP12,000 per month. From 2012 to the present, the salary cap is set at PHP35,000 per month, implying a maximum monthly premium of PHP875 per month per family. This means that a salaried worker receiving PHP35,000 a month pays the same premium as one earning PHP100,000 a month. As implemented, the PhilHealth premium structure is grossly regressive.

A number of factors have prevented total PhilHealth spending from increasing significantly. First, for PhilHealth to deliver larger benefits, it must increase premiums, as noted above. While some adjustments in the premiums have been made, there has been no significant real increase in premiums during the period of relatively rapid economic growth, i.e., 2005-2014.

Second, using “sin taxes” to fully fund the premium subsidy of the poor simply releases LGUs from their obligation to contribute to premiums. The only real effect on benefit spending comes from the certainty of fully nationally- funded premium subsidies.

Third, the lack of information, as well as operational and procedural barriers, prevents a greater utilization of benefits by members so that premium subsidies do not get translated into benefit spending (Quimbo et al., 2008). Operational barriers include heavy documentary requirements, lack of information about membership status and benefit entitlements, and lack of access to accredited facilities.

Fourth, rising real per capita out-of-pocket spending suggests that families are accessing better quality and more expensive medical services. Because PhilHealth benefits have a fixed ceiling, its support value declines as the total health care bills increase. This pressure increases as both public and private facilities respond to rising demand.

44 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Finally, the introduction of new benefit packages without a corresponding increase in premiums also reduces support value. For example, recently introduced benefits like the Primary Care Benefit (PCB) and Case Type Z Benefit Package (Z-Package) cannot be expected to substantially raise PhilHealth share in total spending because these have been introduced within the same budget envelope. Moreover, having PhilHealth extend benefits to senior citizens, backed by less than actuarially fair premium subsidies are not likely to raise PhilHealth share to total health expenditure.

The overall impact of increasing population coverage, the introduction of new benefits, raising benefit ceilings, expanding accreditation, and raising benefit utilization can be measured in terms of the benefit delivery rate (BDR) (Millar, Javier, Norella, & Solon, 2011). The BDR, defined as the product of population coverage, benefit utilization, and support value, essentially approximates the share of PhilHealth to total health expenditures, given existing premium revenues. In 2008, the BDR was estimated at 9.5 percent, i.e., the total payments made by PhilHealth would fully reimburse only 10 of every hundred, or one out of every 10 patients. After the expansion of population coverage and introduction of new benefit packages, the BDR only increased marginally to 13.4 percent in 2012. This suggests that reforms by way of coverage, better benefits, and more effective provider payments can only do so much without raising premiums. Hence, the next wave of reforms may have to involve raising premium contributions, but conditioned on changing specific program elements to improve efficiency and equity. Premium adjustments might have to come sooner considering that as of 2015, total revenues amounted to PHP106.7 billion while total expenditures were PHP102.8 billion, with reserves at PHP131.9 billion (PHIC, 2015a). So if the current benefit spending were to increase by more than 25 percent, PhilHealth would have to raise premiums since its current reserves would only be able to support such an increase for one year.

Private insurance and HMO spending increased but spending by enterprises remained flat

Real per capita health expenditures by private health insurance and HMOs increased over the period, especially since 2005, although their level are still low relative to total health expenditures, as shown by Figure 4.10. Their share of total spending is eight percent in 2014. Spending by private enterprises, which includes direct health service spending or reimbursement of employee health expenses as part of employee fringe benefits, has remained flat relative to total health expenditures. This may be due to the slow growth of formal wage sector employment and the shift of direct spending by enterprises to private insurance and HMOs, and PhilHealth payments.

Figure 4.10 Per Capita Total Health Expenditures and Per Capita Health Expenditures of Private Insurance/HMO and Enterprises/Others, 1991 to 2014 (in PHP at Constant 2000 Prices)

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500 0 x x x x x x x x x x x x x x x x x x x x x x x x 1991 1995 2000 2005 2010 2014

Private insurance/HMO x Enterprises/Others Total Health Expenditures

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

45 Family out-of-pocket payments remain the biggest and fastest-growing financing source

Family out-of-pocket payments remain the biggest and fastest-growing financing source, as shown in Figure 4.11. Its share of total spending has more or less remained the same at around 50 percent. It is even larger than the combined amount from public and private institutional and organized sources, especially since 2005, when economic growth was higher. It has been the real, dynamic, and responsive source of financing. The increase in out-of-pocket payments is mainly driven by increasing disposable incomes of people, which coincides with rising GDP per capita.

Figure 4.11 Per Capita Total Health Expenditures and Per Capita Out-of-Pocket Payments, 1991 to 2014 (in PHP at Constant 2000 Prices)

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0 1991 1995 2000 2005 2010 2014

Out-of-Pocket Payments Total Health Expenditures

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

There are two concerns, however, regarding large out-of-pocket payments in relation to total health spending. The first is concerned with inequities where, given the uneven distribution of income, only those with capacity to pay can access needed health care. Equity concerns shall be discussed in detail later when the question on “who benefits” is addressed.

The second pertains to inefficiencies from lack of risk-pooling. A fee-for-service system financed by family out- of-pocket payments misses out on the efficiency gains from risk-pooling. Individual families will have to set aside resources equivalent to the average cost of hospitalization in the face of health risks. With a viable insurance system, individual families will have to save only the equivalent of a premium.

The efficiency gains expected from social health insurance and the public delivery system ultimately rest on their ability to leverage performance for the entire system. While social health insurance and the public delivery system accounted for 37 percent of total spending in 2014, down from 43 percent in 1991, their ability to leverage for performance is impaired by their being highly fragmented. While national government accounts for 11 percent of total health care spending, this fund is spent on various stand-alone programs. The 13 percent share of LGUs is spent by 81 provinces, 143 cities, and 1,459 municipalities, each managing its own fund independently and addressing a widely heterogeneous set of local health issues. While the social health insurance share has moderately increased to 14 percent, its influence over both the public and private health care delivery sector becomes weaker as it introduces more and more benefit packages, all funded by a fixed budget envelope.

46 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

There are undoubtedly efficiency advantages associated with out-of-pocket spending. First, it is choice-based, so that it can instill cost discipline and make high quality care available. Families can go to wherever they think they can get the best care. Second, services are not physically rationed, allowing families to access care according to capacity to pay. Third, the system being funded on a fee-for-service basis also drives innovation, thus ensuring that quality care is available. In contrast, public delivery systems, which operate on fixed budgets have less incentive to innovate and provide quality care. Fourth, an out-of-pocket funded fee-for-service system also instills discipline on the demand side. Since families pay for the full cost of care, there is a natural incentive to be less wasteful, and more careful in making choices.

The features of a fee-for-service system that generates the above efficiency needs to be carefully understood and applied in public settings. Premium discounts, expansion of benefits, and the expansion of co-pays can take the place of market-driven costs to instill discipline among PhilHealth members. For example, premium discounts can be given to the families whose children are completely vaccinated. Families whose members do not smoke or who exercise or lead healthy lifestyles may be given higher benefits to cover unpreventable diseases like those associated with aging.

Out-of-pocket payments are the largest component of total health spending, while organized public and private financing sources have remained relatively small, as shown in Figure 4.12. The good news is that real per capita health spending went up. The question, however, is: Who was responsible for the increased spending? One can see the contrast between out-of-pocket payments and the rest of the sources of spending. While out-of-pocket payments increased with economic growth, organized sources of financing were not able to cash-in on the increase in disposable income. For example, PhilHealth could have increased premiums during the economic upswing.

Figure 4.12 Per Capita Total Health Expenditures by Financing Agent, 1991 to 2014 (in PHP at Constant 2000 Prices)

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0 1991 1995 2000 2005 2010 2014

Local Government National Government Social health insurance Private insurance/HMO Enterprises/Others Out-of-pocket payments

Sources: National Statistical Coordination Board 2004, 2013, 2015; Philippine Statistics Authority, 2015; Racelis et al., 2016

For Expenditures on Health Services, Most are Paid Out-of-Pocket Even those with Public Health Benefits

Most health services in the Philippines are paid for by family out-of-pocket payments even for services with public health benefits. Figure 4.13 shows significant out-of-pocket spending for health concerns like Maternal, Neonatal and Child Health and Nutrition (MNCHN) services, respiratory infections, TB, diarrhea, and other infectious and

47 parasitic diseases. Contrary to expectations, government sources pay for less than half of total spending on these health concerns. However, there seems to be little or no willingness to pay from out-of-pocket for mental health, malaria, and HIV and AIDS.10

Figure 4.13 Per Capita Current Health Expenditures by Disease Group and by Financing Agent, 2014 (in PHP at Constant 2000 Prices)

Tuberculosis

Respiratory infections

Diarrheal diseases

HIV/AIDS and other STDs

Malaria

Neglected tropical diseases

Other infections

Vaccine preventable diseases

Cardiovascular diseases

Neoplasms

Endocrine and metabolic disorders

Other and non-communicable diseases

Maternal conditions

Perinatal conditions

Unspecified reproductive health conditions

Nutritional deficiencies

Injuries

Mental and neurological conditions

Diseases of the genito-urinary system

Other diseases.and conditions

Non-disease specific

0 10 20 30 40 50 60

Local Government National Government Foreign Assistance Social health insurance Private insurance/HMO Enterprise financing schemes Household out-of-pocket payment

Sources: 2014 National Health Accounts in Racelis et al., 2016

As Beneficiaries of Health Spending, the Poor Do Not Receive Adequate Support from Public Financing Sources

The question of who benefits from health spending can be answered by looking at health expenditures by wealth quintiles. The poor do not receive adequate support from public financing sources, as can be seen inFigure 4.14. As expected, higher income groups use out-of-pocket payments, but they also dip into public sources provided by the DOH, PhilHealth, and LGUs. The policy concern is that the poor are crowded out from public subsidies. In total,

10 Due to scale, contributions from different financing sources for mental health, HIV and AIDS, and malaria may not be visible in Figure 4.13.

48 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance higher income groups get more subsidies from various public financing sources as there is no preferential access for poor families in the health system.

Figure 4.14 Per Capita Current Health Expenditures by Financing Agent and by Income Quintile, 2014 (in PHP at Constant 2000 Prices)

10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0 First quintile Second quintile Third quintile Fourth quintile Fifth quintile (bottom) (top)

Local Government National Government Social health insurance Private insurance/HMO Enterprises/Others Out-of-pocket payments

Source: 2014 National Health Accounts in Racelis et al., 2016

It is no surprise that mainly higher income groups are better able to access health care services in general. What is a cause for concern, however, is that funds delivered through the public sector do not effectively target the poor. Moreover, where budgets are lacking, public facilities will increasingly depend on “outside purchases,” further limiting access by lower income patients who cannot afford to pay for complementary inputs. In short, the poor are unable to access health care because of their own limited resources and their inability to capture public subsidies.

A fee-for-service system, which is still what largely exists, exposes the near-poor and middle-income families to greater financial risks. These families are put in a precarious situation owing to the absence of a viable insurance scheme that effectively pools risks. Under fee-for-service, hospitalization can easily wipe out family savings and compromise future investments, including human capital. Even some of those who are slightly above the poverty line could easily fall below it if hit by a financially catastrophic illness (Van Doorslaer, et al., 2007; Ulep & dela Cruz, 2013; Brendenkamp, & Buisman, 2016).

Public Finances Should Be Consolidated to Improve Access to Health Care by the Poor

There are enough public funds to provide for those who cannot pay for their own health care owing to inequities. However, the application or the use of such funds have been rendered ineffective, especially with the devolution.

One reason is that the funds have been lodged in various independent accounts: 1,589 municipal health budgets; 81 provincial health budgets; 143 city health budgets; and the health budgets of national agencies, of which the DOH has the largest. In addition, there are institutions like the Philippine Amusement and Gaming Corporation (PAGCOR) and the Philippine Charity Sweepstakes Office (PCSO) which contribute to public funds for health. That these are in various accounts poses a challenge in terms of coordination even if they all had the same priority.

49 Two, each of the sources mentioned above may have different priorities. Overlapping priorities are expected, but what is more problematic are priorities that none of the existing sources would like to fund. An example would be family planning.

Three, even if funds were effectively pooled and directed at the same disease priorities, targeting may be problematic. For example, each of these depositories of public funds may have different ways of identifying the poor. Many of these agencies do not even have explicit targets from various age groups.

Four, these various depositories, especially local governments, may be using a wide range of technologies to deliver benefits to the beneficiaries. For example, for maternal care, some still espouse giving birth at home, while others recommend that births be done in hospitals. Variations in technology might also be depicted in terms of the presence or absence of appropriate diagnostic facilities and trained providers.

Finally, the availability of information about what was spent for what services for which families vary widely across these depositories. This makes it difficult, if not impossible, to determine the contribution of health expenditures to overall health outcomes. Consequently, future adjustments in the budget and that for each depository cannot be based on its incremental contribution to health status.

Improving access to health care by the poor requires pooling of public finances and targeting them to the poor. Two scenarios for improving access are explored under the two scenarios below.

Scenario 1: Where we could be, given current public resources

The first scenario assumes that there are no additional resources so that improvement in access to health care by the poorest three quintiles can only be obtained by removing all subsidies from the higher income quintiles and transferring these to the bottom quintiles, as shown in Figure 4.15. This can be done by charging users from the top quintiles the full cost of care through user fees. If these users continue to access public services and pay, the revenues can be used to cross-subsidize services for the poor.11 On the other hand, if they stop going to public facilities, health budgets can be freed up, allowing more resources to be used by the poor. To complement user fees, the premium contributions of families from the richer quintiles need to be increased to an amount commensurate to the benefits that they receive. For example, premium contributions can be made more progressive. Earlier the Report noted that premiums collected from payroll tax have low salary caps. These will free up enough funds to raise the health care expenditures of the lowest two quintiles without increasing out-of-pocket payments. The distribution of publicly procured commodities can also be redirected to facilities that serve poor communities. In Figure 4.15, the desired result is shown in the right panel, where the potential expenditures of the two poorest quintiles are now increased.

Scenario 2: Where we could be, given additional resources

Under the second scenario, it is assumed that additional public resources can be generated. The overall approach is to use the additional resources to even out health spending, as shown in Figure 4.16. The desired result in the right panel shows that the potential expenditures for families belonging to the poorest three quintiles have now been increased to the level of health spending by families from the second richest quintile. Expressed in terms of total expenditures for the three lowest quintiles in 2014 prices, the required increase is roughly 30 percent of total spending. It should be emphasized that the introduction of user fees, increases in premiums, and targeting of public commodities should still be undertaken.

11 This includes a substantial portion of medical assistance funds from agencies like the PCSO, which spent PHP7.99 billion in 2015 with 300,000 beneficiaries (Agoncillo, 2017).

50 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 4.15 Possible Reallocation of Current Public Funds by Quintile Where we are Where we can be 10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0 First quintile Second Third Fourth Fifth quintile First quintile Second Third Fourth Fifth quintile (bottom) quintile quintile quintile (top) (bottom) quintile quintile quintile (top)

Local Government National Government Social health insurance Transfer Private insurance/HMO Enterprises/Others Out-of-pocket payments

Sources: Authors calculations using 2014 National Health Accounts in Racelis et. al., 2016

Figure 4.16 Possible Allocation of Additional Public Funds by Quintile Where we are Where we can be 10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0 First quintile Second Third Fourth Fifth quintile First quintile Second Third Fourth Fifth quintile (bottom) quintile quintile quintile (top) (bottom) quintile quintile quintile (top)

Local Government National Government Social health insurance Private insurance/HMO Enterprises/Others Out-of-pocket payments Transfer Additional Resources

Sources: Authors calculations using 2014 National Health Accounts in Racelis et. al., 2016

51 52 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

5. REDUCING FRAGMENTATION AND EXPANDING CAPACITY TO IMPLEMENT REFORMS

In the previous sections, the Report discussed how the devolution weakened the ability of the public health care delivery and financing system to secure access to quality of care of poor Filipinos. With the devolution, the public health care delivery system, which was once an integrated network of public providers and facilities, has been fragmented into relatively independent units assigned to municipalities, cities, and provinces. These LGU-ran units also now have independently determined and executed health budgets.

In this section, possible approaches to address the fragmentation of the public health system brought about by the devolution are discussed. These include the renationalization of the devolved system, consolidation at the province level, and contracting service delivery networks. The implication for health of a move to adopt a federal form of government is also discussed.

Before discussing the merits of these approaches, there is need to point out that even the capacity needed to properly design and effectively implement reform strategies may have been weakened by the devolution itself. Fragmentation arrested the development of the capacity of health sector managers. It has also limited the growth of the community of health scientists.

Before the devolution, the establishment of an integrated public health care delivery system was the main policy instrument to secure access to health services for the poor. Health sector managers had to gain skills in setting service delivery standards, managing nationwide logistics system, and managing the deployment of health workers to various health facilities and stations all over the country. With the devolution, however, service delivery was devolved to the LGUs, effectively reducing the need for managers of networks of facilities. Moreover, public service delivery networks, which previously exerted competitive pressures on the private sector, ceased to become an effective regulatory instrument. Meanwhile, the DOH was slow at acquiring new capacities to allow it to effectively employ new regulatory instruments, especially the use of financing and contracting mechanisms.

As discussed in more detail in Section 10 on EREIDs, the need to maintain an adequate scientific community may be perceived to be lower. Owing to fragmentation, the flow of health information from frontline facilities up to research facilities would be diminished. Limited frontline capacity to detect and report problems, like unknown and rare diseases, reduces the case load of the scientific community. This, in turn, could lower effective demand for health scientists, making it difficult to argue the case to maintain investments needed by such a community.

Hence, in addition to discussing approaches to address fragmentation, this section also describes approaches to build the capacity of health sector managers and expand the community of health scientists. The approaches described here range from traditional graduate programs, collaborative research through international linkages, and mentoring.

Addressing Fragmentation Can Be Done Through Legislation or Public Financing

There are two broad approaches to address fragmentation in financing and healthcare delivery. The first is to introduce legislation amending the Local Government Code (LGC) so that service delivery networks are consolidated. The second approach is to use public financing, say through PhilHealth, to contract service delivery networks rather than individual providers.

53 Regarding the first approach, there have been suggestions for the renationalization of health services that were devolved to LGUs. There are also ongoing discussions regarding a shift to a federal form of government, which imply that health services and financing will be devolved to the federal states. This Report discusses issues regarding renationalization and federalism, as well as a possible approach to consolidation at the provincial level. This consolidation at the province level, which includes cities located within the geographic boundaries of the province, maintains the current form of decentralized government except that the assignment of health functions is given to the province instead of to each LGUs within the province.

Renationalization might reduce transactions costs in dealing with LGUs, but will require more capable managers

A common and persisting suggestion to address problems arising from the fragmentation the public health service delivery and financing is to revert to a national system of centralized “command and control” of the pre-devolution era. There are issues with this approach. With 25 years of devolution, we saw wide variation in the performance of LGUs. Some were able to make investments in their local health systems, while others not quite so. One issue with renationalization is what to do with the difference in value of the local health infrastructure before devolution versus under devolution? LGUs that did not invest in local facility upgrading due either to lack of local resources or lack of priority placed on health, may want to transfer their facilities to the central government. LGUs who made substantial investments in their local facilities, particularly hospitals, may demand payment for such investments prior to take-over by the national government, perhaps net of government investment under HFEP. For LGUs that are doing well with their local health systems, they may want to keep their facilities and personnel rather than turn them over to the national government or they may demand an opt-out clause for renationalization. If they opt-out, would they need to pay off national government for the upgrading under HFEP? What is the implication of opt-out for integration of public health delivery system? Would the LGUs who would opt-out act like part of the fragmented private sector or be part of an integrated public health delivery network through inter-LGU cooperation mechanism?

Another issue has to do with personnel. Will LGU personnel be automatically absorbed into the renationalized system or will they be terminated and rehired selectively? An advantage of renationalization is that the budgetary cap on local personal services set by the LGC would no longer constrain the hiring the needed personnel, and nationally hired personnel can be deployed anywhere in the national health service delivery system.

Assuming no opt-out and the transfer of facilities and personnel are completed (all transfer issues sorted out), what we will immediately have is a national system that inherits the wide variation in access and quality across the different provinces and municipalities. The challenge is the rebuilding for efficiency (functional networks), equity (physical and financial access) and quality of care (applying national standards for all). Perhaps, with “command and control,” the rebuilding would be relatively easier than in a devolved set up, since this would avoid the difficult task of reconciling different LGU preferences and priorities under devolution. However, with 25 years of devolution, the DOH might not be ready to manage a national health system. The scale and scope of management requirements are likely to be larger and more complex. The managerial capacity that would be required would range from formulating and implementing policy reforms to managing operations such as budget execution and supply chain management, and evaluating impacts of reforms.

Consolidating at the level of federal states may not coincide with natural healthcare markets

There had been discussions on the shift to a federal form of government since President Rodrigo Roa Duterte announced his administration’s intent to adopt a federal form of government. Key issues in adopting a federal form of government “include the allocation of functional responsibilities, taxing powers and financial resources, intergovernmental transfers and equalization, treatment of local government units, and delineation of territorial boundary of states” (PIDS, 2017). Other than the delineation of territorial boundary of states, the other issues are similar to issues faced in the devolution of political power and a number of economic and social services to local government units.

54 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

How many federal states and how the state boundaries will be delineated would depend on a number of criteria that could range from political, economic, social and historical characteristics on the one hand and considerations of economies of scale on the other (Corpuz, 2017). While a federal state system can help consolidate, within its boundaries, what is now a fragmented public health delivery system arising from the devolution in 1991, an issue is whether the delineated state boundaries would coincide with natural healthcare markets that include strategically located medical centers to complete the continuum. Whatever the size of the state and its boundaries, there is a need to delineate a catchment for a range of services and to pick the best location for facilities. This might involve a rearrangement of different types of facilities and their location to respond to a natural state level health care market.

Consolidation at the province level also faces many challenges

A viable catchment area may be a province, where a full range of public and private providers can be organized into one or more service delivery networks. A province-level approach also recognizes that many public health concerns like vector-borne diseases that cross municipal boundaries are likely to be contained within a province.

However, amending the LGC to consolidate public health services at the province level must also deal with a number of challenges, which are somewhat similar to issues in renationalization and federalism. Challenges specific to consolidation at the province include the following. First is the transfer of health personnel, facilities, assets, and budgets from municipalities and cities to the province. It is one thing to reassign property rights and plantilla items but it is more difficult to pool and raise enough resources to adequately address the needs of all constituencies within the province. Second is whether to transfer DOH property and resources to the province, considering that DOH regional facilities mainly serve residents of the province where it is located. Third is to determine the appropriate governance arrangements. One possibility is to designate the governor as the responsible and accountable person for the management of the consolidated province-wide health system. Another possibility is to create a corporate body composed of national and local governments who have contributed personnel, assets and budgets to the provincial network.

Addressing fragmentation through contracting requires legal mandate, the capacity to manage funds, and mechanisms to reduce variance in access to care

The second approach to addressing the challenge of fragmentation is to use public financing, say through PhilHealth, to contract service delivery networks rather than individual providers. It is in this context that specific proposals to reform various aspects of PhilHealth should be examined. The introduction of “pay for performance” schemes needs to be discussed in terms of delivering the continuum of care by service delivery networks composed of public and private providers. Concerns that case rates do not adequately cover costs need to be addressed, but only in the context of the continuum of care rather than individual services.

The main challenge in this approach is to pool the DOH budget, PhilHealth premiums, local government budgets, and state lotteries into a single fund that can be used to contract service delivery networks. This involves not only finding the appropriate legal mechanism to pool the funds, but also assembling the capacity to manage the fund. A second challenge is to develop a viable option in places where no service delivery networks can be contracted. The concern is for provinces where adequate facilities are not available, and for specific population groups that are in the fringes or are hard to reach. The third challenge is to determine how these contracts can help reduce the wide variance in quality of care across service delivery networks.

Whichever approach will be taken, one must address the lack of information available to poor families in terms of health risks, options for care, and sources of financing. Families must be provided with sufficient information to link up with, and navigate within, a service delivery network. The informational requirement needed for poor families to effectively access the continuum of care will become more complex and challenging so that the need for effective information delivery systems like navigation will become more important.

55 Addressing the Lack of Scientific Community Requires Sustained Investments

Scientific community needed to understand health problems and devise solutions is lacking

Analysis of key health concerns, which are described in full in Part II of this Report, has underscored the need for better scientific understanding of evolving disease burden (non-communicable diseases or NCDs), riskof epidemics (HIV and AIDS, emerging and re-emerging infectious diseases or EREIDs), cost-effective interventions in local settings (dengue, NCDs, injuries), and impact of interventions on health outcomes.

To even begin to understand evolving disease burdens, a number of outstanding questions of an empirical and scientific nature must be answered, some of which were raised earlier in this Report. One of these involves identifying specific differences in the diet between the poor and the rest of Filipinos, and how these specific differences contribute to the increasing prevalence of hypertension and diabetes mellitus. To investigate this question requires a team of scientists headed by a nutritional epidemiologist. Another question that requires currently available data pertains to why TB prevalence and incidence are projected to be on the decline yet deaths remain high. Questions like these require expertise in population dynamics and disease modelling.

In terms of assessing risk from epidemics, an example is the need to understand why HIV and AIDS prevalence remains low despite relatively low condom use and limited access to testing and antiretroviral drugs (ARVs). In addition to addressing measurement problems, hypotheses concerning changing sexual norms and practices influence HIV and AIDS prevalence need to be carefully analyzed.

In the case of severe acute respiratory syndrome (SARS) and avian flu, there are questions about how the physical environment contributes to arresting the spread of these diseases. Specifically, is there anything about the Philippine environment in terms of climate, temperature, humidity, and trade winds that reduces vulnerability to these threats? Answering these questions requires expertise in disciplines like epidemiology and infectious diseases.

Decisions on the cost-effectiveness of specific interventions have on occasion been challenged, as in the case of pneumococcal vaccines. The issue here is that there are few experts performing economic evaluations in health. Only a small pool of experts can be tapped to do cost-effectiveness analysis, as well as do independent review and validation of findings from these studies, construct league tables, and provide advice on resource allocation.

Questions on the safety of specific interventions have also been raised with the recent introduction of Dengvaxia, the world’s first dengue vaccine developed by French drug maker Sanofi Pasteur. Despite concerns about antibody dependent enhancement raised by some experts, the vaccine was licensed by the Philippine Food and Drug Administration (FDA), recommended for provisional approval by the National Formulary Committee, and was subsequently administered targeting one million children. The issue of capacity building raised by this case is to provide the FDA and similar health agencies with enough scientific capacity to appraise evidence and promote transparent discussion and debate involving a broader scientific community as basis for deciding independently.

Another controversy that has reached the Supreme Court concerns the use of contraceptive implants. As in the case of Dengvaxia, this debate boiled down to whether regulatory agencies had enough confidence in their scientific base to argue the case in court. A specific challenge is to determine whether implants are indeed non-abortifacient.

Another example concerns the scientific soundness of proposed interventions to reduce maternal deaths, which requires the ability to evaluate and attribute the impact of these interventions on specific health outcomes. For example, the Zuellig Family Foundation (ZFF) reports that training local chief executives in good governance for health led to reductions in maternal mortality in participating municipalities (ZFF, 2014). The DOH needs to develop the capacity to validate such reports as basis for promoting replication of such initiatives. This capacity includes being able to rule out the possibility that chosen municipalities were the ones more likely to yield positive outcomes. One approach is to ensure that both high and low mortality municipalities are equally likely to become

56 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance intervention sites. Moreover, mortality trends before and after the intervention need to be tracked and compared with municipalities that did not receive any intervention as control sites.

The gap in the supply of the country’s scientists can be roughly measured by a cross-country comparison the number of publications and citations in selected fields of medicine relevant to the questions raised earlier.Table 5.1 shows the H index, a measure of scientific productivity and impact of researchers, for countries with publications in infectious disease, obstetrics and gynecology, pulmonary and respiratory medicine, and cardiology and cardiovascular medicine. The table includes the Philippines and selected neighboring countries with the addition of the United States as a benchmark being the country with the highest H index.12

Table 5.1 H Index of Core Medical Fields in Selected Countries from 1996 to 2015 Infectious Diseases Obstetrics and Pulmonary & Cardiology & Gynecology Respiratory Cardiovascular Medicine Medicine United States 418 233 314 509 Malaysia 64 31 22 32 Indonesia 69 33 17 15 Vietnam 75 22 25 9 Thailand 118 43 37 48 Philippines 56 18 24 31 Source: Compiled from SCImago Journal and Country Rank (SJR)

If in the medium-term, the goal at the minimum is to build the same capacity as Thailand, then according to Table 5.1, the Philippines would have to double its scientific base in infectious disease as well as in obstetrics and gynecology. In the case of pulmonary and respiratory medicine and in cardiology and cardiovascular medicine, the base must be increased by at least 50 percent.

Moreover, the Philippines needs to draw lessons on how the Thai scientific community is supported so that it continues to grow and be an active participant in the understanding of disease burdens. One lesson from Thailand is the deliberate and sustained investments made by the government in sending scholars abroad to earn advanced degrees. Between 2002 and 2014, the Office of Civil Service Commission of Thailand sent as many as 7,000 scholars each year to study in the UK, USA, Japan, and Germany, and Australia (Lao, 2015).

Sustained public investments are needed to expand and strengthen the scientific community

As described earlier there is a need to expand and strengthen the scientific community to provide the needed expertise in helping define and prioritize health problems and scientifically evaluate appropriate interventions. Approaches to expanding and strengthening such a scientific community have been described by various organizations (e.g., Lansang & Dennis, 2004).

There is a need to undertake a systematic situation analysis with respect to the current stock of scientists and specific information on their training, institutional resources, institutional partnerships within and outside the

12 Schreiber (2008) defines H index as “the highest number of publications of a scientist that received h or more citations each while the other publications have not more than h citations each.” It is basically a measure of both the scientific productivity and the apparent scientific impact of a scientist.

57 country. From such an analysis a national plan can be formulated to include short-term and long-term strategies for capacity building directed at 1) production of individual scientists through graduate and post-graduate (master’s, doctoral, and postdoctoral) training; 2) strengthening institutional bases where trained scientists will work – to teach, undertake research, publish and pursue a career in science, including supporting outstanding research groups (Centers of Excellence); and 3) strengthening partnerships with international and national institutions.

In the past, the scientific base was developed primarily with support from international donors like theFord Foundation and Rockefeller Foundation. More recently, scientific training has been made possible through international linkages and partnerships largely based on individual initiatives. With the expanded fiscal space made possible by improved economic conditions, it is time government took on the responsibility of investing in building the scientific community over the long-term.

All the approaches to expanding and strengthening the scientific community will require new resources. Based on the experience of other countries, financing can be obtained from a range of sources: general taxation, earmarked taxes, revenues from lottery and other games of chance, development bank loans, contributions from external agencies, and earmarking a percentage of government revenues for training and research. The challenge is to distinguish more permanent and sustainable sources over temporary ones. Once identified and secured, more permanent sources like earmarked taxes may be more useful in sustaining capacity building over the long-term. On the other hand, temporary sources like loans and grants from international agencies may be useful to address current gaps immediately. These sources of funds might be more suitable in funding efforts to recruit and retain newly trained Filipino scientists abroad.

Other types of financing are those attached to the output of a built capacity. A portion of taxes raised to fund capacity building must be set aside to be delivered as research grants or awards. Local institutions, through partnerships with international institutions can tap grants for joint research and publication.

A popular approach to capacity building is to link up local institutions with research institutions and universities. The goal is for local institutions to learn and share new knowledge and technology. But what needs to be recognized is that local institutions need to have a minimum basic scientific capacity to be able to collaborate with international institutions.

Sending out young talented Filipinos to train and come back is one thing, but the problem of retention needs to be separately addressed. This, of course, is often discussed in terms of compensation and benefits. But the real challenge is to build the very local institutions to which they return to work and establish a career. Building local institutions is more than just setting aside the physical space and providing access to scientific literature and data. What may be more essential is to have a critical mass of researchers imbued with a culture of scholarship.

Expanding the Capacity To Manage Complex Reforms Require Training, Strengthening Of Institutions, And Building International Linkages

Capacity to manage an increasingly complex reform package is wanting

The DOH 1999 assessment of the health sector that supported the Health Sector Reform Agenda (HSRA) noted two capacity issues: 1) the capacity of the DOH to provide technical leadership over health programs; and 2) the capacity of the DOH to coordinate implementation by a highly decentralized system. With devolution, the DOH assessment suggested that a new management approach using tools like better information, technical competence, and financial leverage needs to be developed. The implementation of the reforms that followed the HSRA revealed gaps in management from operations such as budgetary execution and logistics management to effectively forging inter-LGU cooperation to achieve national health priority targets.

58 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

This Report identifies the broad areas where new expertise is needed. The first area of expertise thatneeds to be enhanced concerns policy development and the issuance of specific orders. This includes presenting the medical and public health arguments underlying specific policy provisions, and the drafting of the actual language of laws and regulations. In the case of Responsible Parenthood and Reproductive Health (RPRH) Law of 2012, for example, this skill set even extends beyond the drafting of the law and the IRR and into the crafting of specific arguments to defend the soundness of proposed health interventions at the Supreme Court.

Once policies have been issued, the second area of expertise needed pertains to designing an implementation strategy with corresponding field operations guidelines. The specific approaches and interventions with corresponding targets, logistic and budgetary requirements have to be developed. In the case of implementing the RPRH Law, such expertise would provide sufficient detail in designating service delivery networks, identifying specific beneficiaries, and setting the corresponding service requirements.

The third area of expertise involves deriving the budgetary and logistic requirements of the implementation strategy and operational guidelines of a given policy issuance. This requires specifying how budgets are going to be spent on the various activities, and the corresponding requirements in terms of personnel, goods and services. Such a plan must specify target beneficiaries as well as where and when such resources will be deployed. Inthe case of RPRH implementation, for example, the DOH needs to specify the necessary work and financial plans at the Department’s regional and central offices to effectively implement RPRH mandates at various levels. Budget and expenditure plans need to extend beyond the prescribed one-year budget cycle, as in the case of disease prevention and control that require multiyear programs to eliminate diseases like TB.

The fourth vital skill set has to do with the design of contracts, selection of contractors, the monitoring of deliverables and key performance indicators, and matching these with the appropriate compensation and penalties. In the case of RPRH, a specific skill needed has to do with integrating the updated family planning clinical standards manual into a contract for both public and private providers. The contracts will then draw from the clinical standards manual the measures of service deliverables, procedures, and the quality with which these shall be delivered to eventually determine compensation for the providers.

Finally, the skill set needed to tie everything together from policy to outcomes involves being able to design an impact evaluation plan supported by measurable outcomes, processes, and input indicators. A data collection plan that describes how and who will generate the information needed to measure the various indicators needs to be developed. In addition, an analysis plan needs to be put in place so that the attribution between observed impacts and outcomes to the interventions introduced are properly established.

What might be needed to address the extent of gaps in the supply of sector managers for various health reforms is the number of people with advanced degrees in management sciences in the universities or in public service. Unfortunately, information is difficult to compile for a number of countries of interest. As an alternative, this Report compares the number of publications and citations in fields related to effectively managing the health sector. The high number of publications and their frequent citations is seen as a measure of scientific activity in these fields, which are in turn, are sources of evidence for management decisions. Table 5.2 shows the H index for countries with publications in epidemiology, public health, health policy, health social science, and management science and operations research. The table includes the Philippines and selected neighboring countries with the addition of the United States as a benchmark being the country with the highest H index.

Table 5.2 shows the H index for fields relevant to the effective design, implementation, and evaluation of health sector reforms. The H index is being used as a proxy of the size and contribution of the scientific community working in epidemiology, public health, health policy, health social science, and management science and operations research.

59 Table 5.2 H Index of Fields Related to Effective Health Sector Management from 1996 to 2015 Epidemiology Public Health, Health Policy Health Management Environment (social science) Science and and Operations Occupational Research Health United States 340 364 205 187 254 Malaysia 30 41 23 15 29 Indonesia 29 46 17 24 15 Vietnam 40 51 18 27 26 Thailand 60 70 32 34 34 Philippines 26 42 22 17 6 Source: Compiled from SCImago Journal and Country Rank (SJR)

Similarly, suppose that Thailand were to be set as the Philippine benchmark for the medium-term. Using data in Table 5.2 would mean that the Philippines would have to invest in at least double the capacities in most of the fields. A special case may have to be made for management science and operations research where capacities would have to increase five times.

The lesson from Thailand, which is to send scholars abroad to get advanced degrees, may also need to be applied by the Philippines to build its health management capacity. In addition to Thailand, the Philippines also needs to pay attention especially to the more recent developments in Vietnam whose scientific community is catching up with Thailand.

Expand capacity through training, strengthening of institutions, and building international linkages

Earlier, this Report described the gaps in the supply of expertise in the fields related to effective management of health sector reform. Building the supply of such expertise follows more or less the approaches described for expanding and strengthening the scientific community in core medical fields. This involves situation analysis and adoption of the three major approaches to capacity building: 1) graduate and short-term training, 2) strengthening of institutional base in which these trained experts will work; and 3) strengthening of institutional linkages with the rest of the world.

It may be worth investing in young talented professionals to get advanced degrees such as Master of Business Administration (MBA) and Master of Public Health (MPH). Locally, programs offered by the University of the Philippines (UP), Ateneo De Manila University, De La Salle University, and the Asian Institute of Management are highly recommended. International programs such as those offered by Harvard University and Johns Hopkins University in the US, and regional programs at National University of Singapore and Mahidol University in Thailand are also suggested.

Middle level managers in health agencies may be sent to short training courses. Useful ones include the World Bank Institute’s Flagship Program on Health Sector Reform and Financing, the short course on private health insurance and social health insurance at the University of Cape Town’s Health Economic Unit, executive courses in public policy at RAND, short courses on health financing by the Royal Tropical Institute of Amsterdam, short courses on health financing and equity by FUNSALUD in Mexico, and the training course on social health insurance by the National Health Insurance Services of Korea.

60 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

A key consideration in selecting short training programs is to see how participants are introduced to reform levers including financing, financial incentives to providers and consumers, organization of the delivery system, regulation, and behavior change. Training can occur at different levels of management and can focus on theme-specific issues such as health financing and targeting public subsidies, performance-based contracting, public policy and the private sector, decentralization, and quality improvements.

Public investments are also needed to allow local institutions to link up with their international counterparts. Major local institutions include the UP College of Medicine, UP College of Public Health, UP Visayas, Ateneo School of Medicine and Public Health, Ateneo School of Government, AIM, Silliman University, University of San Carlos, and research institutions such as UP National Institute of Health, UP Population Institute, Philippine Institute for Development Studies, and Social Development Research Center. On the other side, the FUNSALUD of Mexico, the Institute of Health Metrics and Evaluation (University of Washington), and the Institute of Global Health at the University of California-San Francisco are examples of networks that our local institutions can join and collaborate.

Another type of short-term training is the coaching/mentoring of middle level managers by experts from the scientific community either within or outside the country on the implementation of specific reform measures. This transfer of knowledge and skills can be done quickly, until staff sent for advanced studies return home. Lansang and Dennis (2004) cited the International Health Policy Program of Thailand which provided mentoring for policy analysts and researchers at the Thai Ministry of Public Health and the Health Systems Research Institute.

There will no doubt be challenges to capacity building programs. The first is the fragmentation of the public health delivery and financing system itself. The current system is so fragmented that there is very little externality generated from training. For example, there is very little opportunity for trained municipal health officers to share knowledge and new expertise with other municipal health officers. There is also limited opportunity to build upon training because career paths of local health personnel tend to be closed and possibly uncertain due to the vagaries of local politics.

A final challenge is to recruit and retain health sector managers. Though not discussed earlier, a key to attracting and retaining competent reform managers in the health sector is the provision of a competitive compensation package. Providing a competitive package for health managers does not mean matching the pay grade of private sector managers, because serving government implies a certain level of commitment and dedication to public service. However, compensation needs to be set so that it is commensurate to the effort, skill, and responsibility, and would ensure that the public health manager is able to afford a decent standard of living.

61 62 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance PART II: Fundamental Problems and Strategic Responses to Specific Health Problems

Ensuring a Continuum of Care to Improve Maternal and Neonatal Health

Intensifying Tuberculosis Control in High Burden Areas

Adopting a Programmatic Approach to HIV and AIDS Prevention and Control

Adopting a Set of Cost- Effective Interventions to Reduce Mortality and Morbidity from Non- Communicable Diseases

Investing in Capacity to Respond to Threat from Emerging and Re-Emerging Infectious Diseases

Strengthening the Process of Accountability to Reduce the Burden of Vaccine- Preventable Diseases

Investing in Inter- Jurisdictional Emergency Services for Injuries and Disasters

63 64 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

6. eNSURING A CONTINUUM OF CARE TO IMPROVE MATERNAL AND NEONATAL HEALTH

Maternal and neonatal deaths have not declined over the last 25 years. The Report argues that these deaths can be prevented by providing access to a continuum of care with a more effective set of interventions than what is currently available in the public health care delivery system. These more effective interventions require a higher level of expertise and more advanced technology that can be provided by doctors and hospitals, rather than by midwives and birthing homes.

The main hypothesis of the Report is that further decline in maternal and neonatal deaths can only be achieved if more advanced interventions in the continuum of care can be provided, especially to the poor. A comparison of Malaysia, Indonesia, Thailand, and Vietnam with the Philippines shows that further reduction in maternal deaths is associated with more deliveries being attended to by doctors in a hospital setting.

A challenge to implementing these more effective and advanced interventions for maternal and neonatal care at scale is the fragmentation of the public health care delivery system. In particular, there is concern about the capability of LGUs to hire more doctors, invest in better facilities and financially sustain the operation of these facilities. Data suggest that the gap between what kind of services are available in the public health system and what is needed to reduce maternal and neonatal deaths remains large and varies widely across provinces.

In order to address the wide gap and variation, four things need to happen: 1) the DOH needs to review the standards of care to reflect the new continuum; 2) the DOH needs to review existing approaches and develop new means to generate demand for services in the new continuum; 3) the PHIC needs to adjust the rates for its maternal and neonatal care packages to reflect the cost of the new continuum; and 4) the PHIC needs to contract service delivery networks composed of public and private facilities that can deliver the new set of interventions in the continuum of care.

Maternal and neonatal deaths have not declined over the last 25 years

The Philippines failed to meet its MDG commitment to reduce maternal mortality to 52 per 100,000 live births by 2015. Figure 6.1 shows the maternal mortality ratio based on three sources of data, namely, the demographic and health surveys, the civil registry and vital statistics (CRVS), and the DOH administrative data consisting mainly of public sector reports. All three sources suggest that maternal mortality ratio (MMR) has essentially remained the same in the last 30 years.

The Philippine Statistics Authority (PSA) surveys, which include several rounds of the National Demographic and Health Survey (NDHS), the Family Planning Survey (FPS) of 2006 and Family Health Survey (FHS) of 2011 report higher levels of MMR but with large confidence intervals. The more recent 2015 National Nutrition Survey (NNS), which reported a maternal mortality ratio (MMR) of 204 per 100,000 live births, also has a wide confidence interval ranging from 155 to 252 per 100,000 live births that overlaps with estimates from previous years.

Data from the Civil Registry show MMR to have fluctuated from 70 to 112 per 100,000 live births from 1986 to 2000. In more recent years, the MMR has fluctuated between 80 and 110 per 100,000 live births. It can be noted

65 Figure 6.1 Maternal Mortality Ratio from Surveys, Civil Registry, and DOH (Per 100,000 Live Births)

300

250 FHS DHS DHS 200 NNS DHS FPS 150 Civil Registry

100

50 DOH

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Sources: 1986, 1993, 1998 National Demographic and Health Survey (NDHS); 2006 Family Planning Survey (FPS); 2011 Family Health Survey (FHS); 2015 National Nutrition Survey (NNS); Civil Registry/ Philippine Statistical Authority (PSA); DOH administrative data/Field Health Service Information System (FHSIS)

that mortality figures from the Civil Registry are lower than that of the surveys. This is explained by limitations in the ability of the Civil Registry to capture the actual number of deaths.13

MMR estimates using DOH administrative data from 1995 to 2013 show a lower range of 60 to 70 per 100,000 live births. These data are mainly based on reports from local health authorities. Administrative data on maternal deaths can be underestimated if local health authorities are unable to account for deaths in private facilities, in the community or those that are registered in the local civil registry.14

The infant mortality rate (IMR) has substantially declined in the 1980s, but the rate of decline from 1990 onwards has slowed down, as shown in Figure 6.2. The NDHS of 2003, 2008, 2011, and 2013 also show no significant decline in neonatal mortality rate (NMR). Data from the Civil Registry also show a similar trend that NMR has not significantly changed in the last 10 years.

Studies suggest that the decline in IMRs in the late 1970s to the 1980s have largely been attributed to improved socioeconomic status of households (Cabigon, 2002; Concepcion, 1982), mother’s education, clean toilet facilities (Cabigon, 2002). However, the slowing down in the decline of IMR from the early 1990s may be due to the persistently high neonatal mortality (Kraft, Nguyen, Jimenez-Soto, & Hodge, 2013). This makes further decline in under five and infant mortality rates are highly dependent on neonatal mortality rates.

13 The World Health Organization (WHO) Task Force on Maternal Mortality recommends that estimates based on the Civil Registry be adjusted with a factor 1.5 to account for underreporting (WHO, 2013a). When the civil registry figures are adjusted, the estimated MMR will closely approximate that of the survey. 14 Deaths are reported by place of occurrence and not based on residence. This can attribute a higher number of deaths to one locality, particularly the LGU where cases are referred. The lack of information on place of residence prevents the identification of local factors that led to death. Non- residents who die in local health facilities may not be recorded in their own LGU. There is a lack of systematic mechanism for one LGU to forward this information to the LGU where the deceased mother is a resident. However, how widespread this situation is cannot be ascertained.

66 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 6.2 Infant and Neonatal Mortality Rates, 1980 to 2014 (per 1,000 Live Births)

50 IMR (PSA) 45

25 NMR (PSA) NMR (Survey) 20 x x x x 15 x x x x x x x 10 x x x x x x x x x x x x x 5 x x x x x x x

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Sources: 2003, 2008, 2013 NDHS; 2011 FHS; 2015 NNS; CRVS (PSA)

Most maternal and neonatal deaths are due to preventable causes

As shown in Figure 6.3, up to two-thirds of maternal deaths is attributable to hemorrhage and hypertension. The risk factors for hemorrhage include high-parity and multiple pregnancies. On the other hand, the risk from gestational hypertension is increased by the first pregnancy, multiple pregnancies, history of chronic hypertension, gestational diabetes, and maternal age below 20 years old and over 35 years old. Furthermore, the incidence of gestational hypertension is also elevated among pregnant teenagers.15

Figure 6.3 Counts of Age-Specific Causes of Maternal Deaths, 2012

350

300 74 75 250

34 68 200 122 45 106 150 79 78 13 79 34 18 100 15 12 36 8 8 112 50 88 89 100 50 65 0 Under 20 20-24 25-29 30-34 35-39 40 and above

Gestational HPN, Pre-eclampsia, and Eclampsia Indirect Causes Hemorrhage (Antepartum, Intrapartum and Postpartum) Others

Source: 2012 PSA Vital Statistics

15 This is due to the underdeveloped cardiovascular system of adolescents, which has to cope with the extra circulatory load brought about by pregnancy (National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy, 2000).

67 In the case of neonatal mortality, up to three-fourths of deaths can be attributed to disorders associated with low birth weight and prematurity, infections and complications from labor and delivery, as shown in Figure 6.4. Infections account for about a third of all neonatal deaths. In the early neonatal phase, these infections are usually acquired from the mother such as streptococcal infections. During the late neonatal phase, as much as half of deaths are due to infections that may have been acquired at the place of delivery or in the community.

Figure 6.4 Number of Neonatal Deaths by Cause, 2012

12,000

10,000

1,988 8,000 1,718 6,000

4,000 3,620

847 2,000 206 2,572 379 1,429 0 Early neonatal Late neonatal

Infections Disorders Primarily Associated with Birth Weight and Gestational Age Disorders Primarily Associated with Intrapartum Event Others

Source: 2012 PSA Vital Statistics

Prevent deaths by using more advanced and effective interventions in the continuum of care

The Report argues that providing access to a continuum of care (Kerber et al., 200716) can prevent maternal and neonatal deaths. The provision of an interconnected set of services delivered appropriately and in a timely manner across each of the life stages from pre-pregnancy all the way to postpartum and postnatal care has been proven to be lifesaving and cost-effective.17

The potential returns to securing access to services in a continuum of care, such as the ones shown in Table 6.1, are high. As suggested by a study of 75 high-burden countries, increased coverage and improved quality of pre-pregnancy, antenatal, intrapartum, and postpartum interventions could avert 71 percent of neonatal deaths, and 54 percent of maternal deaths per year (Bhutta et al., 2014). In particular, family planning programs generate high returns, especially in countries with current high fertility rates, through its effect on the demographic dividend. In addition, there may be specifically high returns on investment in maternal care for adolescents, given

16 Kerber et al. (2007) explains that “the health of mothers, newborn babies, and children consists of sequential stages and transitions throughout the life cycle. Women need services to help them to plan and space their pregnancies and to avoid or treat sexually transmitted infections (STIs). Pregnant women need antenatal care that is linked to safe childbirth care provided by skilled attendants. Both mothers and babies need postnatal care during the crucial 6 weeks after birth; postnatal care should also link the mother to family-planning services and the baby to child health care. Adolescents need education and services for nutritional, sexual, and reproductive health. If women, babies, children, or adolescents experience complications or illness at any point, continuity of care from household to hospital, with referral and timely emergency management, is crucial.” 17 The continuum of care has dimensions of service delivery across time, space, and type of care. The services in this continuum span the different stages of the life cycle from adolescence, pregnancy, postnatal period, and childhood. Delivering these services require functional linkages at different levels of health care from the home to health facilities (Stenberg et al., 2016), including system interventions, e.g., coordinated referrals, emergency transportation, and communication.

68 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance that adolescent pregnancies pose a much higher risk for both mother and newborn (Stenberg et al., 2016; Patton et al., 2009). Specific nutrition interventions also underlie the clinical interventions outlined in Table 6.1.18

Table 6.1 Indicative Maternal and Neonatal Interventions in a Continuum of Care Life-Stage MATERNAL Interventions NEONATAL Interventions Pre-pregnancy Modern family planning Pregnancy Antenatal Care, including screening and management of co-morbidities (e.g., hypertension and infections) Birth planning Folic acid supplementation Labor and Delivery Clean and Safe Delivery, including Essential Intrapartum and Newborn Caesarian Section (CS) Care (EINC) Corticosteroids for preterm delivery Partograph Postpartum/ Postnatal Postpartum care and management Postnatal care, including of complications (e.g., hemorrhage) management of complications Postpartum family planning (e.g., infections) System intervention, e.g., coordinated referral, emergency transportation and communication Source: Compiled from Disease Control Priorities 3 (DCP3) (2016) and DOH MNCHN Manual of Operations (2011)

But for the Philippines to further reduce maternal and neonatal mortality, it needs to implement a set of interventions that respond to the specific drivers of maternal and neonatal morbidity. This will require interventions that are more advanced and effective than what is currently and routinely available in the public health care delivery system. Moreover, these services should be made available at scale, especially in areas that have the highest burden of maternal and neonatal deaths.

For modern family planning, this will require scaling up more effective methods like progestin subdermal implants (UPecon-HPDP, 2015; Trussel et al., 2009). This is in contrast to the current method mix dominated by oral contraceptive pills and injectables (PSA and ICF International, 2014), that are highly dependent on adherence of users, require frequent access to trained providers and steady commodity supply (Trussel & Wynn, 2008).

For antenatal, there is need for advanced diagnostic equipment like an ultrasound machine and blood tests to screen and provide proper management of co-morbid conditions like hypertension19, diabetes20, placental abnormalities21, and infections.22 This is in contrast to current practice where compliance to the required four antenatal care visits is low, and basic screening as well as treatment services are not adequately provided, as described in Section 3 of this Report.

18 At the pregnancy stage, for example, the mother needs to receive advice regarding the importance of maternal nutrition and exclusive breastfeeding, including iron and folate supplementation. At the postpartum stage, early latching is encouraged as part of newborn care. The neonate should then be exclusively breastfed for at least the first six months of life. Poor nutrition in the neonatal phase contributes to undernutrition, particularly stunting, during childhood. It should be emphasized that during these stages, the mother should also receive proper nutrition. These and other issues related to childhood stunting, as well as recommendations, are discussed in Herrin (2016). 19 While blood pressure screening and monitoring can be done readily at RHUs, managing hypertension in pregnancy also require baseline and monitoring using blood tests and ultrasound. Dietary supplementation with calcium and low-dose aspirin are currently the only effective means of reducing preeclampsia risk in selected populations but these interventions are not routinely available in RHUs19. 20 Blood glucose and glycated hemoglobin tests need to be periodically performed as well as insulin therapy is required for gestational diabetes 21 Placental abnormalities like placenta previa can be detected either clinically or by use of ultrasound and will likely need surgical intervention. 22 Antibiotic treatment is needed to manage maternal infections that can potentially be passed on to the neonate during the antenatal period (Gomez et al., 2013). Two doses of tetanus toxoid can also reduce mortality from neonatal tetanus by 94 percent (Blencowe et al., 2010).

69 Managing these co-morbid conditions during the antenatal phase is critical as these are associated with the maternal and neonatal complications that eventually lead to deaths. Specifically, gestational hypertension and diabetes increase the risk of labor complications, placental abnormalities often cause hemorrhage, maternal infections are associated with premature deliveries, and neonatal infections that can lead to neonatal deaths.

During delivery and the postpartum and postnatal stage, the routine use of uterotonics like oxytocin in the active management of the third stage of labor (AMTSL) can prevent postpartum hemorrhage (Black, Laximinarayan, Temmerman, & Walker, 2016). In addition, the use of a partograph is useful in diagnosing obstructed labor and promotes early referral. However, preventing deaths from eclampsia and hemorrhage will require access to emergency care23, surgery and blood supply as stand by capacity.

On the other hand, the provision of routine essential intrapartum and newborn care (EINC)24 in all health care facilities helps improve neonatal outcomes (UNDP, 2013).25 Continuing essential newborn care, during home visits by community health workers in the first week after birth, has also been shown to significantly reduce neonatal mortality (Black et al., 2016). Meanwhile, antibiotic treatment for maternal infections, proper dry cord care (i.e., umbilical stump) and breastfeeding reduces infections. But preventing deaths from neonatal complications such as those associated with prematurity or infections will require additional interventions like surfactant therapy, antibiotics and neonatal intensive care as a stand by capacity to manage conditions owing to infections, prematurity, and low birth weight.

Underlying all these interventions within the continuum of care for maternal and neonatal conditions is a demand generation strategy that can effectively guide women in seeking care, especially those who are poor and less educated. Early attempts at introducing navigation services showed promising results in raising the use of family planning and facility based services.26 In another demo study, the use of the CCT/4Ps platform in the context of a service delivery network also improved family planning and FBD use rates.27

Since 2008, DOH has shifted to a maternal and neonatal mortality reduction strategy anchored on facility-based deliveries. This was followed by sizable investments in developing basic and comprehensive emergency obstetric and neonatal care capacities in public facilities. But the effectiveness of these investments is highly dependent on being able to provide the needed life-saving interventions across the continuum in a timely manner, and at scale. The UNFPA study reporting that only four percent of BEmONCs are able to provide all the signal functions indicates that this emergency capacity is sorely lacking. Access to emergency transport and communication facilities, especially for mothers who deliver at home or in birthing homes, is also necessary but is not widely available.

Access to doctors and hospitals is key to reducing maternal and neonatal mortality

The main hypothesis of the Report is that further decline in maternal and neonatal deaths can only be achieved if more advanced interventions in the continuum of care can be provided, especially to the poor. As midwives and birthing homes can only provide a limited set of services, preventing deaths will require increased access to doctors and well-equipped hospitals.

23 Midwives are allowed to administer a loading dose of Magnesium sulfate to prevent preeclampsia but the mother has to be referred immediately to a hospital for definitive care. 24 EINC are evidence-based standards for safe delivery of mothers and their newborns, delivered within the first 48 hours, and a week of life for the newborn. 25 Among low-birth weight infants, kangaroo mother care has been shown to reduce neonatal mortality by 40 percent, hypothermia by 66 percent, and nosocomial infection by 55 percent (Black et al., 2016). 26 In the Family Health Book pilot study in Compostela Valley, the use of a navigator, book and health use plan was able to raise FP use and FBD, by as much as 35 and 30 percentage points from baseline, respectively. 27 In the MNCHN Scale Up demo studies in Pangasinan, Quezon City, Batangas City, Leyte and Davao del Sur, using the CCT/4Ps platform in a service delivery network was able to raise FP use and FBD, by as much as three and 34 percentage points from baseline, respectively.

70 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

To verify this hypothesis, the Report examined long-term trends in maternal mortality for the Philippines from 1960 to 2015. In addition, the Report also compared observed maternal mortality patterns of the Philippines with that of selected ASEAN countries to draw inferences on what type of interventions could explain the trends. While only maternal mortality is being discussed in this analysis, it is a suitable proxy for neonatal mortality with the two being closely related as to its various determinants (Lassi, Salam, Das, & Bhutta, 2014).

Two data plots for the Philippines are shown in Figure 6.5. The trend line from 1990 to 2015 is data from WHO, while the trend line from 1960 to 2013 is from the civil registry. It is likely that the difference between the two lines has to do with adjustments made by the WHO to account for underreporting. Assuming that underreporting is consistent through time, the unadjusted trend line from the civil registry would still be useful in the analysis.

Figure 6.5 Cross Country Maternal Mortality Ratio (per 100,000 Live Births)

500

450

400

350

300

250

200

150

100

0 8 960 970 1 1962 1964 1966 1968 1 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 199 2000 2002 2004 2006 2008 2010 2012 2014

Philippines (WHO) Malaysia Indonesia Philippines (CRVS) Thailand Vietnam

Sources:1960-2013 Philippine Health Statistics and WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division (2015)

71 The MMR trend line for the Philippines may be broken into two segments. One segment, which runs from 1960 to 1980, shows a declining trend of MMR from 260 to around 100 per 100,000 live births. The other segment, which runs from 1981 to 2014, shows MMR to have remained relatively flat at around 100 per 100,000 live births. The questions that this raises are: What caused the decline in the first segment? And why this did not cause MMR to continue to decline into the second segment?

The lack of data prevents comparing mortality trends from 1960 to 1990 for the selected ASEAN countries. But a common pattern observed for Malaysia, Thailand, and the Philippines is that the MMR trend for these three countries have essentially remained the same from 1990 to 2015. The difference, of course, is that Malaysia and Thailand have much lower MMR levels. While MMR for the three countries seem to have moved sideways, the question is what accounts for the differences in the levels. Interestingly, the answer to this question might actually be the same one that would explain the continuous decline in MMR for Indonesia and Vietnam.

Another hypothesis of this Report is that any declining trend in the pattern represents the effect of the introduction of new and more effective health interventions. Similarly, any flat trend would suggest that the existing set of health interventions has likely exhausted its potential, so that the incremental effects are close to zero.

There are two inferences that can be made from these observations. One, that the Philippines, Malaysia, and Thailand are using different sets of interventions to reduce maternal mortality that have already exhausted their potentials. Obviously, Malaysia and Thailand are likely using a more effective set of interventions than the Philippines. Two, Indonesia and Vietnam have introduced a new and effective set of interventions that could explain the decline in MMR from 1990 to 2015.

The pattern of declining MMR levels that was observed for the Philippines from 1960 to 1980 could be attributed to the adoption of increasingly more effective interventions over time. Maternal and neonatal care shifted away from traditional birth attendants to trained birth attendants and eventually, professionally-trained midwives as part of the primary health care strategy. Deliveries also shifted away from the home into birthing clinics and later into hospitals as district health systems became more widespread.

Obviously, the deployment of more skilled personnel professionally-trained midwives providing the continuum of care from family planning, antenatal care to normal vaginal delivery would be more effective compared to the widespread practice of home deliveries assisted by traditional birth attendants. In addition, the district health system expanded access to the continuum of care as they were being established in communities not served by modern providers. It should be noted however, that the more effective set of interventions offered by the district health systems was already available in the private sector, but only to segments of the Philippine population who can afford to pay out-of-pocket when seeking care in private hospitals.

The pattern shown in Figure 6.3 shows that by the 1980s, the effectiveness of this set of interventions may have reached its potential to further reduce MMR. The question then as to what interventions other countries introduced that further reduced maternal mortality may be found by comparing performance of the Philippines and selected ASEAN countries.

The success of countries like Thailand and Malaysia may be attributed to having been able to make the more effective interventions available much earlier and at scale. Meanwhile, countries like Vietnam and Indonesia appear to be well on their way in introducing such interventions to a wider population.28

28 Given the leading causes of maternal and neonatal deaths in the Philippines, reducing MMR below 100 per 100,000 births would require a set of interventions that would be allow detection, treatment and referral of complicated cases that cannot be handled by midwives in the current RHU/ birthing clinic setting. As shall be discussed later, the average RHU will not have the capability of detecting and handling complications such as diabetes. Moreover, many district hospitals, which serve as the referral facility for the RHU, do not have the capacity to do caesarean sections and provide blood transfusions.

72 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Following Malaysia and Thailand, if access to physicians and hospital-based maternal services became widely available, the Philippines might be able to reduce maternal mortality by up to 70 percent by avoiding deaths owing to hemorrhage and hypertension, as shown in Figure 6.6.

Figure 6.6 Deliveries Attended by a Doctor (Percent of Total)

100

0 8 1987 198 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Philippines (P) Indonesia (I) Thailand (T) Vietnam (V)

Sources: 1960-2013 Philippine Health Statistics and WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division (2015)

The Report argues that the doctor is a suitable standard in comparing the prevailing technology for reducing maternal deaths across countries. After all, it is the doctor who has the wider range of knowledge and skills required in providing services across the continuum of care as described in Table 6.1. More importantly, it is also the doctor who is most capable of determining what type of clinical care is needed, especially during complications. It is also the doctor who drives the demand for facilities to have the necessary diagnostic equipment and supplies. In case such facilities are not present, it is also the doctor who knows best when and where to refer patients. In Thailand and Vietnam, more than 80 percent of births are attended by a doctor (see Figure 6.4). In contrast, only 40 percent of births in the Philippines are doctor-attended (the same level as Thailand thirty years ago). Among poor Filipinos, only 15 percent of births are attended by doctors (PSA & ICF International, 2014).

On the other hand, hospital-based delivery is also used as a common standard in comparing these countries. This is because delivery in hospitals can proxy for the equipment and supplies needed to manage complicated births, such as having an operating room, surgical and anesthesia equipment, as well as blood supply and other emergency medicines. While there is lack of comparable data specific to hospital-based births, it can be inferred that most births in Thailand and Vietnam, are also done in hospitals given the high proportion of facility-based deliveries as shown in Figure 6.7 and high rates of attendance by doctors. In Malaysia, all births are delivered in a hospital facility, 80 percent of which are in public facilities (Ministry of Health Malaysia, 2016). In the Philippines,

73 the proportion of births delivered in health facilities is only 60 percent and among the poorest, less than 30 percent of deliveries are done in hospitals.29

Figure 6.7 Births Delivered in a Health Facility (Percent of total)

100

0 5 7 8 4 988 993 003 011 1987 1 1989 1990 1991 1992 1 1994 199 1996 199 199 1999 2000 2001 2002 2 200 2005 2006 2007 2008 2009 2010 2 2012 2013 2014

Philippines (P) Malaysia (M) Indonesia (I) Thailand (T) Vietnam (V) Source: data.unicef.org, 2017

Fragmentation poses a challenge to implementing more effective interventions at scale

A challenge to implementing these more effective and advanced interventions for maternal and neonatal care at scale is the fragmentation of the public health care delivery system. The delivery of maternal and neonatal care services covers the continuum from pre-pregnancy, pregnancy, delivery, and postpartum and postnatal care. Providing these services involves different levels of healthcare facilities from health centers and clinics to birthing homes and to hospitals. With devolution, ownership and management of these public health facilities have been delegated to local authorities that are autonomous and independently operate from one another. For example, BHSs, RHUs, and birthing homes where family planning, ANC, normal deliveries, and postpartum and postnatal care can be provided are operated by municipalities or cities. However, district and provincial hospitals that are referral facilities for complicated deliveries and permanent methods of modern family planning are under the authority of provincial governments. Lastly, regional medical centers that serve as end referral facilities for complicated cases that need intensive care are owned by the national government. As a result, accountability for maternal and neonatal outcomes is difficult to assign.

29 Computed from NDHS 2013.

74 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

While fragmentation owing to devolution has not actually affected the rate of maternal and neonatal deaths, it may have prevented the shift to more effective interventions as providing access to the continuum of care became subject to the preferences and capacities of local authorities.30 In particular, there is concern about the capability of LGUs to hire more doctors, invest in better facilities, procure supplies and sustain the operation of these facilities. These require substantial investments in capital upgrading and personnel. Even if DOH provided support in upgrading facilities and equipment, not all LGUs are capable of shouldering the additional operating cost of hiring and training personnel, procuring adequate supplies, and maintaining upgraded facilities.31

This is particularly true for LGUs that have limited capacity to raise local revenue such as those that have a population that is too small to viably maintain higher level facilities. Devolution also limited career paths of doctors as the public health system was now divided across different jurisdictions. For example, the position of municipal health officer is already the highest public health post available for a municipal doctor, unless he or she opts to apply for a post outside of the municipal or city government.

Gap in access to services is large and varies widely across provinces

Various data suggest that the gap between what kind of services are available in the public health system and what is needed to further reduce maternal and neonatal deaths remains large and varies widely across provinces.

In the case of modern family planning, the varying preferences and capacities of LGUs manifest in their willingness and ability to procure family planning commodities, as mentioned earlier in this Report. Some LGUs even issued ordinances that banned artificial methods of modern family planning (Lee, Nacionales, & Pedroso, 2009) even after the RPRH Law was passed (Villa, 2016).32

For antenatal care, iron and folic acid supplements are procured and distributed by DOH, but calcium supplements and low-dose aspirin for mothers at risk of gestational hypertension are not provided by LGUs nor by the DOH. Moreover, the proportion of women with urine sample and blood sample taken during antenatal care are still low at 65 percent and 59 percent, respectively. Despite clear guidelines on the performance of these tests and the simplicity of equipment and reagents needed, it seems that the public health delivery system is able to screen only half of pregnant women for such complications as gestational hypertension, anemia, and urinary infections.

Moreover, the 2013 NDHS survey shows that the women who reported that they did not receive information about pregnancy complications during ANC visits were younger, poorer, and less educated. This points out the need for more effective ways of delivering information to women with this set of background characteristics. These observed gaps may be due to factors that include the lack of clear understanding of standards, unavailability of trained personnel, poor enforcement of regulations, lack of capacity to invest in acquiring the necessary equipment and expertise, or a combination of these.

30 Both maternal and neonatal mortality rates have essentially been flat even before devolution up to present. This may be due to the fact that the set of interventions that led to the decline in MMR from the 1960s to 1980s, i.e., antenatal care and skilled attendance at births can be readily delivered by individual municipalities and cities. This may have allowed the Philippines to sustain its gains in reducing maternal and neonatal deaths since the 1980s. 31 In 2010, only 10 percent of RHUs were accredited for the maternity care package, implying that only a few meet the ideal standards for providing maternal care. The proportion of RHUs that meet MCP accreditation requirements increased to 46 percent in 2015. With around half of RHUs still not accredited for MCP, despite receiving support to upgrade the physical structure and equipment, this implies that half of LGUs may have been unable to deploy the necessary staff or secure needed budgets to operate upgraded facilities. This is one explanation for the wide variation in the capacity of health facilities to provide mandated services. As a result, facilities that are unable to deliver such mandated services would likely refer their clients to other providers that end up absorbing this undue burden. For example, many district and provincial hospitals, including DOH medical centers get swamped with normal deliveries due to the lack of birthing homes in some municipalities. 32 The issuance of ordinances by these LGUs are associated with the anti-artificial contraception stance taken by its local chief executive that is also consistent with the position of the Catholic Church.

75 During labor and delivery, the main problem is that around 30 percent of pregnant women, or roughly 600,000, deliver at home (PSA and ICF International, 2014)33 where interventions to avoid maternal and neonatal deaths are not available. Home deliveries are considered risky for both mother and neonate because access to clean and safe delivery services are not readily available. It is also likely that early signs of complication will be missed and prompt referral to facilities will be difficult. From the 2013 NDHS, the top three reasons cited for not delivering in a facility were: 1) cost, 2) deemed unnecessary, and 3) the facility is too far or no means of transportation. This implies that local health authorities vary in their ability to inform mothers and provide the needed support for accessing maternal and neonatal care.

Of those that delivered in facilities, many are exposed to unsafe practices. Up to 70 percent of patients in RHUs were subjected to fundal pressure, while more than a third underwent routine episiotomy, or had their babies bathed within six hours from birth. The same practices were observed to occur even in hospitals where health workers are expected to be more specialized and updated with the most current practice guidelines (UPecon-HPDP, 2015a). On the other hand, those who deliver in public facilities and private lying-in clinics may also be exposed to undue risks, with 14 percent of public facilities and five percent of private lying-in clinics do not have oxytocin (UPecon- HPDP, 2014a). This is alarming as oxytocin is the main drug to prevent hemorrhage. In addition, only a fourth of private lying-in clinics and half of public birthing homes have magnesium sulfate in stock. This means that when there is a case of pre-eclampsia, these facilities will be unable to provide the loading dose prior to referral.

Moreover, many women deliver in facilities that are unable to manage complications. A study on basic emergency obstetric and newborn care (BEmONC) functionality of RHUs (UNFPA, 2014), also showed that out of 95 centers assessed, only four were performing the seven signal functions34 expected of such a facility.35 Moreover, only 22 percent of district hospitals can perform CS, and less than 70 percent can provide blood transfusion services. Delay in access to these lifesaving interventions increases the risk of dying for both mother and baby. Among the reasons cited for the non-provision of caesarean services include: 1) lack of staff, i.e., surgeons, Ob-Gyne, and anesthesiologist, to perform CS; and 2) no operating room or emergency room.

Lastly, utilization of postpartum and postnatal services is low. Using postnatal check-up as a proxy indicator for postpartum care, around 20 percent of all mothers and newborns did not undergo check-up within the first 28 days after birth. Of those that did not undergo check-up, around half were from poor households. This could indicate that both early and late complications in the postpartum and postnatal phase are not properly addressed. Within the critical first week of life, only around 60 percent of all newborns were able to undergo postnatal check-up (PSA & ICF International, 2014).

As reported in the 2013 NDHS, around half of poor mothers did not undergo postpartum care from health professionals. Of these women, more than half reported receiving postpartum care with a hilot or traditional birth attendant (PSA, 2014). This gap in postpartum care may be driven by the lack of information on the importance of postpartum care received from health professionals as well as the limited access to providers. There is need

33 Of these, it is estimated that 475,000 women belong to poor households. From the 2013 NDHS, home delivery is highest among older mothers in the 35 to 49 age groups. 34 A BEmONC facility should be capable of seven signal functions, namely: 1) Administer parenteral antibiotics; 2) Administer uterotonic drugs (i.e., parenteral oxytocin); 3) Administer parenteral anticonvulsants for pre-eclampsia and eclampsia (i.e., magnesium sulfate); 4) Manually remove the placenta; 5) Remove retained products (e.g., manual vacuum extraction, dilatation, and curettage); 6) Perform assisted vaginal delivery (e.g., vacuum extraction, forceps delivery); and 7) Perform basic neonatal resuscitation (e.g., with bag and mask) (WHO, 2009). Current guidelines adopted these signal functions with the qualification that only the initial or loading dose of parenteral antibiotics, anticonvulsants, and uterotonics will be administered. The DOH is considering the dropping of items 4 and 5 and limiting item 6 to imminent breach deliveries from the list of signal functions (NCDPC, 2013). 35 Twenty-seven percent did not perform any of the seven signal functions at all. The same report raised the question of quality of training. Results of the assessment showed that many supposedly trained providers refused to perform some of the signal functions as they lacked confidence in performing the tasks of: 1) administering anticonvulsants; 2) performing assisted vaginal delivery; and 3) removing retained products of conception. This reported lack of confidence may be interpreted to mean a lack of cases by which to develop competency in performing certain procedures, lack of post-training evaluation, limited equipment, among others.

76 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance to improve rates for accessing postpartum and postnatal care in order to detect and manage complications from delivery. This is particularly important considering the high incidence of misdiagnosis of pregnancy complications that are associated with poor maternal and neonatal outcomes described in Section 6 of this Report.

Addressing the gap requires updating standards, increasing investments, and contracting out the continuum of care

As stated earlier in this section, four things need to happen in order to address the wide gap and variation: 1) the DOH needs to review the standards of care to reflect the new continuum; 2) the DOH needs to review existing approaches and develop new means to generate demand for services in the new continuum; 3) PhilHealth needs to adjust the rates for its maternal and neonatal care packages to reflect the cost of the new continuum; and 4) PhilHealth needs to contract service delivery networks composed of public and private facilities that can deliver the new set of interventions in the continuum of care. It is recommended that these four major actions be mandated explicitly in the implementing rules of the RPRH Law.

First, the DOH needs to review and update its standards of care for maternal and neonatal conditions. Current practice guidelines already describe the necessary clinical interventions to promote health and prevent mortality among pregnant women and their babies. However, public health standards and protocols have yet to catch up in terms of ensuring that the necessary interventions are provided in a continuum of care. This will require, among many others, the following: 1) updating public health standards to provide information on the relative effectiveness of methods to couples, including which providers are allowed if not preferred to administer specific methods36; 2) specifying guidelines for the screening and case management of pregnant women with co-morbidities37; 3) advising pregnant women to deliver in hospitals, or have ready access to hospitals if delivering in lower level facilities; and 4) define standards for postpartum and postnatal care.38 Compliance to these standards shall be enforced by ensuring that licensing and accreditation requirements as well as financing packages are oriented towards ensuring the availability of said services.

Second, there is need to revisit and update guidelines and approaches to demand generation. Generating demand for maternal and neonatal services should include how to encourage women and their families to seek services within the new continuum of care, such as delivering in hospitals, instead of at home or in less capable and equipped facilities. A primary challenge is still convincing about 600,000 poor women each year that deliver at home where access to emergency care is not available. The next challenge is shifting the behavior of women, as well as providers, to shift births to hospitals, when accessible. The review and updating of demand generation guidelines need to re-examine the value of current approaches, particularly those anchored on volunteer health workers and explore shifting to formally hired and trained navigators. These navigators are expected to be better at conveying information on the risks, services needed, costs of services, and available sources of financing in the area.

Third, the updated standards of care and demand generation mechanisms is expected to cost more to implement. Consequently, PhilHealth needs to adjust its benefit packages, not only to prescribe the new standards but to also increase benefit payments commensurately. For example, the current maternity care package is designed for normal, uncomplicated deliveries. While there is a separate benefit for complicated pregnancies, this only covers

36 The DOH has allowed midwives to insert progestin subdermal implants but legal and safety considerations may warrant that these should be mainly inserted by physicians. 37 The current capacity of rural health units/public health centers is inadequate to screen and manage pregnant women for conditions such as hypertension, diabetes and placental disorders. 38 As mentioned earlier in this Report, as much as a third of complicated cases in birthing homes were misdiagnosed and associated with providers that have low vignette scores.

77 the procedure (e.g., caesarean section) but will not cover antenatal and postpartum care of women that have co- morbid conditions.39

Lastly, PhilHealth needs to change its approach to providers to enforce the new standards and negotiate for favorable prices with providers. One approach is shifting from the current accreditation mechanism into contracting service delivery networks composed of public and private facilities. For this to happen, PhilHealth needs to jointly determine with the DOH the clinical standards under the new continuum of care. In addition, PhilHealth needs to estimate the cost of providing the services, set and negotiate case rates, mandate no balance billing and fixed co-payments depending on capacity to pay and estimate the actuarially-fair premium to be imposed on members. As these are fairly new activities for PhilHealth and the DOH, both agencies should conduct implementation research studies involving service delivery networks that are willing to implement the new continuum financed by global budgets.

It is expected that the transition into this new continuum for maternal and neonatal services will be expensive and complicated. For example, the facility upgrading costs to ensure standby surgical capacity for caesarean sections will be high. However, these investments need to be viewed as joint costs with other programs that require similar surgical capacity. On the other hand, managing the contracting process along with other related tasks (e.g., costing) will require new capacities from the DOH and PhilHealth. However, it is also in contracting whereby these capacities can be acquired in an accelerated manner by engaging the services of transaction managers and by shifting the burden of innovation to the contractors rather than government.

39 Roughly, care for a complicated pregnancy could cost roughly around PHP200,000 in the private sector which includes antenatal, intrapartal, and postpartum care. However, a woman can only expect to get PHP19,000 from the current PhilHealth case rate for a caesarean section.

78 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

7. INTENSIFYING TUBERCULOSIS CONTROL IN HIGH buRDEN AREAS

Several studies have reported a steady decline in TB prevalence over the past 25 years. However, the projected decline in prevalence seems to be inconsistent with the high number of missed cases and reported deaths. The suspicion that the TB burden is actually higher than projected is confirmed by findings of the 2016 National TB Prevalence Survey (NTPS). The NTPS reports no significant decline in culture prevalence since 2007. Moreover, use of the GeneXpert indicate that the TB burden could be nearly double than previously known.

The question is why TB prevalence remained the same despite current efforts being based on the globally-accepted DOTS strategy. Among many possible explanations is the shift of the TB burden towards urban areas. As the TB burden gets concentrated in urban areas, control efforts in affected LGUs may be insufficient leading to persistent infection pools, particularly among poor households. The fragmentation of service delivery and financing owing to devolution prevents LGUs from effectively controlling the spread of TB. Infected cases are highly mobile and move across different jurisdictions. However, resources such as personnel, drugs, and equipment cannot be readily shared across LGUs.

This Report recommends an intensified TB control effort focusing on urban poor communities. This approach requires customized application of active case finding approaches, use of new diagnostic technology, and measures to ensure adequate case holding of TB cases. These intensified efforts should be packaged as a nationally- implemented program, where goals, accountabilities, mandates, and resources rest with the DOH. Local health facilities and private providers will then be engaged through a contracting mechanism that stipulates the individual targets, range of acceptable interventions, performance benchmarks, availability of resources, and compensation.

Moreover, this Report suggests amending the Comprehensive TB Elimination Plan Act of 2016. Specifically, the law needs to mandate an intensified TB effort in urban poor communities, the creation of inter-city programs, define the key elements of a TB service package including quality of care, create and fund a grant facility that would complement local investment and identify a specific (time-bound) source of financing, and mechanisms to strengthen the information system to monitor performance and evaluate impact.

Prevalence of TB Declined but a Substantial Number of Missed Cases Remain

TB prevalence has been reported to have declined over the past 25 years. These reductions in the TB burden have been taken as evidence of the success of TB control efforts in previous years. In 2014, the World Health Organization (WHO) estimated that prevalence for all forms of TB, except HIV/TB, was at 417 per 100,000 population, a decline of about 58 percent compared to 1990 levels. This was the basis for the WHO to declare that the Philippines had met the 2015 Stop TB Partnership goal of reducing TB prevalence by half (WHO, 2015b). Similarly, USAID recognized the Philippines as a TB Champion for its efforts that reduced TB prevalence and mortality rates by half from 1990 levels (USAID, 2015).40

40 However, the Philippines remains one of the 22 high-burden countries (HBCs) that collectively account for 80 percent of the global TB burden. According to the WHO 2015 Global Tuberculosis Report, the Philippines ranked eighth highest among the HBCs for estimated prevalence rate and ninth highest for estimated incidence rate. Among the 27 HBCs, the Philippines ranked sixth highest for multiple drug-resistant tuberculosis (MDR- TB) among notified pulmonary tuberculosis (PTB) cases.

79 However, the reported decline in prevalence seems inconsistent for three reasons: 1) actual death rates are higher than what has been projected by WHO; 2) the large number of estimated missed cases; and 3) high number of latent TB infections (LTBI). The reported number of TB deaths as recorded in the Philippine Civil Registry and Vital Statistics (CRVS) implies that TB prevalence could be higher than what WHO projected. In Figure 7.1, the bars that correspond to data from the civil registry show a much slower decline than the line that corresponds to WHO mortality estimates. Since the reported number of deaths from the civil registry is higher beginning 2010, TB prevalence, the pool from which deaths derive, should be higher. If indeed prevalence is low but TB deaths are high, this could only mean that treatment is ineffective. Conversely, if case detection and treatment success rates were truly high as reported while deaths remain high, this suggests that prevalence is higher than projected.

Figure 7.1 Death Rates from Tuberculosis, 1980 to 2014

20 Mortality per 100,000 population 10

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

CRVS: all TB deaths WHO: deaths, excluding HIV

Sources: 1980-2014 CRVS and WHO Global Tuberculosis Database

Another indication that prevalence could be higher than current estimates is the large number of missed cases. While on the average, the country has achieved program targets for case detection and treatment success41, wide variation in case finding and case notification efforts continue to persist across LGUs (DOH-NTP, 2017). Particularly, areas with high population concentration and poor performance contribute to a high number of missed cases constituting an infection pool that amplifies into new cases and further increases prevalence.42

The size of the infection pool may be underestimated since TB control programs use incidence rates in computing missed cases.43 For example, by getting the difference between the number of incident cases and the number of those detected, there will be 43,000 missed cases in 2014. However, by using prevalence, the estimated missed cases would be approximately 163,000, as shown in Figure 7.2.

41 The program target of detecting at least 70 percent of cases has been achieved since 2012. The target of successfully treating at least 85 percent of new smear-positive cases has been met as early as 2000. 42 Regions IVA and III, the two regions that rank highest in terms of the estimated number of TB cases, achieved a case detection rate of only 77 percent and 86 percent, respectively, in 2012. 43 The Stop TB Partnership defines missed cases as the gap between the estimated number of people who became ill with TB in a year and the number of people who were notified to national TB programs. The use of case detection in this example provides a conservative estimate of missed cases in the Philippines.

80 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 7.2 Undetected Prevalent Cases (Missed Cases) Based on TB Prevalence, 1991 to 2014

700

600

500 410 400 290 300 247 200

cases detected, thousands 100 Prevalence, incidence, and 0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year

PrevalenceIncidence Cases Detected

Source: WHO Global Tuberculosis Database

Among the factors that contribute to the high number of missed cases include: poor health-seeking behavior, large number of cases seen in the private sector that are not reported, and presence of latent TB infection (LTBI). According to the 2016 NTPS, up to 81 percent of symptomatics do not seek care from a health care worker, and instead self-medicate (40 percent) or do nothing (41 percent).

A second factor leading to missed cases is that a large number of people who get diagnosed and treated by private providers are not reported. This should be a significant factor considering that in the 2016 NTPS, close to 20 percent of those receiving treatment go to a private health care provider.

A third factor related to missed cases concerns the presence of a large pool of individuals with latent TB infection (LTBI). Cases of LTBI remain largely ignored as a contributor to the TB epidemic despite increasing international recognition that these infections constitute the most sizeable reservoir from which new cases arise (CDC, 2013a). It should be emphasized, however, that the conditions precipitating activation of LTBI closely mirror those associated with high prevalence of clinically active infection, depressed host immunity as in cases of HIV, malnutrition, vitamin D deficiency, and viral infections (Esmail, Barry, Young, & Wilkinson, 2014).

The questions raised about the TB prevalence being higher than projected are settled by the results of the 2016 NTPS. The official report finds that the 2016 culture prevalence rate is no different from that of 2007levels. Moreover, TB prevalence based on GeneXpert44 is double the culture prevalence rate of 2016 as shown in Figure 7.3. The graph also shows higher prevalence levels than what is implied by the trajectory of an earlier WHO projection.

The pattern in Figure 7.3 suggests that progress in reducing TB prevalence may be divided into three phases. The first phase, which covers the period 1982 to 1997, reflects the diminishing effect of TB short course chemotherapy using single drug formulation that was introduced since the 1950s (pyrazinamide and isoniazid), 1960s (ethambutol), and in the 1970s (rifampicin). An explanation for the diminishing effect may have to do with poor compliance since these drugs were administered separately.

44 GeneXpert is a molecular test that detects mycobacterium tuberculosis DNA, as well as possible resistance to the drug Rifampicin in less than two hours. The collected sputum is mixed with the reagent that is included with the assay. Then, a cartridge containing this mixture is placed in the GeneXpert machine, where everything is automated from this point forward. (CDC, n.d.; TBfacts.org, 2017).

Figure 7.3 Tuberculosis Prevalence Rates (per 100,000 Population) 1200

1000 860 855 800 810 576 600 417 400

Mortality per 100,000 population 463 512 200

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

NTPS: prevalence, culture+ WHO: prevalence, all forms

Sources: WHO Global Tuberculosis Database and National Tuberculosis Prevalence Survey (NTPS) reports (1982, 1997, 2007, 2017)

The second phase, from 1997 to 2007, is the period where fixed-dose combination drugs were introduced45 and the DOTS protocol was implemented. It can be hypothesized that the decline in prevalence from 1997 to 2007 owes to these developments. It should be noted that such decline in TB prevalence were accomplished even under a devolved public health system. The roll out of TB-DOTS from a pilot of 16 provinces to the rest of the country seem to have overcome difficulties from the devolution of the public health delivery system beginning 1992 (Romualdez, 2007). After all, the technology required by TB-DOTS implementation can be provided in rural and city health centers.

But during the third phase, from 2007 to 2016, TB prevalence is shown to have remained the same, if not increased. The question, of course, is what could explain the lack of progress. Several explanations may be offered.

One explanation is that while progress during this phase was expected to be substantial as program targets were being met, the case detection rate (CDR) targets were set too low by using incidence, not prevalence. However, this explanation may be insufficient as the practice of setting CDR targets using incidence has been in place since the first phase.

A second explanation offered is that deviations from the original DOTS protocol were made, either by the DOH or the LGU managers. An example would be the use of treatment partners in lieu of direct observation by providers. Another modification was that TB drugs were given to patients to take at home (DOH, 2014b). But this explanation cannot uniquely account for the lack of progress observed in the third phase since much of the variations were introduced as early as the second phase.

A third explanation points at possible variations in quality and performance across LGUs. Such variations include availability of drugs, presence of trained personnel, diagnostic capacity, and the deployment of treatment partners (DOH, 2014c; DOH-NTP, 2017; NTRL-RITM & DOH, 2014). But these variations may have already been a factor in the first and second phases.

45 The DOH started central procurement and distribution of TB drugs in 1999 but availability of fixed dose combination formulations came later.

82 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

A fourth explanation points at a largely unregulated private sector that contributes to missed cases and increasing number of drug-resistant TB cases. Several studies describe wide variance in practice among private providers relative to TB-DOTS standards (DOH-NTP, 2017; UPecon-HPDP, 2015b and 2015c; Kraft, Capuno, Quimbo, & Tan, 2008). For example, most private providers use X-rays instead of sputum smears as the primary diagnostic test. Private providers also differ in terms of prescribing practice as to the combination of anti-TB drugs and product formulations being used. Most private providers also do not report their TB cases to DOH. The volume of TB drug sales was also estimated to be roughly equivalent to public sector procurement (Islam et al., 2013) implying that many patients are being treated, but their level of compliance and treatment outcomes are largely unknown. To rationalize use of TB drugs, DOH is considering banning the sale of anti-TB drugs in private pharmacies (Cepeda, 2017).

This Report raises reservations regarding attempts to limit private sector participation, either through regulation or through incentives. The concern is that weaknesses in the public sector, which also contributes to missed cases and MDR TB, prevent it from handling patients displaced from the private sector. Local facilities barely have enough personnel to handle current case load as RHUs that also serve as DOTS centers are burdened with implementing other programs. This limits their capacity to actively search for TB cases in the community, either as a separate activity or in tandem with other programs. At the national level, weaknesses in supply chain management and budget execution prevent TB drugs and reagents from reaching service delivery points in the right quantities and at the right time (Brown, Chin, Rutta, Gabra, & Zackin, 2015; UPecon-HPDP, 2015a).

It should be noted that there were previous attempts to influence the diagnostic and treatment practices of private providers. However, these have been limited to public-private mix DOTS (PPMD) pilots which have yet to be introduced at scale. Attempts to use incentives to influence private practice using the PhilHealth DOTS package have also been limited and not sustained. In 2010, the number of private providers accredited with the PhilHealth TB-DOTS package was 81 (Mantala, 2010). By 2014, the number increased to around 200 facilities (DOH, 2014c). In 2016, this was reduced to only 91 (PHIC, 2016). A major reason why the number of private providers accredited for the DOTS package declined was the high cost of operations relative to reimbursements. Many private DOTS referring facilities are also unable to receive referral fees as their share of total reimbursements since the latter go directly to partner hospitals or LGUs (Alejandria et al., 2015). But poor regulation of the private sector and the limited success with PPMDs cannot fully explain the lack of progress in the third phase as these conditions have existed earlier.

High TB Burden is Not Likely Distributed Equally across the Country

The only plausible explanation for the lack of progress in the third phase is that TB prevalence may now be concentrated in urban areas where current control efforts are inadequate to reduce the high burden. Recall that for the 1982, 1997, and 2007 prevalence surveys, the prevalence between urban and rural areas were essentially the same. In the 2016 NTPS, 52 percent of all TB cases were urban dwellers. This is quite significant considering that the rural population is oversampled relative to urban by as much as eight percentage points.

When TB prevalence is relatively uniform across the country, the distribution of RHUs should be sufficient to handle a relatively manageable case load. For example, a RHU staffed by a physician, a medical technologist to perform sputum microscopy, and having a stable supply of TB drugs should be able to handle the expected 200 cases per year in a municipality with 20,000 individuals. A similar pattern, but perhaps with higher average case load, should be the same for districts in large metropolitan areas.

Through migration, populations get concentrated in urban areas. In 2010, 45 percent of Filipinos now live in urban areas. Four regions with the highest percentage of urban population are the National Capital Region (100 percent), CALABARZON (60 percent), Central Luzon (52 percent), and Davao (59 percent). These regions had relatively high population growth rates between 1990 and 2010 (PSA, 2015). In the 2016 NTPS, the estimated TB prevalence rate in Metro Manila, CALABARZON, and Central Luzon is the highest in the country at 1,358 per

83 100,000. This is 30 percent higher than the prevalence rate in the rest of Luzon, 10 percent higher than that of Visayas, and nearly twice that of Mindanao. The large urban population in these three regions could partly explain why TB prevalence is higher in these areas.

With this shift in population, city health centers will now have case load that is larger than their existing capacity. However, due to fragmentation of the service delivery and financing system resulting from devolution, excess capacity in some areas cannot be moved to where excess demand exists. Movement or transfer of critical staff can now only happen within a jurisdiction. Moreover, hiring restrictions, constrained health budgets, a highly mobile target population, and possibilities to free-ride on national and resources of neighboring cities reduce the likelihood that individual cities would upgrade their capacities to address the increased TB prevalence.

With higher case load now more likely to be concentrated in cities, capacity gaps and shortfalls in case detection and treatment can rapidly increase the number of missed cases and treatment failures. Moreover, to cope with increasingly limited public capacity, demand for private alternatives are expected to increase. And whatever limitations that exist in TB care delivered by private providers will magnify missed cases and treatment failures.

TB Burden could be Heavier among the Urban Poor

Currently available data do not allow for estimating TB prevalence at the level of LGUs. However, TB prevalence is associated with poverty and its proximate determinants of transmission such as crowding, impaired host defenses owing to malnutrition and indoor air pollution among others (Narasimhan, Wood, MacIntyre, & Mathai, 2013). This implies that TB burden is not likely to be distributed equally across the country, but rather is concentrated among poor households within high-population areas, such as major cities and large provinces.

Within urban areas, it is the poor who face greater risk. A study using the 1997 NTPS reported that the prevalence of both culture- and smear-positive TB in urban poor communities was as much as 2.5 times higher than in non- poor urban communities (Tupasi et al., 2000). In the 2007 NTPS, the proportion of radiographic PTB cases is higher at 7.4 percent in the bottom two quintiles, compared with 5.5 percent in the richest quintile. Although the 2016 NTPS is not directly comparable with 2007 NTPS, the results show higher TB prevalence among the poor, as represented by the 4Ps households. These survey results support the general understanding that disease transmission risk factors are associated with poverty.

An approach to identifying poor families in urban centers is to locate informal settlements. Data from the National Housing Authority (NHA), as shown in Table 7.1, identify Metro Manila as having the largest number of families located in informal settlements. The National Capital Region (NCR) to which Metro Manila belongs, together with the adjacent regions of Central Luzon (Region III) and CALABARZON (Region IV-A), account for roughly 60 percent of the country’s informal settler families.46

Furthermore, TB prevalence may be higher among families living in informal settlements as TB-DOTS facilities may not be readily accessible. For example, in the top cities of Manila and Navotas, the location of TB-DOTS centers in 2014 were not readily accessible to National Household Targeting System (NHTS) poor households. The more than 47,000 residents of Baseco, which is one of the largest informal settlement areas in Manila, can be served by four PhilHealth accredited TB-DOTS facilities but all are more than 30 minutes away by private vehicle. On the other hand, while the more than 84,000 residents around the Navotas Fish Port are less than 30 minutes away by private vehicle, only two clinics are accredited by PhilHealth as TB-DOTS centers (UPecon-HPDP, 2016).

46 While the population share of the regions is only 38 percent, it is possible that TB prevalence in the three regions could be higher as these areas account for 60 percent of informal settler families. It is also possible that there are many missed cases as the three regions only account for 41 percent cases detected as reported in the 2012 DOH-NTP Report.

84 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Table 7.1 Informal Settlers and TB Prevalence Region Population1 Number of Informal Distribution of Informal Settler Families2 Settler Families3 Philippines 94,104,738 1,502,336 100.0 Region IV-A 12,996,924 221,284 14.7 NCR 12,067,011 584,425 38.9 Region III 10,354,685 117,670 7.8 Region VI 7,198,321 31,129 2.1 Region VII 6,920,543 63,681 4.2 Region V 5,499,549 142,028 9.5 Region I 4,806,777 44,364 3.0 Region XI 4,556,594 8,255 0.5 Region X 4,385,848 82,272 5.5 Region XII 4,210,666 14,725 1.0 Region VIII 4,153,819 9,212 0.6 Region IX 3,471,071 55,393 3.7 ARMM 3,305,308 16,771 1.1 Region II 3,274,048 13,292 0.9 Region IVB 2,793,801 29,949 2.0 Region XIII 2,465,419 44,339 3.0 CAR 1,644,354 23,547 1.6 Sources: 1 UPecon-HPDP estimates of 2011 regional population based on the Census of Population and Housing, 2010 2 National Housing Authority (NHA), July 2011 3 UPecon-HPDP calculations using census population and 2011 NHA data

Intensified TB Control In Informal Settlements Should Be Adopted As A National Program

This Report recommends the implementation of intensive TB control efforts in informal settlements in large urban areas. This intensified effort includes the customized application of active case finding approaches, use of new diagnostic technology through cost-effective diagnostic algorithms, and measures to ensure adequate case holding for TB cases. An illustration of how this can be done in a specific locality is as follows:

Conduct active case finding.Depending on various considerations such as the estimated level of prevalence in the area, the available mechanisms to reach households in the community and capacity of providers, at least three mechanisms can be tapped to reach poor families to look for TB cases. First, elementary schools can be tapped by leveraging the enrolment and participation in school-based feeding programs with attendance to parent-teachers meeting where TB cases can be identified. Second, active case finding can also tap the Family Development Sessions (FDS) of poor families that belong to the Pantawid Pamilyang Pilipino Program (4Ps). Third, house to house visits may also be done with the participation of community health workers and volunteers (Lorent et al., 2014; Yadav, Nishikiori, Satha, Eang, & Lubell, 2014).

Use a symptom checklist and chest x-ray as initial methods to identify and screen for TB symptomatics. Studies indicate that diagnostic yield is highest at 87 percent when combining the use of chest x-ray followed by GeneXpert for Mycobacterium tuberculosis/ resistance to rifampicin (MTB/RIF). The use of symptom checklists is also recommended to screen for TB symptomatics, especially in high prevalence areas (see WHO, 2015d). The 2016 NTPS results, however, imply that using symptoms alone would miss up to two-thirds of TB cases.

85 Trace household members and close contacts of TB cases. Among adults or children that test positive for TB, contact tracing for household members and other close contacts is recommended. Close contacts are at higher risk of contracting TB due to constant exposure and shared risk factors.

Treat latent TB infection among high risk close contacts of TB cases to prevent activation. Treating latent TB infection prevents activation of infected cases, especially among close contacts of TB cases that are considered high risk like children and those with HIV (Sharma, Mohanan, & Sharma, 2012). Close contacts of people with active TB have a high possibility of having been infected (Fox, Barry, Britton, & Marks, 2013) and their reactivation rate of TB is 15 times greater than the general population (Ai, Ruan, Liu, & Zhang, 2016; Landry & Menzies, 2008).

Treat TB cases with six-month short course chemotherapy. Adults and children diagnosed with TB need to undergo the recommended short course regimen. To monitor treatment status, TB patients should be assessed for clinical improvement as well as conversion, if sputum is positive. TB cases that do not improve despite good compliance need to be tested further for drug resistance. There is also a need to trace defaulters on treatment to avoid treatment failure. As mentioned earlier, schools, the FDS, and house to house visits by community health workers and volunteers can be used as platforms to ensure case holding.

Engage public and private providers to control TB. The identified weaknesses in the delivery of the continuum of TB care can be addressed by issuing contracts that will cover prevention, case finding and case holding activities. These contracts can be issued to both public and private providers that are best suited to serve the informal settler communities. For example, these can be local governments that have health centers near these areas or nongovernment organizations (NGOs) that serve these communities.

Meanwhile, current TB control efforts in the rest of the country shall be maintained. This will ensure that TB surveillance continues, diagnosed cases are treated and that further transmission of TB is prevented in the rest of the country. Furthermore, the Report recommends that implementation of these intensified efforts be packaged as a national program, where goals, accountabilities, mandates, and resources rest with the DOH. In this proposal, local health facilities and private providers will be contracted by the DOH to deliver TB services. The contracts or agreements shall stipulate the individual targets, range of acceptable interventions, performance benchmarks, availability of resources, and compensation. The monitoring and evaluation of TB control objectives should be undertaken at the national or regional levels, considering the nature of TB transmission as well as the mobility of people highly susceptible to TB.

However, there are a number of challenges that need to be addressed in implementing intensified TB control in urban poor communities. One, the location of urban poor communities often consisting of informal settlers, cuts across jurisdictional boundaries. There is a need, therefore, to establish a mandatory mechanism for inter- LGU cooperation in TB control.47 Secondly, the cost of the intensified effort might be higher than what cities can individually or collectively afford. Hence, there is a need to augment local investments with national funding. To ensure high quality of care among both public and private providers, there is a need to introduce incentives and penalties among participating providers. The lack of capacity of both national and local governments to manage the TB program noted earlier also needs to be addressed.

47 This recommendation follows the same principle for the creation of the Metro Manila Development Authority (MMDA) that provides an inter-LGU mechanism to address cross-cutting concerns of LGUs in Metro Manila, e.g., traffic management, flood control, etc. (RA No. 7924).

86 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Current Law Needs to be Amended to Implement Intensified TB control in Urban Poor Communities

The newly passed Comprehensive TB Elimination Plan Act of 2016 (RA No. 10767)48 and its implementing rules provides for a wide range of approaches for reducing the TB burden, engagement of private providers to implement TB control activities, reporting, research and capacity building of program staff. However, the law fails to provide the necessary mandates to address challenges brought about by fragmentation owing to devolution, especially in the context of a TB burden that is double than previously known and is likely concentrated in urban poor communities.

This Report recommends that the current law be amended to set time-bound targets in reducing the TB burden, and specify strategies that can be implemented effectively and financed adequately to substantially impact on TB prevalence and deaths. Specifically, the law should mandate the establishment of an intensified TB effort in urban poor communities, mandate the creation of an inter-city program, prescribe the key elements of the TB package, create and fund a grant facility that would complement local investment, and identify a specific (time bound) source of financing. Moreover, given the limited data on TB, the new law should strengthen the information system to design effective programs, to assess performance and determine the impact of interventions on TB prevalence and deaths.

48 RA No. 10767, otherwise known as “An Act Establishing a Comprehensive Philippine Plan of Action to Eliminate Tuberculosis as a Public Health Problem and Appropriating Funds therefor.”

87 88 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

8. ADOPTING A PROGRAMMATIC APPROACH TO HIV AND AIDS PREVENTION AND CONTROL

Over the last 25 years, prevalence of human immunodeficiency virus (HIV) infection that causes Acquired Immunodeficiency Syndrome (AIDS) remained low in the general population but is increasing amongkey populations. But a deeper understanding of the prevalence as well as the transmission of HIV in the Philippines remains hampered by lack of information. This poses the challenge of selecting the appropriate mix of interventions suitable to the profile of the epidemic and given the available resources.

In the absence of specific information, this Report recommends the adoption of a programmatic approach to HIV and AIDS prevention and control. This programmatic approach has two objectives: 1) preventing transmission, and 2) preventing complications and premature mortality from HIV and AIDS. This programmatic approach can be implemented through two sets of interventions directed at specific populations. The first set of interventions aims to provide HIV information and promote condom use as means to reduce risky sexual behavior among the young. The second set of interventions aims to provide cost-effective interventions to prevent transmission and ensure continuity in the HIV treatment cascade among key populations. The scope and scale of providing these cost-effective interventions for key populations should be driven by the level and nature of the epidemic in specific areas.

In providing information on HIV and AIDS, economies of scale can be achieved by using the education system. Integrating HIV and AIDS education in the curriculum will also help promote safer sex behavior among teens, especially those that also belong to key populations. However, the country has yet to adopt minimum standards for HIV IEC and services in schools and apply necessary changes in the curriculum. Moreover, the requirement for parents’ consent to access condoms and HIV testing and treatment among the young serves as a barrier to reducing risky behavior and promoting voluntary testing. Laws need to be amended to remove the barrier posed by requiring parental consent among minors.

In providing cost-effective services for key populations, particularly those related to early testing and access to treatment, the scale and scope of services need to be customized depending on the size and nature of the epidemic. Scale economies can be better achieved when these interventions are implemented in large cities, especially in areas with high HIV prevalence among key populations. Specific sets of interventions need to be assembled and its delivery mechanisms customized depending on the drivers of the epidemic in specific area.

There are three main challenges in providing the needed interventions for key populations. First, there is limited information on HIV and AIDS and its drivers. This Report recommends strengthening of surveillance systems. Second, there are restrictive legal provisions that prevent especially the youth from accessing services. Specifically, the Report recommends to amend the HIV law, as well as specific provisions of the RPRH law to lift restrictions for minors to access services such as condoms and HIV testing and other services. Third, is the fragmentation of the service delivery and financing system owing to devolution that has resulted in the wide variation in the performance of HIV prevention and control programs of LGUs. Given that key populations are highly mobile, there is need for LGUs to mount a common program but the transactions cost of fostering inter-LGU cooperation is high. Moreover, the cost of HIV control may be too expensive for cities, both individually and collectively. The delivery of the cascade of services requires a certain scale to be implemented, hence the need to complement local investment with national funds.

89 Prevalence of HIV and AIDS Remains Low but is Increasing among Key Populations

The HIV prevalence in the general population remains below one percent based on administrative data (DOH, 2017). From 1984 to May 2017, a total of 44,010 people living with HIV and AIDS (PLHIVs) are listed in the HIV registry. Of these, 4,181 have become full-blown AIDS cases and 2,156 have died. It is important to note that the reported number of cases started to rise beginning in 2011, with 86 percent of cases registered from 2011 to 2017 (DOH, 2017). To help explain the rise in registered cases beginning 2011, consider the number of reported HIV cases and AIDS deaths as shown in Figure 8.1, which shows an increase in reported deaths also beginning 2011. Having both reported cases and deaths rise in the same period suggests that the observed pattern could be caused by improvements in the reporting system, rather than from a dramatic change in infection rates. In fact, the DOH notes that the official reporting scheme was established in 2012 (DOH, 2013b).

Figure 8.1 Actual Number of HIV/AIDS Reported Cases and Deaths, 1984 to 2016

10000 500 9000 450 8000 400 7000 350 6000 300 5000 250 4000 200 3000 150 2000 100 1000 50 0 0 9 6 1 3 1984 1985 1986 1987 1988 198 1990 1991 1992 1993 1994 1995 199 1997 1998 1999 2000 200 2002 200 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Reported Cases Reported Deaths

Source: DOH HARP Data of May 2017

When compared with other Southeast Asian countries, HIV prevalence in the Philippines remains low (see Figure 8.2). However, the pattern across these selected countries raises interesting questions concerning the nature of the epidemic in the Philippines. The pattern suggests that there is need to confirm if the variation in prevalence owes to specific epidemiological factors (e.g., modes of transmission and practices like male circumcision) or due to differences in the surveillance system (e.g., registry and access to testing) or the effectiveness of their respective HIV and AIDS control programs. Carefully understanding cross-country differences will allow the formulation of better strategies to control HIV and AIDS.

While prevalence in the general population remains low, it is increasing among key populations (see Figure 8.3). Among the key populations, infection among males who have sex with males (MSMs) has increased the fastest. As of May 2017, close to half of cumulative cases were infected through this mode of transmission. Moreover, prevalence remains highest among the age group 25-34 years. But beginning 2002, prevalence grew the fastest among the age group 15-24 years, indicating that those infected are getting younger (DOH, 2015b).

The challenge in preventing infections among key populations, especially the young, is that prior to getting infected and testing positive, they are difficult to distinguish from the general population (Yu et al., 2014). Because key populations cannot be readily identified, especially in low prevalence conditions, population-wide information and safe sex campaigns are needed to prevent infection.

90 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Figure 8.2 Prevalence of HIV, Total (Percent of Population Ages 15 to 49), 1990 to 2015

2.5

1.5

0.5

19901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

Philippines Thailand Malaysia Indonesia Vietnam

Source: UNAIDS, 2017

Figure 8.3 HIV Modes of Transmission, 1984 to 2016

10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0

5 6 3 6 1 1984198 198 198719881989199019911992199 19941995199 1997199819992000200 200220032004200520062007200820092010201120122013201420152016

Number of PLHIV Male-Female Sex People who inject drugs (PWID) MSM Others

Source: DOH HARP Data of May 2017

Moreover, that infection among young people is rising suggests that population-wide information is severely lacking. Consequently, young people who are beginning to become sexually active are not aware of HIV and AIDS risks and how infections can be prevented. Poor knowledge levels on HIV and AIDS and low rates of condom use and testing are confirmed in various surveys like the Young Adult Fertility Survey (YAFS)49 and the National Demographic Health Survey (NDHS).50

49 Based on Young Adult Fertility Survey (YAFS), 95 percent expressed knowledge on HIV and AIDS in 1994. This remained largely the same in 2002. However, the level dropped to 83 percent in 2013. The decline is about the same for both males and females, from 94 percent in 1994 to 82 percent in 2013, and from 95 percent to 85 percent in 2013, respectively. Regarding knowledge on preventing sexual transmission of HIV, i.e., using condoms and limiting sex to one faithful uninfected partner, the results showed that 59 percent correctly identified using condoms, while 68 percent correctly identified limiting sex to one faithful uninfected partner, in preventing HIV transmission (DRDF & UPPI, 2014; 2013 YAFS4 Key Findings). These results imply that while sexual activity is increasing among the youth, their knowledge about prevention of HIV transmission is lacking. 50 Data from National Demographic Health Survey (NDHS) 2013 show that while 92 percent of women 15-49 years old have heard of AIDS, only 57 percent say that using condoms every time they have sexual intercourse can prevent HIV. The corresponding percentages in NDHS 2003 are 95 percent and 48 percent, respectively. The corresponding percentages in NDHS 2008 are 94 percent, 59 percent, and 52 percent, respectively. Moreover, among women 15-49 years, only 55 percent know where to get an HIV test. The corresponding percentage in 2008 is 52 percent. In 2003, this question was not asked. In NDHS 2013, among young women aged 15-24 years, 67 percent say they know of a condom source. In the 2003 and 2008 NDHS, questions regarding knowledge on condom source were not asked. What was asked, instead, was whether HIV can be prevented by using condoms. Results showed 44 percent and 54 percent in 2003 and 2008, respectively, said that HIV can be prevented by using condoms. These data indicate that HIV knowledge is not yet universal. 91 The only available instrument that attempts to generate information about key populations before they get infected and tested is the Integrated HIV Behavioral and Serologic Surveillance (IHBSS). The IHBSS has the potential of improving the understanding of risks, risky behavior, condom use, and access to testing and treatment. This kind of information is what is needed for effective program targeting. However, the IHBSS might have to be improved to address the following: 1) increase the sample size and introduce weights to reflect prevalence across regions51; 2) new approaches to identify sample other than by time and location might be introduced to reflect changes in the way key populations meet, such as through social media and dating apps52; and 3) set the sampling scheme so that survey results are comparable from one period to another.53

A Programmatic Approach is Needed for the Prevention and Control of HIV and AIDS

The challenge of addressing HIV and AIDS where prevalence is low among the general population but rising among known key populations, is that targeted interventions may not be sufficient. The provision of prevention, testing, and treatment services targeted at key populations requires that members of this high-risk population are first identified. However, key populations are hidden populations and difficult to distinguish from the general population, especially among the young. Moreover, current laws that protect individual privacy and prevent discrimination and stigma, make the identification and targeting of these populations and their close contacts extremely difficult. In the case of PWIDs and commercial sex workers, criminalizing drug use and prostitution respectively, drives these populations further underground.

In the absence of specific information, this Report recommends the adoption of a programmatic approach to HIV and AIDS prevention and control. This programmatic approach has two objectives: 1) preventing transmission, and 2) preventing complications and premature mortality from HIV and AIDS. These objectives can be achieved by implementing two sets of interventions directed at specific populations. The first set of interventions aims to provide HIV information and promote condom use as means to reduce risky sexual behavior among the young. The second set of interventions aims to provide cost-effective interventions to prevent transmission and ensure continuity in the HIV treatment cascade among key populations. The scope and scale of providing these cost-effective interventions for key populations should be driven by the level and nature of the epidemic in specific areas.

In providing information on HIV and AIDS, economies of scale can be achieved by using the education system.54 Integrating HIV and AIDS education in the curriculum will also help promote safer sex behavior among teens, especially those that also belong to key populations.55 However, the provision of sex education in schools is not

51 It has to be noted that prevalence figures from IHBSS are based on a sample from key populations in 35 cities that are suspected to be high risk for disease transmission. Since there are no estimates as to the actual number of individuals belonging to any of the key populations, the actual number of HIV positives could not be readily estimated based on these prevalence estimates. This leaves the possibility that the prevalence could be underestimated and that the epidemic could also be raging undetected elsewhere. 52 It is difficult to identify MSMs, commercial sex workers, and PWIDs. For example, not all gays are necessarily MSMs. Gays do not necessarily hang around gay bars anymore. Commercial sex workers may no longer just be in the usual places like bars, massage parlors, and brothels. PWIDs may no longer be found in the usual addicts’ joints. For MSMs and commercial sex workers, transactions are now conducted virtually. If these people who are at-risk are no longer found in their usual physical location, then it would be difficult even for IHBSS to locate and to obtain information about them. 53 Survey data may not be comparable across survey periods and survey sites owing to differences in the number of survey sites across rounds. In addition, the results across survey rounds are not directly comparable due to the fact that analysis of previous rounds did not include sampling weights and other statistical adjustments that were applied in 2013 to correct for the effect of the survey design. 54 Due to high costs, use of mass media needs to be done prudently. Evidence shows that mass media helps in increasing condom use, especially if the campaign is done on a large scale, for a longer period, and in countries that have low human development index scores (Lacroix, Snyder, Huedo-Medina, & Johnson, 2014). However, IEC needs to be customized since no single intervention works for all cases. Crafting the messages and determining how these should be communicated require an understanding of social drivers and sensitivity to cultural norms. 55 The integration of HIV and AIDS education into the curriculum has been shown to significantly reduce risky sexual behavior, delay age of first sexual intercourse, and increase condom use (CDC, 2015). To further increase effectiveness, this information should be tied to specific health goals like the prevention of HIV/STI, and avoidance of teen pregnancy, which can be achieved through specific behaviors such as abstinence, and condom use (Kirby & Laris, 2007). Studies show that students who received school-based sex education interventions had significantly greater HIV-related knowledge and decreasing sexual risk behaviors, including increasing condom use, greater self-efficacy related to refusing sex or condom use, fewer sexual partners and less initiation of first sex during follow-up. More importantly, no individual study found detrimental effects of school-based education on increased risky sexual behavior (Fonner et al., 2014). 56 Sexuality education in schools focus on human reproductive functions and hardly discuss STIs and condom use as a prevention measure (Human Rights Watch [HRW], 2016).

92 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance standardized56, especially in the case of private sectarian schools. The Department of Education (DepEd) has already completed the standards for comprehensive sexuality education (CSE) but has yet to implement this as part of the curriculum as mandated by the RPRH Law57. The mechanisms to provide HIV information among out- of-school youths are also limited. This is critical as the youth among the poor may not only be less informed on HIV but would also have the least capacity to access services. The Department of Social Welfare and Development (DSWD) is the main agency providing information on HIV to out-of-school youth, including youth offenders.

Education on HIV and AIDS also needs to be complemented with condom promotion. First, there is need to remove legal barriers that prevent access to condoms and other services related to HIV and AIDS. Specifically, the Philippine HIV law and the RPRH law prevent minors from accessing condoms as well as sexually transmitted infection and HIV testing and treatment without parental consent. Second is to address market inefficiencies in condom procurement and distribution (Bertozzi et al., 2006). This can be done through social marketing of condoms together with incentives for commercial as well as community-based condom distribution. Where feasible, condoms may even have to be sold at subsidized rates (UNAIDS, 2000).

In providing cost-effective services for key populations the scale and scope of services needs to be customized depending on the size and nature of the epidemic. Scale economies can be better achieved when these interventions are implemented in large cities, especially in areas with high HIV prevalence among key populations. Specific sets of interventions need to be assembled and its delivery mechanisms customized depending on the drivers of the epidemic in specific areas.

While studies specific to the Philippines are lacking, the most cost-effective services are those related to early testing and providing access to treatment. Promotion of HIV counseling and testing (HCT) is important as this serves as a gateway to treatment (Strode, Rooyen, Heywood, & Karim, 2005). Specifically, physician-initiated testing and counseling (PITC), especially when coupled with an opt-out strategy, could raise the uptake of testing, counselling and treatment services.58 Anti-retroviral therapy (ART) can prevent premature mortality and reduce risk of HIV transmission. It is recommended to start ART for all HIV-infected individuals with detectable viremia, regardless of CD4 count (Günthard et al., 2016).

In terms of prevention, peer-based information and condom distribution has been proven effective in reducing risky sexual behavior among key populations (UNAIDS, 2000; Behrman & Kohler, 2011; Pattanaphesaj & Teerawattananon, 2010). Moreover, social media can also be employed to increase testing and counseling rates and improve adherence among key populations. One example is a community-level online intervention in Taiwan designed to reach young MSMs who engage in unprotected sex, who are not as socially connected with other gay people, and are unlikely to be “out,” and possibly more likely to be stigmatized for their sexual orientation (Ko et al., 2013). A related approach is to use text messaging to promote adherence to ART.59

Challenges in Implementing the Proposed Interventions

57 Based on the proposed timelines, the training of teachers is scheduled from May 2017 to 2018 (Masilang, 2016). This could mean that full nationwide implementation of the CSE can only happen by June 2018. 58 PITC is expected to be more effective since it is not dependent on the patient’s appreciation of risks, symptoms and the relative effectiveness of diagnostic and treatment options. Moreover, access to rapid diagnostic tests (RDTs) in health facilities and communities has also been associated with a large increase in HIV-testing uptake and receipt of results, especially because such tests cut down on waiting time (Pottie et al., 2016). Given the relatively higher cost of RDTs compared to conventional tests, scale economies can justify wider distribution and use if the expected case load is sufficiently large. In the same manner, the use of HIV self-testing (HST) kits can also be promoted for those that prefer more privacy. 59 Studies have found that text messaging had positive effects, especially when implemented with the following guidelines in mind: 1) SMS were sent “less frequently than daily” due probably to “habituation, response fatigue, and the possible intrusion that multiple daily messaging could represent”, 2) SMS allows for response from patient (“bidirectional”) which underscores the importance of the engagement element in communication, (3) message is personalized to patient rather than a generic SMS and, and 4) SMS timing is matched to patient’s dosing schedule which works much like an alarm (Finitsis, Pellowski, & Johnson, 2014).

93 Second, there are restrictive legal provisions that prevent people, especially the youth, from accessing services. Specifically, the Report recommends to amend the HIV law, as well as specific provisions of the RPRH law to lift restrictions for minors to access services such as condoms and HIV testing and other services. Third, is the fragmentation of the service delivery and financing system owing to devolution that has resulted in the wide variation in the performance of HIV prevention and control programs of LGUs. Given that key populations are highly mobile, there is need for LGUs to mount a common program but the transactions cost of fostering inter-LGU cooperation is high. Moreover, the cost of HIV control may be too expensive for cities, both individually and collectively. The delivery of the cascade of services requires a certain scale to be implemented, hence the need to complement local investment with national funds.

Limited information on HIV prevalence and its key drivers

This Report earlier observed that the information provided by the HIV/AIDs registry and the IHBSS is insufficient not only in establishing the true burden of disease, but most especially in understanding its transmission dynamics. The Report also noted that the identification of priority interventions is conditioned on available information on both the general population and key populations. Furthermore, for the key populations, specific interventions would depend on the level and concentration of the epidemic. There is, therefore, a need for timely and accurate information on HIV prevalence and its key drivers among the key populations.

While many of these challenges can be mitigated by specific interventions, the gains that can be derived are likely to be temporary and limited to specific areas owing to a restrictive legal environment. For example, access to condoms, testing and treatment services especially among the young is restricted by both the HIV law and the RPRH law. Furthermore, difficulties in inter-LGU cooperation are due to the fragmentation of service delivery and financing as a consequence of the Local Government Code of 1991.

Transactions Cost of Securing Inter-LGU Cooperation is High

The prevalence of HIV and AIDS is concentrated in highly populated regions. A majority (65 percent) of cumulative cases were reported from National Capital Region (NCR), Southern Tagalog, and Central Luzon. Mobility within and across these cities is high, so that key populations can be infected in one locality within these three contiguous regions, get tested in another, and reside in yet another place. This implies that HIV and AIDS control must be effectively coordinated at least across the cities in these regions. There are at least three reasons why inter- jurisdictional cooperation is necessary.

First, the attitude, willingness, and capacity of LGUs to finance and manage their local HIV and AIDS programs vary widely. The wide variation in the performance of local health systems in HIV prevention and control can lead to ineffective public health control of the epidemic. Poorly-performing localities, particularly those that are averse to certain interventions like condom distribution60 and harm reduction61, could become persistent infection pools. There is no assurance that localities where the pockets of high prevalence are located would be willing and able to prioritize HIV and AIDS prevention and control programs. For example, there are few reports indicating that the 100 percent condom use program espoused by the DOH since 1985, was adopted in other areas of the country and whether early initiatives were sustained. One barrier to the implementation of the 100 percent condom use policy is that in some LGUs, sex workers were harassed or, even detained by the police for mere possession of condoms in entertainment establishments (HRW, 2004).

60 Based on the IHBSS 2015, MSMs that reported having received free condoms from social hygiene clinics and peer groups show a wide variation ranging from 6 percent in San Jose del Monte City to 61 percent in Davao City. Another concern, particularly for MSMs is that minors need parental consent to obtain condoms (DOH, 2015c). 61 In addition to condoms, safe injecting equipment were provided to PWIDs in Cebu as part of a harm reduction program. Despite promising results in reducing prevalence of HIV among male PWIDs from 52 percent in 2013 to 43 percent in 2015, this harm reduction program was stopped by the City Anti-Drug Abuse Council citing violation of Section 12, Article 2 of RA 9165 or The Dangerous Drugs Act (Lim, 2015).

94 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Second, key populations can be highly mobile due to lifestyle preferences and stigma. It is not uncommon for members of key populations to reside in one locality, have sexual encounters with other individuals from other towns or cities, and seek care in other localities where they are less likely to be known by health workers and other clients (Taylor et al., 2012).

Third, the set of HIV services from information campaign, condom use promotion and distribution, diagnostics, treatment, and monitoring can only be delivered by a well-organized and equipped network of facilities. Except in a few areas, these services may not be readily available. For example, there are currently 40 diagnostic and treatment hubs recognized by the DOH, 43 percent of which are found in NCR (DOH, 2017). However, this can be expected as the delivery of services requires a certain scale to be implemented. For example, an HIV specialist need not be available in all cities and municipalities, but rather be available to service the towns and cities as part of a delivery network. Similarly, the availability of rapid diagnostic tests may only be expected in district or provincial hospitals, for example, rather than in all RHUs. Thus, in some areas, a set of services might have to be provided across facilities that belong to different municipalities and cities, especially outside Metropolitan Manila, Cebu, and Davao. For a network of facilities and services to be available, there is a need for inter-jurisdictional cooperation among localities.

Local budgets insufficient to prevent and control HIV

The cost of delivering services by a well-organized and equipped network of facilities, especially in cities where prevalence of HIV among key populations is high may be too expensive for cities, individually or even collectively to finance. Currently, measures to prevent and control HIV and AIDS are financed through different sources. LGUs mainly cover the cost of personnel and facilities, the grant from the Global Fund for AIDS, TB and Malaria provides the antiretrovirals (The Global Fund, 2016), while PhilHealth has an outpatient HIV and AIDS treatment (OHAT) package worth PHP30,000 per year to cover for follow-up diagnostic tests like CD4 counts and medicines (PHIC, 2015b). The package may be sufficient if ARVs are subsidized and the PLHIV will not have any complications during the year. The cost of first line antiretroviral drugs alone is estimated at PHP8,000 per year (Salvana, 2012). With an estimated 18,000 cases in NCR (DOH, 2017), the annual cost of first line ARVs will be at least PHP144 million – equivalent to nearly half of the Internal Revenue Allotment (IRA) of San Juan, a small city in NCR (DBM, 2017). Once Global Fund support ceases, national government may have to cover for these costs.

Amend HIV Law to Address Specific Challenges

To address the fundamental challenges and to be able to properly implement the programmatic approach of intervention, this Report recommends the review and amendment of the Philippine AIDS Prevention and Control Act of 199862 (RA No. 8504).

To address the rapid increase in HIV and AIDS prevalence among the youth, there is a need for stronger emphasis on the law towards reaching the youth. This can be done by promoting access to HIV and AIDS information through schools. Specifically, the law needs to mandate minimum standards of HIV and AIDS information, education, and communication and services in all schools. Moreover, there is need to remove the provision requiring written parental consent for minors to access condoms, testing and treatment for HIV. The same amendment needs to be made in the RPRH law.

62 RA No. 8504 – “An Act Promulgating Policies and Prescribing Measures for the Prevention and Control of HIV/AIDS in the Philippines, Instituting a Nationwide HIV/AIDS Information and Educational Program, Establishing a Comprehensive HIV/AIDS Monitoring System, Strengthening the Philippine National AIDS Council, and for other purposes. RA No. 8504 mandates the following: instituting nationwide HIV and AIDS information and educational programs; promoting safe practices and procedures; establishing guidelines in testing, screening and counselling; making health and support services available; establishing a comprehensive HIV and AIDS monitoring program; upholding strict observance of confidentiality; stating discriminatory acts and policies; and strengthening the Philippine National AIDS Council. However, given the current status of the suspected burden of HIV and AIDS, amendments are recommended to address the gaps in the law.

95 Given the need for localities to mount a common program, the law should mandate for inter-jurisdictional cooperation among localities, especially in areas with high prevalence of HIV among key populations. However, the cost for HIV control may be too expensive for these localities, individually or collectively. The law should mandate the use of national funds to complement local investments.

Moreover, given the limited available information, the law should also mandate the design and implementation of an effective monitoring system to be able to gather data, assess performance, and evaluate impact of interventions on health outcomes.

Finally, the Report recommends that the appropriate package of interventions be delivered as a national program. This will make the DOH accountable to the President (through the Philippine National AIDS Council) over the outcomes of the HIV and AIDS program. This recommendation does not mean that the national program will now be directly providing services, but rather, the national program can be mandated to issue contracts to LGUs and private providers for the delivery of HIV and AIDS prevention, treatment and care services. These contracts should have clear terms of engagement, such as the specific input (e.g., deployment of personnel with specific skill sets and responsibilities), process (e.g., conduct of specific IEC, condom promotion, testing and treatment services), output (e.g., number of individuals informed and counseled, people tested, PLHIVs enrolled for treatment) and outcomes (e.g., knowledge levels on HIV, condom use rates, STI rates, CD4 levels, etc.) deliverables that are the basis for the release of payments. For example, the conduct of the IHBSS every two years can serve as the basis for the releases that are linked to outcome indicators.

Furthermore, this means that the accountability of fully understanding the epidemic and identification of priority areas and populations rest on the national government. The monitoring and evaluation of the program elements (e.g., IEC, service delivery contracts, and outputs) will also rely on national managers and scientists. This presupposes that there are capable managers to develop programs, design and manage contracts, and coordinate with other agencies. In the same manner, this will require trained scientists and researchers at the national level to monitor epidemiologic trends, identify at-risk groups, and measure performance, among others.

Several bills have been filed in Congress63 to address these legal barriers. It is recommended that the DOH and other stakeholders consider the issues and recommendations made in this Report, as the bill is being deliberated in Congress.

63 Senate Bill 186 was among those filed in the 16th Congress to propose exceptions on the need for parental consent for minors to avail of HIV testing services. In the 17th Congress, Senate Bill No. 1390 serves as a substitute bill that consolidates five other bills and one resolution filed in the Senate. The bill proposed, among others, exceptions for minors to access services, removal of restrictions in the design and teaching in schools and allows for harm reduction interventions and opt out testing. While the bill seeks to strengthen the Philippine National AIDS Council, the proposed law still delegates the implementation of the HIV programs to LGUs. In the House of Representatives, 16 bills were filed to date that seeks to legislate similar proposals.

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9. ADOPTING A SET OF COST-EFFECTIVE INTERVENTIONS TO REDUCE MORTALITY AND MORBIDITY FROM NON-COMMUNICABLE DISEASES

Non-communicable diseases (NCDs) are now the leading causes of mortality and morbidity in the Philippines. About half of deaths from NCDs are due to diseases of the heart and of the vascular system, collectively known as cardiovascular diseases (CVDs). Instead of looking at the full range of interventions to prevent, detect, and treat NCDs, this Report focuses on a smaller package of interventions recommended by the Copenhagen Consensus, with the addition of intensive care and surgical management.

These recommendations are considered appropriate for middle-income countries like the Philippines. However, the fragmentation of health service delivery and financing owing to devolution can prevent the effective implementation of these interventions. The delivery of services like those recommended in the Phil PEN vary across LGUs owing to differences in priorities and capacities. In general, LGU hospitals do not have capacity for intensive care that is needed to manage complications from CVDs. Furthermore, only six government hospitals are able to perform open heart surgery.64 The extent of enforcement of regulatory measures such as smoking bans tend to differ across LGUs. Lastly, the financing of health services needed to control and prevent CVDs come from multiple sources. The efficiencies generated by these different financing sources are lost once they are used to pay for all types of interventions. A key reform measure would be to realign the use of various funding sources given their comparative advantages.

This Report focuses its recommendations in investing in health regulation. Regulating consumption of tobacco, alcohol, salt, and sugar will require substantial investments in research, public advocacy, and enforcement.

NCDs are now the Leading Cause of Morbidity and Mortality

NCDs are now the leading causes of mortality and morbidity in the Philippines, accounting for 240,666 deaths or 45 percent of registered deaths from all causes in 2013 (DOH, 2013a). Cardiovascular diseases (CVDs) account for at least 50 percent of all deaths from NCDs. Figure 9.1 presents mortality per 100,000 of diseases of the heart and diseases of the vascular system from 1960 to 2013 (DOH, 1960-2013). The actual number of deaths from diseases of the heart increased from 13,400 in 1960 to 39,163 in 1986. By 2013, deaths from diseases of the heart increased to 118,740. This is five times the number of deaths from TB, and 78 times the number of maternal deaths.

Morbidity and mortality from CVDs are influenced by independent risk factors such as hypertension, diabetes, and obesity. Based on the Food and Nutrition Research Institute (FNRI) data, hypertension affects 22 percent of Filipino adults. Its prevalence increases with age and peaks at 43 percent among 70 years old and above. Moreover, five percent of Filipinos have diabetes. As with hypertension, the prevalence rate of diabetes increases with age and peaks at 12 percent among those aged 60 to 69 years old. Diabetes prevalence has been observed to drop to eight percent among those 70 years and older. This can imply that fewer diabetics survive beyond 69 years of age. Obesity, on the other hand, now affects seven percent of Filipino adults (FNRI, 2015).

64 These hospitals are the Philippine Heart Center and the Philippine General Hospital in Metro Manila; Region I Medical Center in Pangasinan; Bicol Regional Teaching and Training Hospital in Albay; Northern Mindanao Medical Center in Misamis Oriental; and, Southern Philippines Medical Center in Davao (Santos, 2014).

97 Figure 9.1 CVD Mortality (Rate per 100,000 Population) 140

120

100

0 8 0 0 6 6 60 62 64 66 6 70 72 74 76 78 8 82 84 86 88 92 94 98 00 02 04 08 10 12 9 9 99 99 00 0 19 19 19 19 19 19 19 19 19 19 1 19 1 19 19 1 19 19 1 19 20 20 20 2 20 20 2

Diseases of the Heart Diseases of the Vascular System

Source: 1960-2013 Philippine Health Statistics

In turn, hypertension, diabetes, and obesity are driven by non-modifiable (e.g., family history, age, and sex)65 and modifiable risk factors. Modifiable factors include diet, environmental exposure, and physical activity. High salt intake has been associated with developing hypertension. The high salt intake among Filipinos that was reported earlier in this Report (see Section 5) could partly explain the prevalence of hypertension in the Philippines. Exposure to cigarette smoke has been linked to CVDs. Data from FNRI (2015) show that smoking prevalence is at 25 percent or roughly 13 million Filipinos. Peak smoking prevalence is at 60 percent among the 30-39 year age group after which it declines slightly. Moreover, the same FNRI data show that nearly half of Filipino adults have insufficient physical activity. Together with the consumption of calorie-dense food, lack of physical activity could explain increasing prevalence of obesity. This lack of physical activity is also considered as an independent risk factor for developing diabetes (Martin-Timon et al., 2014).

Cost-effective Interventions to Reduce Morbidity and Mortality are Available

The continuum of care to address NCDs, particularly CVDs, spans four types of interventions. It must be noted that these interventions are not alternatives, but must all be provided as a package.

First in the continuum are regulatory interventions directed at the consumption of tobacco, alcohol, salt, and sugar. Efforts to develop and introduce regulations affecting the consumption of tobacco products and salty food are essentially public goods as the entire population benefits from its implementation. The concern is, without public support, there will be inadequate resources available to develop and effectively enforce these regulations. Part of the investments needed would be to support studies to better understand the local epidemiology of NCDs and the link of various risk factors. While information is available on the levels of salt intake and the amount of salt in specific foods, there are no studies estimating how much reductions in salt intake will lead to how much reduction in the incidence of CVDs for the local population (Batcagan-Abueg et al., 2013). A systematic review of salt reduction measures reported that while there are clinically measurable effects like reduction of blood pressure

65 In a local study by Punzalan, et al. (2014), people who are older, male, employed, and living in urban areas tend to have more cardiovascular risk factors.

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(Aburto et al., 2013), effects on long-term morbidity and mortality cannot be established, especially since studies on population-level salt-reduction measures are few (Adler et al., 2014).

The reduction of salt intake reduces the risks for hypertension and related cardiovascular conditions (Aburto et al., 2013). The Copenhagen Consensus recommends reducing salt content in processed food by 30 percent through product reformulation. This intervention is estimated to avert 16 million deaths from CVDs worldwide by 2030. Smoking has been associated with increased risk for CVDs and cancer (CDCP, NCCDPHP, & OSH, 2010). There is robust evidence that increasing cigarette prices reduces smoking rates. In particular, the imposition of excise taxes that raise prices causes current smokers to quit and prevents uptake of smoking among the young. The Copenhagen Consensus recommends a 125 percent increase in tobacco prices in order to cut tobacco use by 50 percent and avert an estimated 2.5 million deaths among 30 to 69 year olds worldwide by 2030.

The impact of regulatory measures like sin taxes are likely to be more significant for the poor. For example, the poor consume twice the recommended daily intake of salt such that much higher taxes need to be imposed, if only to meet desired nutritional levels. Similarly, taxes on tobacco products need to be raised further, considering that one year into the implementation of the Sin Tax Law, smoking prevalence among the poor went from 38 percent to only 25 percent (SWS, 2014).

Second in the series is polydrug therapy which might include anti-hypertensive, statin therapy, and anti-diabetes drugs.66 It should be emphasized that an integral part of the second intervention is access to regular screening and diagnostics. The population targeted for polydrug therapy include those who, perhaps owing to genetic predisposition, develop CVDs despite the presence of effective regulatory measures against “sin products.” According to the Copenhagen Consensus a multi-drug regimen at 60 percent adherence rate among those with high risk from CVDs can avert an estimated 880,000 deaths among 30 to 69 year olds worldwide by 2030 (Nugent, 2015).

The recommended program for secondary prevention for CVDs is provided in the Phil PEN protocol67 issued through the DOH AO No. 2012-0029 “Implementing guidelines on the institutionalization of Philippine Package of essential NCD interventions (Phil PEN) on the integrated management of hypertension and diabetes for primary health care facilities” and its manual of operations. The Phil PEN protocol serves as a guide for early detection and initiation of treatment at the primary care level through risk factor assessment, risk screening, risk stratification and risk management of individuals 25 years and above (DOH, 2012b).

The protocol requires performance of certain procedures, accomplishment of specific forms and use of specific equipment to screen, classify, manage and monitor patients. However, compliance to these protocols is not being adequately monitored. In the absence of effective monitoring, it is difficult to identify what challenges are faced in implementing Phil PEN. It is difficult to determine how well it is implemented by RHUs considering that the introduction of Phil PEN adds to the growing list of programs and services that are expected to be handled by the existing, and often understaffed and poorly equipped RHUs. It also makes it difficult to assess if the trainings provided were adequate and useful and that the drugs supplied are adequate and delivered on time.

Limitations in the capacities of public health providers pose a challenge to Phil PEN implementation. In terms of screening68 the target population for NCDs, Phil PEN relies on: 1) patients consulting for complaints related to NCDs, 2) clients visiting the RHU to avail of other services, and 3) referrals from the community health workers

66 Since 2015, the DOH Maintenance Medicines Program supplied the various Hypertension and Diabetes Clubs organized by the different RHUs nationwide. There are currently only four types of drugs provided by the medicines program, namely Amlodipine, Metoprolol, Losartan and Metformin. The first three drugs represent three important classes of anti-hypertensive medications namely, calcium channel blockers, beta- blockers and angiotensin receptor blockers, respectively. Metformin is the only drug being provided for diabetes. 67 The Phil PEN is based on the WHO protocol that identifies a set of prioritized cost-effective interventions for primary care in low-resource settings (WHO, 2010b), particularly the integrated management of diabetes and hypertension. 68 Although health checks had no effects on total morbidity and mortality in high income settings, there is still insufficient evidence from currently available systematic reviews to confirm beneficial effects of blanket screening for hypertension and diabetes in low-and middle income countries (Durao et al., 2015).

99 and volunteers (DOH, 2012c). These approaches to screening are mainly passive and opportunistic with the RHU essentially waiting for clients to come on their own or be referred. Additional capture points to actively seek out clients and widen the reach of the program have yet to be utilized. These include making use of family development sessions for those in the 4Ps, as well as riding on processes related to government transactions that involve medical examinations such as in securing health certificates, applying for driver’s licenses and in claiming benefits from SSS and GSIS. In addition, many public facilities are unable to perform basic tests like CBC.69 This implies that local facilities may not have the diagnostic capacity to manage NCDs like hypertension and diabetes.

While the DOH has been distributing diagnostic equipment like sphygmomanometer and glucose meters to RHUs, there is no information on whether RHUs are now able to provide basic diagnostic services.

Third in the series is the administration of aspirin at the onset of acute myocardial infarction (AMI). Aspirin is considered standard treatment for AMI by preventing the formation of blood clots that could block arteries in the heart and injure cardiac muscles (Gara et al., 2013). Taking aspirin at the onset of AMI, particularly within the first 24 hours from the onset of symptoms (Antman et al., 2004) is considered a “best buy” that prevents two percent of deaths from CVDs (WHO & World Economic Forum, 2011). The use of aspirin is estimated to avert 56,212 premature deaths from ischemic heart disease among 30 to 69 year olds worldwide by 2030.

The administration of aspirin at the onset of AMI might nominally look cheap and easy to provide. It should be pointed out, however, that for this intervention to work, skilled personnel who can promptly detect the onset of AMI is required. In the Philippine context, such trained personnel must include barangay health workers (BHWs) and rural health midwives, in addition to family members. The readiness to administer aspirin must be maintained despite effective levels of the first two interventions.

Fourth intervention, notwithstanding the first three, addresses people who will need surgical interventions such as stenting and coronary artery bypass graft (CABG). It is, of course, expected that the number of patients requiring such interventions would decrease dramatically with interventions one to three (Maugh II, 2011).

Applying the estimates in the case of the Philippines, provides an estimated annual cost of PHP50 per person70 to implement the first three interventions. With a population of 105 million Filipinos, these interventions will cost an estimated PHP5.3 billion per year. It should be noted that nearly half of the cost for these interventions is accounted for by the cost of implementing regulatory measures. Specifically, for tobacco, this covers the cost of comprehensive bans on smoking in work places, dissemination of health information, media campaigns, and bans on tobacco advertising. For salt reduction, this involves cost in voluntary salt reduction by manufacturers, and sustained mass media campaigns (Asaria et al., 2007).

While the expected reduction in premature deaths by 30 percent will only be achieved by 2030, the combined effect of the first three interventions in terms of reducing mortality builds up over time. When extrapolated to the Philippines, the annual benefit of implementing these four interventions is estimated at PHP39571 per person or a total of PHP41.5 billion for the whole country. This gives a benefit cost ratio of PHP8 for every peso spent.

The cost of providing surgical interventions might be indicated by the treatment of ischemic heart disease (IHD), which typically consists of diagnostic procedures, surgical or other advanced medical procedures, and post- operative and long-term outpatient care. A typical hospital admission will cost over PHP400,000, depending on the length of stay, severity, and the nature of surgical intervention. The costs of surgical procedures, including

69 See Section 3. 70 This estimate was computed by dividing the annual cost of USD8.06 billion to implement the four interventions with the global population of eight billion people. This gives an estimated per capita cost of USD1, which is equivalent to PHP50 based on the current exchange rate of 1 USD = PHP50. 71 This amount was computed by dividing the annual cost of USD63.3 billion to implement the four interventions with the global population of eight billion people. This gives an estimated per capita benefit of USD8, which is equivalent to PHP395 based on the current exchange rate of 1 USD = PHP50.

100 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance catheter-based procedures (stenting and angioplasty) or coronary artery bypass surgery (CABG), can easily run up to a million pesos per patient per procedure depending on the diagnostics, the complexity of the procedure, and whether medical therapy and recovery costs were included in the total cost estimates (Brouwer et al., 2015). In comparison, the PhilHealth Z-Package provides only up to PHP550,000 in reimbursements (PHIC, 2013).

Fragmentation Prevents Effective Control of CVDs

Fragmentation, owing to the devolution of the public health delivery system, increases the difficulty of delivering a continuum of care to address CVDs by the poor. Of particular concern is the capacity of the devolved system to deliver polydrug therapy, with the appropriate screening and diagnostics tests. At their current state, RHUs are not fully equipped to deliver polydrug therapy for their constituents. RHU personnel, including BHWs, might even still have to undergo intensive training for them to effectively recognize symptoms and administer aspirin therapy at the onset of AMI. Such training should also prepare rural health personnel to educate members of the community regarding the use of aspirin therapy.

A related concern has to do with the capacity of LGU hospitals to manage complications from CVDs, especially conditions requiring intensive care. That many LGU hospitals do not have the facilities and the personnel required to do caesarean sections (CS) suggests that the capacity to provide cardiovascular surgery is severely limited. And it may very well be the case that even at the provincial level, there may not be enough resources to build and maintain such capacity. Furthermore, the number of cases expected at the province level might be too few to maintain a high level of competency. The alternative, possibly more viable approach to provide for surgical care required by CVD patients would be via social health insurance program. Local budgets for hospital facilities might be better used to subsidize premiums for the poor who can then use insurance coverage to access even privately- provided surgical care. Surgical care for CVDs, being relatively rare but expensive, is a textbook candidate for being covered by insurance. In contrast, the intervention that prescribes screening and maintenance medications might be better handled by directly financing public or private service providers.

Fragmentation also affects how well regulatory measures to reduce the consumption of “sin products” are enforced. The case of banning smoking and the sale of alcohol to minors are examples of regulatory measures that are hard to enforce uniformly across LGUs. The recent Presidential Executive Order No. 26, which bans smoking in public places across the country addresses the problem of LGU compliance by involving the Philippine National Police (PNP) as enforcers.

A more viable regulatory measure, which need minimal enforcement effort, is to impose taxes on “sin products.” In principle, taxes should be set high enough to reduce consumption. This also implies, however, that such regulatory measure cannot be relied on for revenue purposes. In fact, an effective sin tax would eventually generate no revenues. From this perspective, the current taxes on tobacco products need to be further raised given that substantial revenues continue to be collected, implying that a significant number of people continue to smoke.

At present, the four types of interventions to control CVDs are funded from multiple sources. However, except perhaps for regulations, each funding source attempts to fund a bit of each of the three interventions in the continuum. For example, the DOH buys maintenance medicines and provides technical assistance, capacity building, diagnostic equipment and supplies, health promotion campaigns, and performance monitoring. The DOH also provides for the surgical services through their regional hospitals and medical centers. Meanwhile, LGUs also pay for drugs and medicines, and equipment and supplies needed across the last three interventions, in addition to health personnel. Select provinces and cities also maintain hospitals that can provide the necessary surgical facilities. PhilHealth similarly covers a bit of everything through their out-patient benefit package and hospital services paid out through case rates, and more recently the Z-Package.

101 Different sources of financing have different comparative advantage in paying for different types of services. DOH funding is more appropriate in paying for regulatory interventions, including health promotion, given its scope and national significance. LGU funding, being closer to the community, might be better used to screen and provide maintenance medications. PhilHealth, being a social insurance program has the comparative advantage of paying for relatively expensive but infrequently used services such as CABG. The efficiencies generated by these different financing sources are lost once they are used to pay for all types of interventions. A key reform measure for CVDs and perhaps for healthcare services in general is to realign the use of various funding sources in line with their comparative advantages.

Substantial Investments in Health Legislation is Recommended

The delivery and financing of the last three proposed interventions to control CVDs face similar challenges arising from fragmentation as with the other health programs. What is unique about control of CVDs is the need for strong regulatory measures to influence the consumption of tobacco, alcohol, salt, and sugar. Hence, this Report will focus its recommendations on the first proposed intervention, which is to invest in health legislation.

Regulating consumption of tobacco, alcohol, salt, and sugar will require substantial investments in health legislation, which involves research, public advocacy, and enforcement. The important point here is to recognize that health legislation, if done properly, is relatively expensive, and would require as much research and attention as one would expect from developing a new clinical intervention. A large part of such cost has to do with addressing opposition to the legislation and enforcement of regulations.

In terms of research, the studies that need to be conducted include, but are not limited to, the following: 1) the amount of reduction in consumption to generate health outcomes, 2) the price elasticity of the commodity to be regulated, and 3) the trade-offs and unintended effects in the reduction of product consumption in order to recommend fair compromises to affected industries. These types of studies were done to inform the formulation of the Sin Tax Law of 2012 (Quimbo, Casorla, Miguel-Baquilod, Medalla, Xu, & Chaloupka, 2012; Sta. Ana III & Latuja, 2010; Udaundo, 2010).

First, extensive research must be done to identify and determine the amount of reduction in consumption to generate the desired health outcomes. In the case of tobacco, among the evidence presented during the hearings for the Sin Tax Law of 2012 include estimates for the number of smokers, and the number of premature deaths associated with smoking. It was estimated that 75,000 premature deaths will be prevented with a 70 percent increase in tobacco prices through excise taxes (Dans & Latuja, 2012). In the case of salt regulation, the approach used in other countries involved assessing the sodium content in food, followed by studies that estimate consumption of food products with high salt content that later served as basis for identifying products to regulate. Once these products were identified, salt reduction levels were then set in consultation with affected industries (Magnusson & Reeve, 2015).

Second, research is also needed to determine elasticity, which will show how much change in demand will result from a price change. Specifically, in proposing the Sin Tax Law of 2012, the Department of Finance (DOF) calculated the price elasticity of demand for cigarettes to be -0.5, which means that a 10 percent increase in cigarette prices would yield, on average, a five percent reduction in cigarette consumption (Madore, Rosenberg, & Weintraub, 2015).

Lastly, research is needed in determining the trade-offs and unintended effects in the reduction of consumption of specific products. Information on these matters can help guide government in mitigating the effects ofthe policy on affected populations. For example, in the legislation of the Sin Tax Law of 2012, the tobacco industry

102 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance warned that lower consumption of tobacco products would reduce incomes of local tobacco farmers and cigarette manufacturing companies.72 The government argued that increased spending and employment in other sectors will offset this. More importantly, 15 percent of tax revenues were earmarked to fund economic development projects in tobacco-growing provinces. In the experience of other countries on salt regulation, food industry representatives argued that salt reduction would affect their product’s flavor, which in turn will influence food selection and buying behavior. The proponents of salt regulation then recommended coordinated reduction of salt in foods across all manufacturers to level the playing field. Then to avoid consumer dissatisfaction of the flavor that the buyers are used to, a stepwise process that systematically and gradually lowers salt levels across food supply as well as salt substitutions were suggested (Institute of Medicine, 2010).

Investing in legislation needs to cover all aspects of developing and implementing the law. These actions cover the drafting and lobbying for the law, public advocacy and constituency building, as well as enforcement. The drafting and lobbying for the law will require assembling teams to review current laws, policies, and programs in order to determine gaps in laws and regulatory capacities, create an enabling institutional and governance environment to drive the necessary reforms, and create the capacity for government-wide response. It is recommended that these teams will be coordinated by a dedicated unit with secure funding, adequate human resources, enforcement powers and geographical reach (Magnusson & Patterson, 2014).

Public advocacy and constituency building will entail the conduct of information campaigns to increase awareness and knowledge on the negative health effects from consuming certain products and in promoting a healthier lifestyle. This will also include mobilizing support from various organizations in order to create a movement in support of the proposed law. Examples of these strategies from other countries include mass media campaigns in Latin America (Argentina, Chile, and Brazil), public education campaigns in UK and China, distribution of informational booklets in Japan, and providing information through mandatory nutritional labelling in the United States, United Kingdom, and China. These accompanying measures further strengthen and promote salt regulation and improve health outcomes (CDC, 2013b).

Enforcement of regulation will entail costs related to monitoring and review, the provision of incentives for compliance and setting up mechanisms to deter violations. There needs to be an accountable body that will oversee implementation and enforce the regulations. This body will monitor the implementation of the program and periodically report on its status through the conduct of regular performance reviews. A system of incentives also needs to be in place to promote compliance (e.g., tax breaks, public recognition). In a similar manner, sanctions also need to be meted out to deter non-compliance (e.g., public naming, fines, etc.) (Magnusson & Reeve, 2015). For example in Finland, limits to the salt content of eligible products, like cheese, were enforced by providing subsidies and incentives to compliant manufacturers (European Commission, 2012).

In addition to the Sin Tax Law of 2012, experiences from other countries provide a watershed of lessons for the Philippines in regulating salt in food.73 Effective implementation of regulatory interventions for NCDs require a multi-sectoral, “all-of government” approach (WHO, 2013b), as seen in the implementation of the Sin Tax Law of 2012 and in the regulation of salt content in food in Argentina and Australia. In Argentina, the government and the food manufacturing sector agreed to voluntarily reduce salt content by around five percent to eight percent in the food processing of artisanal and bakery bread (Allemandi et al., 2015). In Australia reformulation of processed food was done through voluntary agreements between government and the food industry (Cobiac, Vos, & Veerman, 2010). The implementation of mandatory nutrition standards including eliminating food and drinks high in saturated

72 Industries who share an economic interest will perceive these reforms and regulations as potential threats to revenues and will seek to oppose the reforms through political lobbying, legal maneuvers, advertising and such. To a significant degree, progress will depend on both the willingness of the industry as well as the capacity of government and civil service organizations to regulate the business sector (Magnusson & Patterson, 2014). 73 An earlier attempt at regulating salt intake was the filing of Senate Bill No. 2602 “An Act to Regulate the Salt Intake of Consumers by Providing Alternatives to the Conventional Use of Salt, Requiring Strict Labeling Standards, Consumer Education and Initiating Partnerships with the Food Industry”. The bill was filed in the 15th and 16th Congress but has yet to be refiled in the 17th Congress..

103 fat, sugar or salt across schools (World Cancer Research Fund International, 2015) was also found to be beneficial and cost saving.74 Overall, it is recommended that additional improvements in health will require further regulatory action from the government and cooperation from all sectors.

Current strategies for salt regulation include food reformulation, consumer education, nutrition labelling, nutrition guidelines for food and meals served in public institutions (e.g., public schools, hospitals, workplaces) and taxation. These different strategies are being implemented usually in combination in order to yield better outcomes. Regulatory measures need to be tailored to fit a country’s consumption profile. For example, in countries like Japan and China, processed food is not the major source of sodium. Because of this, the focus was on public education and consumer awareness campaigns instead of the food industry (Trieu et al., 2015). For countries like the United Kingdom and Australia which obtain their sodium mostly from processed foods, the food industry is actively engaged through public-private partnership deals (Magnusson & Reeve, 2015).

Lastly, the effects of regulation need to be evaluated in terms of specific outcomes. For example, in the UK, salt reformulation and education campaigns led to a decrease in salt intake of 14.7 percent (i.e., 9.5g to 8.1g) from 2001 to 2011 (Sadler et al., 2011). In Finland, the combined mass media campaigns, voluntary salt reductions from the food industry, consumer education and compulsory labelling of products led to a decrease of 36 percent (i.e., 13g to 8.3g in men and 11g to 7g in women) in population salt intake from 1979 to 2007 (Pietinen et al., 2010). Moreover, in middle income countries like Syria, Tunisia, Palestine and Turkey, combined labelling and reformulation along with a health promotion campaign was projected to realize the biggest cost savings as a result of salt regulation (Mason et al., 2014).

74 The Department of Education has recently issued Department Order No. 13 s. 2017 on the promotion of healthy eating habits among the youth and its employees by setting healthy food standards and making nutritious food available in schools and DepEd offices. This amends Department Order No. 8 s. 2007 that was issued to provide guidance in the operation of school canteens that includes restricting junk food in schools.

104 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

10. INVESTING IN CAPACITY TO RESPOND TO THREATS FROM EMERGING AND RE-EMERGING INFECTIOUS DISEASES

Emerging and re-emerging infectious diseases (EREIDs) are infections that are “newly recognized, newly evolved, or occurred previously but have shown an increase in incidence or expansion of geographical, vector or host range” (WHO, 2014a). Despite the ever-present threats, the Philippines has yet to experience a widespread epidemic from the more recent emerging infections. A question that remains, however, is whether the Philippines can cope with a higher number of cases that emerge either from within or from outside the country.

To mount an effective response to EREIDS, four elements need to be assembled in order. First is the network of frontline providers that can detect threats and deliver the appropriate response once such threats have been identified. Second is an effective surveillance system that is able to capture and analyze information coming from the frontline. Third is the scientific capacity to understand the nature of the disease, the factors that drive transmission, and the effective interventions to prevent spread and reduce morbidity and mortality from these diseases. Fourth is a network of specialists who can provide definitive care for EREIDs.

The Report recommends investments in each of the four elements. Investments in ensuring the competency of frontline providers and building the scientific base for disease control in general and for EREIDs in particular should be given priority. A network of competent frontline providers and a critical mass of scientists should generate enough political pressure to drive investment in the other two elements. In parallel, immediate efforts in improving surveillance systems and creating a network of end-referral providers can be implemented by building on the experience in dealing with EREIDs.

Inherent Vulnerabilities to EREIDs Exposes the Country to Widespread Epidemics

Despite the ever-present threats, the Philippines has yet to experience a widespread epidemic from the more recent emerging infections like Middle East respiratory syndrome coronavirus (MERS-CoV) and Zika. The limited spread of emerging infections may be attributed to global surveillance, quarantine, and other disease control efforts that have so far proven effective in containing the spread of infection, and in warning countries like the Philippines about cases that enter through its various ports of entry.

A question that remains, however, is whether the Philippines can cope with a higher number of cases that emerge either from within or from outside the country. This is especially so as there are at least three inherent vulnerabilities that continue to expose the Philippines to the risk of a widespread epidemic from any of these infections, namely: 1) proximity to global hotspots; 2) highly mobile population; and 3) large number of poor Filipinos.

The close proximity of the Philippines to countries like China make it a destination of migratory birds that could transmit diseases like the West Nile Virus, Lyme disease, H7N9, and other pathogens (Reed, Meece, Henkel, & Shukla, 2003). Certain parts of the Philippines have been identified as danger zones for H7N9 infection owing to the presence of live poultry markets that are associated with animal to human transmission of avian influenza (Gilbert et al., 2014). The Philippines also imports livestock and poultry from other countries, increasing the risks of contracting animal-transmitted diseases such as avian influenza. Moreover, the porous borders in the southern part of the Philippines make places such as Jolo, Sulu, and Tawi-Tawi vulnerable to disease spread from Malaysia and Indonesia, where the Melaka and Kampar viruses are endemic. For example, the first case of chikungunya

105 that was detected in Davao del Sur may have been introduced from Indonesia. Davao del Sur is approximately 200 kilometers north of central Indonesia and is known to be frequented by Indonesian traders and fishermen (CDC, 1986).

The Philippines has an estimated 2.5 million overseas workers among the roughly 10 million Filipinos who live abroad (PSA, 2016c; Commission on Filipinos Overseas, 2014). Moreover, in any given year, close to 400,000 Filipinos also serve in merchant vessels that ply routes all over the world. These Filipinos are at risk of exposure to these diseases abroad and then bringing them to the Philippines. A more recent case was that of a Filipino nurse who contracted MERS-CoV in Saudi Arabia and brought in the disease when she came home in February 2015. In addition, increasing tourism serves as a potential source of infections as more foreigners and Filipinos travel within and outside the country, possibly unknowingly exposing themselves to risks. In 2015 alone, more than 38 million passengers were processed in the four terminals of the Ninoy Aquino International Airport.

Initially, emerging diseases may be brought in from outside the country by travellers like overseas Filipino workers (OFWs). As these people interact with their families, attend schools, and transact in local markets, emerging diseases can easily be transmitted to the local population. These infections can quickly develop into outbreaks especially when poor communities become infected. Poor communities are most vulnerable owing to weaker health status, lack of knowledge of the disease, poor health seeking behavior, and limited access to health services, including that for surveillance and containment of emerging diseases.

A recent example of how deadly the combination is of having weak health systems and a large community of poor families is the case of the Ebola outbreaks in West Africa where 27,000 people were infected and 11,000 died (CDC, 2015). It should be noted that Ebola is relatively unknown in West African countries, unlike those in equatorial Africa. However, greater mobility between these countries allowed for the faster spread of the disease, especially to urban centers. More importantly, decades of conflict in war-affected countries like Sierra Leone devastated health systems allowing the epidemic to spread rapidly (WHO, 2015a).

Re-emerging diseases pose a large threat also because the nature of the disease has become relatively unknown even among health providers. Take, for example, cholera. The Philippines has had epidemics recorded as early as the 1800s, with the last recorded episode in the late 1950s when a new strain Vibrio cholerae O1 biotype El Tor was found. The disease has since been endemic to the Philippines (Lopez, Macasaet, Ylade, Tayag, & Ali, 2015).

That cholera remains endemic but may not be readily diagnosed and treated by health providers is a deadly combination, as what happened in the 2016 diarrhea outbreak in Samar. While the primary cause of the reported diarrhea outbreak was attributed to contaminated water supply, other case facts suggest that failure of the system to respond led to more infections and deaths. First the epidemic was declared only after three months from when the first reported case was seen and after it had already affected 14 towns in three Samar provinces75 (Philippine News Agency, 2016). By the time the epidemic was declared under control, 9,432 people were infected and 81 have died (Gonzales, 2016). In contrast, the diarrhea outbreak in Zamboanga was declared within 28 days from when the first case was reported. The epidemic was controlled within three months and affected a total of 3,870 cases and 22 deaths (Santana-Arciaga, 2016).

The Samar case not only shows the risk from a disease outbreak of an endemic disease like cholera. It also shows how the outcomes become more severe and deadly when such diseases hit communities where the basic health infrastructure and competency of providers may be lacking, and surveillance is hampered by fragmentation owing to devolution. The implications of these factors would be even more serious in the case of EREIDs.

75 Section 105 of the Local Government Code of 1991 states that the authority to declare outbreaks is with the DOH and not LGUs. However, the DOH is dependent on LGU reports on diseases with outbreak potential. DOH can also temporarily take over local health systems during outbreaks.

106 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Four Types of Investments Are Needed To Create an Effective System to Deal with Threats from EREIDs

The Samar case, in effect, suggests that the entire disease control and prevention infrastructure made up of surveillance systems, laboratory networks, and the referral facilities is what needs to be strengthened for the Philippines to effectively deal with the threat of EREIDs. This is the same system that keeps track of all diseases, recognizes early clinical manifestations, raises signals to alert the health system, and provides immediate interventions. Strengthening this system would require four types of investments: 1) competent frontline healthcare providers to detect, respond and report threats; 2) an effective surveillance system that informs the scientific base; 3) a scientific base to understand EREIDs; and 4) a network of end referral providers.

First, and perhaps the most critical, is strengthening the network of frontline providers that can detect threats and deliver the appropriate response once such threats have been identified. Three types of interventions are needed to strengthen frontline providers: provide continuing education to doctors in RHUs and district hospitals to keep them abreast with latest diagnostic and treatment protocols; provide special training to familiarize and regularly update frontline providers with regards to EREIDs; and improve the reporting system (e.g., FHSIS) by making it frontline-provider-friendly.

Second, there is need to build an effective surveillance system76 that is able to capture and analyze information coming from the frontline. In the Philippines, this is the system that is supposed to be managed and operated by the regional, provincial, city, and municipal epidemiology and surveillance units. However, there is a limited number of trained personnel to monitor outbreaks and prevent epidemics from spreading.

After nearly 30 years, the Field Epidemiology Training Program (FETP) of the DOH has only managed to train a total of 139 field epidemiologists all over the country (WHO-WPRO, 2008). Of these, several have already left the service or have been reassigned to other positions within the public health delivery system. Ideally, at least one epidemiologist should serve each province and municipality in order to serve as the backbone of the health surveillance system of the country. So at any given year, there should be roughly 3,000 trained field epidemiologists serving local communities. It should be noted that this requirement has not yet factored in the increase in demand that will be brought about by such epidemics as SARS and avian influenza, and more recently with Zika.

Another weakness of the surveillance system is the limited capture of information that is largely confined to the public sector. As mandated by AO No. 2008-0009, health facilities are required to submit information on reportable conditions (DOH, 2008a). However, compliance to this reporting requirement vary across health facilities and LGUs due to their capacity to diagnose reportable diseases, access to communication facilities, and willingness to comply with the reporting requirement. For example, the wide discrepancy between the estimated and actual cases of Japanese encephalitis, i.e., only four percent of estimated number of cases could reflect limitations in surveillance rather than absence of disease transmission (Lopez et al., 2015). It has to be noted that RA No. 3573 or the Notifiable Disease Act of 1929 has never been amended with its sanctions rendered ineffective to compel reporting by providers.

Third, there is need to develop the scientific capacity to understand the nature of the disease, the factors that drive transmission, and the effective interventions to prevent spread and reduce morbidity and mortality from these diseases. This scientific capacity is what is needed to address the gaps in information, specifically to correctly identify, detect, and study the disease epidemiology. Currently, only a few local scientists and researchers are studying EREIDs. Most of these scientists are based at the Research Institute of Tropical Medicine and other research units in teaching hospitals like that of the University of the Philippines (UP), as well as some veterinary medicine schools. In Section 5 of this Report, the Philippines has been shown to lag in terms of research in the

76 While not covered extensively in this report, the need to coordinate efforts with the agricultural sector concerned with zoonotic diseases is also important. Likewise, links with international surveillance systems such as that with WHO and CDC are critical.

107 areas of infectious diseases, epidemiology, and public health (see Tables 5.1 and 5.2) compared to neighboring countries. It is also only recently that mechanisms for multi-disciplinary research and surveillance particularly between the health and animal sciences disciplines under the context of One Health77 have been set up.

Fourth is building a network of specialists that can provide definitive care for EREIDs. At present, there are only 221 adult infectious disease specialists and 85 pediatric infectious disease specialists all over the country. However, more than half of these specialists are practicing in NCR followed by Region XI with 20, Region VII with 13, while the rest are found in other regions (PCP, 2016; PIDSP, 2016). One approach to address the limited number of trained personnel to handle EREIDS has been through an agreement between the DOH and Philippine Society for Microbiology and Infectious Diseases (PSMID) to mobilize infectious disease specialists during the response to MERS-CoV (Uy, 2014). However, this agreement was only limited to the MERS-CoV response and did not stipulate specific mechanisms for mobilization, assignment of liability, compensation, and budgetary support. The regional hospitals of the DOH have been designated as referral facilities for EREIDS cases. However, there is no information on the capacity of these hospitals to manage cases, especially with a wider epidemic. In most cases, suspected EREIDs patients are still referred to RITM for further management.

Fragmentation Limits the Capacity to Respond to EREIDS

Mounting an effective response to EREIDS would require these four investments to be assembled appropriately and efficiently to be able to capacitate the country to effectively respond to the threat of EREIDS. However, the Report also identifies challenges in developing this capacity due to fragmentation that was brought by devolution.

First, owing to devolution, the investment for developing and strengthening the network of frontline providers to detect, respond and report on EREIDS is under the discretion of the LGUs and subject to their priorities and available resources. By principle of triage, since EREIDs are rare events, developing this capacity may be given less priority as opposed to the more prevalent diseases like TB and non-communicable diseases. With limited resources, LGUs may not be able to allocate the necessary investments needed for the continuing education and access to new information for their health care workers that include not only the rural health doctors but also the nurses, midwives and barangay health workers. Moreover due to high costs of obtaining and maintaining specific diagnostic equipment for detecting and diagnosing EREIDs, they are not likely to be able to provide the necessary laboratory and imaging facilities needed. Usually the frontline providers are only able to collect samples from suspected cases and then send them out to RITM or capable tertiary hospitals for analysis, unfortunately it would usually take days to a week before results can be obtained (RITM, 2012; RITM, 2014; DOH, 2016c).

Prior to devolution, a public health doctor based in the district hospital would be responsible for supervising, engaging, and collecting reports from his designated area composed of several cities/municipalities. Post- devolution, the same public health doctor either became a program manager in the provincial health office or worked as a clinician in a public hospital. In both instances, he had no more mandate to supervise and engage the RHUs. Due to the fragmentation of the system, as well as the poor reporting of municipalities owing to the lack of sanctions, the exercise of surveillance functions suffered from the loss of wide scope of coverage from designated cities and municipalities. This made the detection of disease clusters that signal possible outbreaks, even more difficult.

Second, devolution also affected the capacity to build an effective surveillance system by fragmenting the public surveillance system and necessitating the individual LGUs to shoulder the costs for maintaining the surveillance system. Prior to devolution the case reporting system that ran through the RHUs, district and provincial hospitals

77 The One Health concept provides for unified interaction between disciplines and agencies in solving global and environmental health challenges such as addressing zoonotic infectious disease outbreaks. In the case of the Philippines, the One Health approach has been adopted in the response to diseases such as rabies and avian influenza. The Office of the President issued Administrative Order No. 10, series of 2011, entitled “Creating the Philippine Inter-agency Committee on Zoonosis, defining its powers, functions, responsibilities, other related matters, and providing funds thereof.”

108 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance to the regional offices before reaching the central office bureaus comprised the basic structure of the public health surveillance system. This system became fragmented after devolution, severing the connection from both the LGUs to the central office and among the LGUs themselves. Notwithstanding the ability to pay, the cost of maintaining a complete surveillance system may also be larger than what individual LGUs would be willing to pay for, owing to joint and overhead costs from the necessary epidemiologists and health providers needed from each LGU and those who will be overseeing the data collected from the LGUs.

Third, regardless of devolution, the strengthening of the scientific base to better analyze, understand, prevent, and reduce the threats of EREIDs rests at the national level. Given the post-devolution state, if cases are not detected, and if the surveillance system is not effectively functioning, the case load of the scientific community will be significantly reduced. This in turn will eventually atrophy the existing capacity and even induce our scientists to take on jobs elsewhere due to the “perceived” lack of demand from the underreported data. More importantly, the demand for greater scientific capacity will depend on whether or not emerging diseases originate from our country or if we are just a country where the disease may possibly spread. A greater demand is generated by countries where EREIDs would usually originate since these countries need to be able to properly assess the origins of the disease, create protocols to manage and contain the disease. In contrast, countries where diseases may spread to, can rely on alerts and protocols that have already been put in place by international organizations and countries that handle EREIDS.

Fourth, in establishing a network of specialists to manage EREIDs, there must first be a demand for it. Since there has been no current widespread epidemic and the occurrence of EREIDS is rare, these specialists should largely be a standby capacity that can be easily mobilized in the event of outbreaks. The value or returns to this standby capacity largely depends on the expected number of EREIDs cases that are more likely to come from imported, rather than local cases.

Prioritize Investments in Strengthening Frontline Capacity and Building Scientific Base

The Report recommends that among the four proposed investments to strengthen the capacity to respond to EREIDs, developing the competency of frontline providers and building the scientific base for disease control in general and for EREIDs in particular should be given priority. A network of competent frontline providers and a sufficient pool of scientists should generate enough pressure for the other two investments to be made.

In developing a mature surveillance system, competent frontline providers, whose skills need to be regularly updated, are required to provide accurate and timely reporting of data. Meanwhile, the presence of a scientific base ensures that the information gathered is adequate and sufficient to support scientific analysis. On the other hand, enhancing the network of specialists requires the analysis and scientific evidence provided by the critical mass of scientists. The network can only be effectively scaled up if they are in partnership with the competent frontline providers.

Ensuring the competency of frontline providers requires regularly updating and providing special training to improve the knowledge and skills on EREIDs of doctors, nurses, midwives and barangay health workers. The doctors in RHUs and district hospitals need to be abreast with the latest diagnostic and treatment protocols as well as updated on latest guidelines on EREIDs. Meanwhile, efforts should also be geared towards maximizing modern communication technology for frontline providers to provide information, report cases, and handle risk communication.

Acquiring a critical mass of scientists and health professionals that can respond to EREIDs can build on the core capacities existing in institutions like RITM and UP. This can be done by identifying and recruiting junior staff that will be sent abroad to earn advanced degrees in related scientific fields like epidemiology, biostatistics, microbiology, virology, and biotechnology, among others. It may also be important for the Philippines to require these scholars to be proficient in the local language of known disease hotspots in order to make use of local

109 research publications and news articles that may contain signals for an impending threat. The Philippines could negotiate with its various development partners and directly with global disease control centers in providing scholarships to these junior staff in addition to current support being provided through scholarship programs like the US Fulbright, UK Chevening, and Japan Monbusho. In turn, these scholars will be required to render return of service at the end of their scholarships.

International linkages and exchange agreements with leading global disease control centers should be expanded. The kind, level and intensity of interactions between Filipino scientists and health professionals with counterparts in global disease control centers can follow the example of Thailand in the case of EREIDs. Thailand’s Ministry of Public Health works closely with WHO and the US CDC through its Global Disease Detection (GDD) Center (CDC, 2016b). The GDD accomplishes this through partnerships in strengthening laboratory capacity and biosafety; implementing multidisciplinary approaches to disease detection and response and modelling laboratory-based surveillance for high burden diseases like pneumonia, TB, and invasive bacterial infections.

The Philippine version of a disease control center may not necessarily be housed in a single location or institution but rather can be composed of an active network of teaching and research institutions, as well as hospitals. Several institutions in the country can be made to comprise the network that will serve as the base for the critical mass of scientists and health providers that can respond to EREIDs. In addition to RITM, UP, and DOH Epidemiology Bureau, these institutions can include other medical and veterinary schools, hospitals, as well as research institutions like the San Lazaro Hospital, Lung Center of the Philippines, Marine Science Institute in UP Diliman, the Philippine Genome Center, National Institutes of Health in UP Manila, Department of Veterinary Medicine in UP Los Banos in Luzon, Biology Department of the University of San Carlos and Philippines – Armed Forces Research Institute of Medical Sciences (AFRIMS) Virology Research Unit in Visayas, and Research and Social Outreach Cluster at Xavier University in Mindanao. Hospitals with capacity for surveillance and testing should be included in this network. This can include the five hospitals (Northern Mindanao Medical Center, Philippine Children’s Medical Center, San Lazaro Hospital, Western Visayas Medical Center, and the Bicol Medical Center) that have been identified as sentinels for more detailed case-based surveillance for JEV with laboratory confirmation (Lopez et al., 2015).

Investments in developing other critical areas needed to respond to EREIDs can be done by building on existing gains and lessons in implementation. In strengthening the surveillance system, there is need to review the recent assessment of the FETP program in the context of actual demands in field epidemiology and in identifying how gaps in skills and human resources can be addressed in the short-to-medium term. One approach is to deploy international experts to beef up the faculty similar to how the program was started. Moreover, the technology of the surveillance system itself has to be enhanced to be able to capture all the information necessary for scientific analysis while at the same time being frontline provider friendly. Furthermore, performance incentives to regional offices and local health units can be conditioned on the timely and accurate reporting of diseases. Lastly, mobilizing a wider network of specialists can draw lessons from the agreement entered into by the DOH and PSMID in dealing with MERS-CoV. This arrangement can be institutionalized by formalizing the mechanisms to mobilize specialists during emergencies, provide legal cover and define accountabilities, as well as specify corresponding compensation and benefits.

110 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

11. STRENGTHENING THE PROCESS OF ACCOUNTABILITY TO REDUCE THE BURDEN OF VACCINE-PREVENTABLE DISEASES

An effective immunization program is expected to show high coverage rates (i.e., in the high 90s). But available data suggest that current levels of performance are way below standards. Several reasons explain this observed performance, including problems with Department of Health (DOH) central procurement and logistics and large variation in the ability of LGUs to routinely administer vaccines. However, our main hypothesis is that these problems exist because while the DOH is ultimately accountable for the overall performance of the vaccination program, it does not have the necessary sanctions nor incentives to influence individual LGU performance. The law, RA No. 10152, might have to be revised to introduce the appropriate carrots and sticks. The absence of effective instruments to influence EPI efforts of individual LGUs could very well lead to pockets where risks of outbreaks are higher.

Children Are Still Getting Sick from Vaccine-Preventable Diseases

Morbidity and mortality from vaccine-preventable diseases (VPD) among children have dropped significantly in the past two decades largely because of the introduction of the Expanded Program for Immunization (EPI) program of the DOH in 197678. For example, deaths from measles decreased from 5,191 in 1980 to 107 in 2013; deaths from tetanus went down from 1,004 in 1980 to 555 in 2013; and deaths from diphtheria declined from 414 in 1980 to 29 in 2013 (PHS, 1980-2013). The Philippines has also been declared polio-free in 2000 (Ducusin, 2015) and has eliminated neonatal tetanus in 2016, except in Autonomous Region in Muslim Mindanao (ARMM) (WHO, 2017).

However, many children continue to get sick from VPD. For example, in 2012, about 2,600 cases of measles were reported. Sixty percent of these cases came from the regions of Central Luzon, Caraga, and Western and Central Visayas (DOH, 2012d). This suggests that outbreaks are more likely to occur in places where immunization rates fall below herd immunity levels. A spike in measles cases was also reported in 2014 affecting 58,010 individuals and causing 110 deaths. This is 15 times the average of the previous five years (WHO, 2015f).

Another way of assessing the burden of VPDs is by examining how much was spent to prevent and manage these diseases. The 2014 National Health Accounts reported that PHP24.7 billion was spent on VPDs. While data on how much is being spent specifically on vaccinations are not available, the sources of financing for this amount suggest that a large part is due to curative care. By even taking into account government procurement of vaccines, the cost of privately-provided vaccination cannot add up to half the amount spent on VPDs. Hence, it can be inferred that the bulk of out-of-pocket and insurance payments for VPDs are for medical services.

Moreover, LGUs that operate the majority of public hospitals and clinics are reported to have spent PHP14.2 billion on VPDs, representing 35 percent of total LGU health spending. Surely, this amount exceeds the cost of administering immunization, given that the DOH pays for the vaccines. Hence, in addition to large out-of-pocket payments, LGUs are also paying for treatment of VPDs.

Assuming these inferences are correct, it is estimated that roughly PHP25 billion can be saved if immunization programs were to become fully effective. The DOH estimates that the cost of an effective and universal immunization

78 The EPI program started with six vaccines for the prevention of the following diseases: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis, and measles. In 1992, hepatitis B vaccination was introduced. In 2012, pneumococcal vaccines and rotavirus vaccine were introduced.

111 is PHP15 billion (Ducusin, 2015). Comparing this with the cost of care for VPDs provides an estimated 167 percent as the rate of return of a fully effective vaccination program.

The missing information has to do with the relationship between immunization rates and household expenditures on VPDs as proxy for disease incidence. Specifically, what is unknown is the extent at which marginal increases in coverage rates beyond the current 75 percent levels will result in reductions in household spending on curative care for VPDs. However, it may still be possible that spending on curative care would remain positive even with universal vaccine coverage.

But the case for investing PHP15 billion for an immunization program should be based on a clear understanding of why the current one is weak. It is by providing solutions to these weaknesses that the expected rate of return can be realized. The nature of the observed weaknesses of the current vaccination program is discussed in the succeeding sections.

Vaccine Coverage Is Low, Especially Among the Poor

While the burden from VPDs is low, there is risk from outbreaks because immunization programs have not met the 90 percent coverage targets. The 2013 National Demographic and Health Survey (NDHS) reports an FIC79 rate of 77 percent. Similarly, the DOH administrative data report the same coverage rates for 2015 (DOH, 2016a).

Figure 11.1 Percentage of Children 12 to 23 Months who had Received All Vaccines* by the Time of the Survey, 2008 and 2013

100 89.4 90 87.1 82.3 82.4 83.0 84.1 81.6 80.1 77.8 79.5 80 74.9 76.5 72.4 69.3 69.8 70 66.6 63.6 60 55.5

0 Poorest Poor Middle Rich Richest Total 2003 NDHS 2008 NDHS 2013 NDHS

*Received BCG, DPT1-3, Polio1-3, Measles Source: 2003, 2008, 2013 NDHS; ICF International 2012; The DHS Program STATcompiler (August 7, 2015)

79 The FIC rates were computed based on coverage for the following vaccines: BCG, measles, three doses of DPT, 3 doses of polio (excluding dose given shortly after birth). If the FIC for 2013 is recomputed to include three doses of hepatitis B vaccine, the rate goes down to 68.5 percent.

112 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Routine immunization at the primary care level has been the recommended approach under the World Health Organization (WHO) EPI program. The public immunization program is delivered mainly through health centers. However, routine immunization has been unable to fully meet vaccination targets, especially among the poor who are the main clients of health centers. While vaccination rates have increased over the years, as shown in Figure 11.1, it is the poorest quintile that lagged behind with only 67 percent getting all the required immunization in 2013.

Another concern about low coverage rates is shown in Figure 11.2, where vaccine coverage rates decline in succeeding doses, from the first BCG dose at birth to measles on the ninth month. The first vaccine (BCG) starts off at 95 percent declining to 84 percent coverage for measles. EPI coverage is highly dependent on having effective capture points, the first one being at birth. The succeeding vaccinations have increasingly lower coverage rates, as capture points reduce in significance and become increasingly dependent on the time and resources of parents.

A similar pattern is observed for diphtheria, pertussis, and tetanus (DPT) and polio. This suggests that mothers, especially those from poor families, may find it increasingly difficult to bring their babies for vaccination as babies get older. This could be the same reason why measles vaccination, which is given on the ninth month, only reached 85 percent coverage in 2008 and 84 percent in 2013. That these measles coverage rates are lower than the 90 to 95 percent coverage required for herd immunity (Salathé, 2015), could explain the high incidence of measles cases mentioned earlier.

Figure 11.2 Percentage of Children 12 to 23 Months who had Received All Vaccines by the Time of the Survey, 2008 and 2013

100

95.4 95 93.9 94.2 93.2 92.5 92.6 91.9 90.0 90 89.6 89.3

86.1 85.6 85.2 84.6 84.5 85 83.9

75 BCGDPT1 DPT2 DPT3 Polio1 Polio2 Polio3 Measles

2008 NDHS 2013 NDHS Source: 2008 and 2013 NDHS; ICF International, 2012. The DHS Program STATcompiler

Fragmentation Prevented Attainment of Vaccination Targets

Owing to lack of effective capture points, measles vaccination coverage is the most difficult to achieve. Hence, measles immunization rates might be a good indicator of the overall performance of a country’s EPI. In Figure 11.3, we present the immunization rates of measles for the Philippines, Malaysia, Thailand, Indonesia, and Vietnam over the period 1982 to 2015.

We compare the performance of the Philippines in terms of how fast it was able to raise coverage, whether or not it was able to reach the 95 percent target, and whether it was able to maintain high coverage rates. The EPI

113 experience of these five countries suggests that the period from 1982 to 2015 can be split into two phases. The first phase that saw rapid increase in immunization rates from 1982 to 1992 following the introduction of EPI; the second phase from 1993 to 2015 where immunization rates stabilized at high levels.

The Philippines did well in the first phase. It showed the highest rate of increase among the five countries during the first three years of this phase. The Philippines was also the first to break the 80 percent mark in 1989, while the rest of the countries reported coverage rates that were just between 50 percent and 70 percent. But during the second phase, the Philippines’ performance was overtaken by the rest of the countries, save for Indonesia. In fact, Malaysia, Vietnam, and Thailand broke the 90 percent mark by 1995.

The Philippines (and Indonesia) struggled to sustain coverage rates during the second phase, as shown by the relatively low and erratic coverage rates. We know that the Philippines broke the 90 percent mark for the years 2004 to 2008. One explanation is this was a result of an intensive nationwide campaign to eliminate measles (Takashima et al., 2015). After such a campaign, the Philippine EPI performance seems to have settled back to the erratic pattern of the previous years.

Figure 11.3 Measles Immunization Rates, Children Aged 12 to 23 months, 1982 to 2015 (in Percent)

100

80 70

1982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

Malaysia Philippines Thailand Indonesia Vietnam

Source: WHO & UNICEF 2017

There could be many factors that explain the EPI performance of Indonesia and the Philippines. But one thing they have in common is that both countries experienced financial and political instability that eventually led to the decentralization of government. Many observers point out that decentralization, especially in the initial stages, was accompanied by budgetary cuts and the introduction of user charges that led to reduced EPI coverage (Ranis & Stewart, 1994). But the more damaging effect of decentralization on EPI performance in the Philippines are the two problems described earlier: 1) large variation in access and quality across LGUs; and 2) difficulties in coordinating EPI activities of individual LGUs to achieve national targets. It should be noted that the poor EPI performance persisted even when health budgets have significantly increased beginning 2008.

114 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

The hypothesis here is that decentralization affected EPI performance in two ways by making it difficult to: 1) achieve national targets; and 2) sustain high coverage rates over the long term. To understand exactly how decentralization affected EPI performance, there is need to assemble an elaborate network of health facilities, doctors, and health providers into a public health care delivery system that would take care of mothers who are poor and lack education. The idea is for the public health system to track all births and guide mothers to have their babies immunized. The features of a public health care delivery system that are essential to maintaining high coverage rates include a procurement and distribution system for vaccines, including cold chain from central office to the various points of care.

Prior to devolution, the district hospitals that handled facility-based deliveries, also supervised the rural health centers in the district. This allowed for an effective way to track the entire vaccination continuum from birth all the way to one year of age. A public health doctor at the district hospital supervising rural health doctors also made it easier to track mothers as they moved from one place to another. By managing vaccination from the district, it was also possible to reallocate personnel, vaccines, and other resources from one municipality to the other to address differences in coverage rates. Moreover, the cost of large vaccination campaigns as well as routine vaccinations were supported by the national budget.

With the devolution of the public health care delivery system, an immediate consequence was the break in the distribution system of vaccines, including the cold chain, from the DOH to local facilities. While vaccines continued to be centrally procured, these could only be delivered down to the DOH regional offices, which did not have the mandate and the resources to deliver the vaccines to points of care. How vaccines are actually delivered vary from one region to another. In some cases, regional personnel deliver the vaccines to provinces and then expects provinces to do the same to component cities and municipalities. In other regions, LGUs are expected to pick up stocks at either the DOH regional offices or from the provincial health office.

In addition, the district hospitals and its staff were now devolved to provincial governments and ceased to have any supervising authority over the rural health units, eventually leading to loss in efficiency in tracking babies to ensure that they are fully immunized. Shared resources lodged at the district level were now unavailable to individual RHUs.

Individual rural health units that typically have a doctor, a nurse, and up to five midwives, now had the responsibility of tracking babies and doing routine vaccination in addition to providing MCH services, TB control, and primary care. With devolution also came administrative restrictions, including one that limits hiring of personnel only up to 55 percent of local budgets.80 This made it difficult for municipalities to hire additional health workers to meet increased work load. By principle of triage, VPD outbreaks being rare, and the anticipation of annual national immunization campaigns, vaccination tends to be given lower priority.

The central procurement of vaccines also met with problems brought about by budget uncertainties, especially from 1991 to 2005 (Ball & Tisocki, 2009). When health budgets are not secured, there is a tendency to procure more than the estimated requirements to build a buffer. And as buffers accumulate, the distribution tends to be mainly supply driven, where the usual practice is to download vaccines to regional offices equivalent to population requirements of the region. On the other hand, when buffers get depleted, the tendency is to divide existing stocks equally across regions. But when budgets continued to increase beginning 2010, the tendency was to use incremental funding to introduce new vaccines rather than to secure adequate supplies of existing vaccines and improve the logistics systems. Recent examples include investing large amounts on the rotavirus, pneumococcal,

80 Section 325 (a) of the Local Government Code of 1991 prescribes that the total appropriations whether annual or supplemental, for Personal Services (PS) of an LGU for one (1) fiscal year shall not exceed 45 percent in the case of first to third class provinces, cities and municipalities, and 55 percent in the case of fourth class or lower, of the total annual income from regular sources realized in the next preceding fiscal year. (Congress of the Philippines, 1991)

115 and dengue vaccines, while the absence of a truly demand-driven logistics system continued to lead to stock-outs, if not overstocking.

At the point of care (e.g., hospitals and rural health units [RHUs]), the capacity to store vaccines and manage inventories vary widely. For example, most facilities designate vaccination days to reduce wastage of vaccines (DOH CAR, 2016). This is done to ensure that there are enough children to be vaccinated who will share a vial that contains multiple doses. Other facilities use the vaccines as children show up and discard the rest of the vial. The lack of cold chain facilities in LGU hospitals and clinics is critical not only because it leads to stock-outs but also raises the risk of losing potency of vaccine stocks.

Record-keeping practices also vary widely across facilities, making it a challenge to introduce a demand-driven logistics system. The lack of information on demand and stock levels at the point of service runs the risk of either a stock out or an overstock of a specific vaccine product. For a demand-driven system to work, the information needed goes beyond what is made available by a simple inventory management system. Data need to be available to anticipate the effects of behavioral factors such as the location of target beneficiaries (e.g., rural versus urban), where mothers deliver their babies, the education and employment of mothers (e.g., opportunities to visit during working hours), and income. This kind of information also allows field managers to better target and time their interventions for the vaccination program.

The shortcomings of the vaccination program have long been recognized since several attempts have been made to address them. Such attempts include programs to intensify efforts like the Reach Every Barangay strategy and catch up campaigns like the DOH Measles Elimination campaign – Oplan Ligtas Tigdas (WHO, 2006). Interventions have also been made to strengthen the capacity of local providers to do routine vaccination.

Amend the Law to Address Weaknesses of the Immunization Program

A routine essential immunization package is mandated under the Mandatory Infants and Children Immunization Act of 2011 (RA No. 10152). The law provides that this immunization package be given for free at any government facility to infants and children up to five years old. The DOH, other public and private institutions, and all health care providers are obligated to provide information on the benefits of immunization. In addition, the DOH, with the assistance of LGUs, is mandated to provide continuing education and training for health personnel. The DOH budget and PhilHealth were identified as sources of financing to implement the law.

However, the law needs to address how fragmentation brought about by devolution prevents the country from meeting immunization coverage targets. It would seem like the law was written for a fully integrated, centrally- administered system. One type of problem brought about by fragmentation is the absence of well-specified roles and responsibilities of key players with respect to immunization. The law not only needs to define accountabilities but should provide for sanctions for players who do not perform.

Two, the law does not identify who is ultimately responsible and accountable for achieving immunization targets. Under the current specification, the DOH and LGUs are made jointly accountable such that they can just point at each other when immunization coverage falls below target. The Local Government Code mandates municipalities and cities to provide primary care services, including vaccination. On the other hand, the DOH is mandated to provide information, continuing education, and training of personnel. But the law is silent on how LGUs are held accountable for non-performance.

Three, the financing provision of the law does not clearly define the total cost of the mandated immunization package, the portion that is expected to be paid through DOH budgets, and the LGU share. PhilHealth was also identified as a financing source, but a service like immunization should be funded using direct subsidies to providers who immunize children.

116 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Four, the law should clearly provide the principles and guidelines in setting both national and local coverage targets for various vaccines. Moreover, such targets should be mainly driven by public health, rather than economic and political considerations. And the law should prescribe and provide support to implement an effective outcomes monitoring system.

Our main recommendation is to amend RA No. 10152 to address the weaknesses of the immunization program described above. The most important amendment is to specify who is ultimately responsible and accountable for achieving immunization targets. In addition, the new law, as well as its implementing rules and regulations, could also provide for operational solutions. One option is to outsource procurement and logistics management as a possible way to address current weaknesses. For example, a number of private service providers exist that are able to realize economies of scale in the distribution and delivery of commodities, and in building an information system necessary for a demand-driven supply chain. Where public capacities are lacking, especially to catch up with the vaccination backlog, the DOH might consider contracting private provider networks to identify, locate, and then vaccinate children in a well-defined catchment that do not necessarily coincide with political jurisdictions. Social safety net platforms such as the conditional cash transfer (CCT) program81, pre-schools, and day-care centers should be transformed to become effective capture points to help increase utilization of vaccine services, especially for the succeeding doses and boosters.

81 An assessment of the 4Ps showed that immunization rates were not significantly higher among beneficiary households (Chaudhury, N., Friedman, J., & Onishi, J., 2013).

117 118 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

12. INVESTING IN INTER-JURISDICTIONAL EMERGENCY SERVICES FOR INJURIES AND DISASTERS

This section discusses two related problems that can be addressed with the proper assignment of accountability. Reducing deaths and injuries from accidents represents an assignment problem but in a uniquely spatial way. Under a devolved setting, the challenge is the assignment of accountability for the provision of emergency services for accidents that occur in a national highway system that traverses local jurisdictions. In the case of disasters, the people and the areas affected often belong to different jurisdictions. However, the nature and magnitude of disasters determine which level of government should be tasked to deliver the necessary medical response. If a municipality is hit, disaster response may have to come from the province. If the disaster is province-wide, a regional level of response, i.e., from other provinces, would be more appropriate. Furthermore, in the case of major disasters like Typhoon Haiyan, where the disaster affected more than one region, a national authority should have been assigned and made accountable. In a highly devolved setting, the cost of coordinating these overlapping but ladderized authorities warrants the creation of a special body and funding to manage disaster response. For both injuries from accidents and disasters, the key recommendation is to review and amend existing mandates so that it assigns accountabilities and provides for command and control authority with the appropriate financial support.

Prevent Deaths from Injuries by Properly Assigning Accountabilities across Jurisdictions

Deaths from injuries have substantially increased

Deaths from injuries and accidents have substantially increased from 1980 to 2013 as shown in Figure 12.1. It is now the fifth leading cause of mortality in the Philippines (DOH, 2013c). In 1980, deaths from accidents and injuries were only 9,000. In 2013, of the 40,071 deaths due to injuries, over half were from accidents.82

Of the total deaths from accidents and injuries, accidents accounted for 54 percent in 2013, with transport accidents accounting for 22 percent of total deaths from accidents and injuries (or close to half of total accidents were

Figure 12.1 Deaths from Injuries and Transport Accidents

50,000

40,000

30,000

20,000

10,000

0 4 8 2 1980 1982 1984 1986 1988 1990 1992 199 1996 199 2000 2002 2004 2006 2008 2010 201

Injuries Transport Accidents

Source: Philippine Health Statistics (1960-2013)

82 There was a decrease in the number of transport-related deaths from 8,761 in 2013 to 8,666 in 2014 (Sy, 2017). In 2016, the Highway Patrol Group (HPG) reported 2,144 deaths from around 32,000 vehicular accidents, up by 30.87 percent from 2015 figures (Tupas, 2017).

119 vehicular). Moreover, the highest number of reported deaths from road crashes are working age adults (age 15- 64). The economic burden of deaths from this age group is greatest considering that they are likely to be bread winners and active contributors to family income.

It is important to note that over half of road accidents involved the use of motorcycles (see Table 12.1). This trend may be explained by the fact that motorcycle use has increased, being the cheapest form of private transportation available. However, the enforcement of regulations regarding the use of helmets and other protective gear has been weak. The burden from motorcycle accidents is also disproportionately borne by younger as well as lower income groups (WHO, 2015c).

Table 12.1 Number of Cases of Injured and Deaths from Road Crashes, 2012 Vehicle type Number injured Percent Number of deaths Percent among transport related injury TOTAL 19,159 100 139 100 Bicycle 656 3 6 4 Bus 240 1 1 1 Car 450 2 10 7 Motorcycle 9,942 52 61 44 Pedestrian 3,656 19 29 21 Others 617 3 8 6 Tricycle 1,119 6 6 4 Unknown 2,269 12 15 11 Van 210 1 3 2 Source: 2013 DOH Online National Electronic Injury Surveillance System (ONEISS)

Further analysis of the incidence of deaths and injuries from road crashes is limited by the information available. For example, the case fatality rate for road crashes in the Philippines is only one percent. Other low and middle income countries like Thailand, Colombia, and Zambia reported higher case fatality rates of as much as 6.25 percent, 18.8 percent, and 6.4 percent respectively (Ministry of Public Health, 2012; Posada, Ben-Michael, Herman, Kahan, & Richter, 2000; Biemba et al., 2015). This implies that road crashes in the Philippines are not necessarily less fatal but the statistics are highly underreported. A major data challenge is to engage all hospitals to report details of vehicular accidents. Only 45 of the 70 DOH-retained hospitals, 22 out of 662 government hospitals, and only 40 out of 1,089 private hospitals nationwide reported such cases in 2013 (DOH, 2013d). Moreover, available data are also inadequate to determine the contribution to the reductions in death from such measures as helmet use, road conditions, having multiple as well as children passengers, and driving under the influence of alcohol and drugs.

The challenge to delivering appropriate care is determining who is responsible for ensuring its availability

The primary approach to reduce deaths and injuries from accidents is prevention and risk reduction. For example, in the case of motorcycle accidents, such measures refer to enforcement of speed limits83, anti-drunk driving laws84,

83 Republic Act No. 4136, otherwise known as the “Land Transportation and Traffic Code” mandates the various traffic rules which include speed limits, and the like, among other provisions. 84 Republic Act No. 10586, otherwise known as the “Anti-Drunk and Drugged Driving Act of 2013” ensures road safety by penalizing acts of driving under the influence of alcohol, dangerous drugs and other intoxicating substances.

120 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance and use of motorcycle helmets85 (Chisholm, Naci, Hyder, Tran, & Peden, 2012). In addition, correct construction and regular maintenance of road networks, installation of barriers and lighting to protect drivers and pedestrians, compliance with traffic rules on parking, pedestrian crossing, passenger loading and unloading areas, need to be effectively enforced.86 While these prevention measures are primarily handled by the public works, transportation and law enforcement sectors, effective implementation requires a multi-sectoral effort, including contributions from the health sector.

While the health sector can advocate for more effective enforcement of safety standards and regulations, its particular focus is on the delivery of emergency medical services where and when they are needed. In the case of accidents, three things need to be readily available in order to save lives. One, trained first responders must be available to recognize an emergency, call for help, and provide first aid until a formally trained health care provider arrives. Two, ambulance services must be able to provide basic pre-hospital trauma care, including scene management, rescue, stabilization, and the transport of injured people. Three, access to a facility where trauma care is available. Such facility should have surgeons, anaesthesiologists, laboratory and imaging facilities, among others (Mock et al., 2004).

The challenge is to determine who is responsible for ensuring the delivery of appropriate emergency care. When accidents occur within local road networks, the responsibility should rest on local authorities as mandated by the Local Government Code. Notable examples of LGUs that invested in local emergency systems are Davao City (CHMI, 2016), Quezon City (QCPAISO, 2015), and Cebu City (Bongcac, 2014). However, the devolved system makes it difficult to identify accountability when accidents occur in national highways. Accidents in national road systems, being more severe and more frequent, require interventions that are likely to be beyond the capacity and means of local emergency systems.

In the Philippines, three cases illustrate this assignment problem. The first case is when accidents occur along EDSA. The accountability for providing for emergency services is not assigned to any individual city traversed by EDSA. Rather, the Metro Manila Development Authority (MMDA) was mandated and given the budget to provide such services (Congress of the Philippines, 1994). Subsequently, accidents along EDSA are less likely to be handled by individual cities owing to the presence of MMDA emergency services.

The second case of this assignment problem is that of private toll ways like the North Luzon Expressway (NLEX). The government contract with the toll operators requires that it be responsible for all accidents occurring in the entire stretch of NLEX. The toll operator is first responder, ambulance operator, and has a designated emergency referral hospital. The contract also allows the toll operator to include the cost of providing emergency services in the toll fees. In this particular case, only highway users pay for the cost of emergency services (Ventura, 2008).

The third case is that of the Pan Philippine Highway that connects Luzon to the Visayas and to Mindanao. Except along EDSA and in private toll ways where accountability is assigned, there is no clear assignment of responsibility over emergency services. It is not clear whether the provincial, municipal, or city authorities covering the stretch of the highway is responsible for accidents that occur in their respective jurisdictions. While it can be interpreted that municipalities and cities are primarily responsible based on the Local Government Code of 1991, this may only apply in municipal or city roads. Moreover, the ability to provide emergency services becomes highly subject to the priorities and capacities of individual LGUs, especially that the cost of providing emergency response can be too high for a single LGU to bear. This mandate may even be more difficult to enforce when those who are injured may not even be their own constituents.

85 Republic Act No. 10054, otherwise known as the “Motorcycle Helmet Act of 2009”, decrees the mandatory use of standard protective motorcycle helmets. 86 The Philippine Road Safety Action Plan 2011-2020 aligned with the UN Decade of Action for Road Safety 2011-2020 was developed to reduce by 50 percent the traffic accident rate in 2020. The plan provides an overall framework and timeline of activities based on the following pillars: improving road safety and management, developing safer roads, safer vehicles and safer road users, and improving trauma care and rehabilitation (UN Road Safety Collaboration, 2011). In line with this plan, various road safety laws have been enacted, the most recent of which is Republic Act No. 10913 (“Anti-Distracted Driving Act of 2016”). However, policy gaps exist owing to limited implementation of these laws (Francisco, 2017).

121 In this case, possible entities that may be assigned to provide emergency services in the Pan Philippine Highway include the Philippine National Police and the Bureau of Fire Protection that can take on both local and national roles. Institutions like the Philippine National Red Cross should also be considered as they provide ambulance and other emergency services, have skilled personnel, and can mobilize a network of volunteers. Another possible entity that can be assigned the responsibility for managing emergencies would be public transport operators.

It should be emphasized that with the proper assignment of the responsibility over emergency care, sufficient resources should be made available for whoever is assigned to be able to perform its mandate. MMDA has its budget, which covers such accountability. The toll way operators presumably should be able to recover part of the cost as they collect toll fees. However, should a province like Quezon be held accountable for accidents in the national highway that traverses the towns from Tiaong to Tagkawayan, it should be provided resources over and above what it currently receives from the Internal Revenue Allotment (IRA). These resources should cover training and mobilization of first responders, the provision of ambulance services, and some form of retainer fee for designated trauma care facilities to attend to emergency cases.

A law assigning accountabilities for delivering emergency care needs to be passed

The key recommendation is to pass a law governing the delivery of emergency care. Several bills are currently filed in Congress to expand access and improve the delivery and financing of emergency care in the country.87 It is recommended that the law assign accountabilities for delivering emergency care across national highway systems and roadways. Furthermore, it is important that the entities given such accountabilities have sufficient administrative mandates and financial capacity to operate and maintain the provision of emergency services within assigned jurisdictions. Such entities may include provincial health systems, private provider networks, or relatively large civil society or nongovernment organizations.

The law should also describe the roles and responsibilities of entities designated to provide emergency care, including mechanisms to define and enforce standards of care. These roles and responsibilities include ensuring the integrity of the care continuum from the place of injury to the designated referral centers. The provision of emergency services shall be governed by minimum standards to which these entities will be held accountable.

In addition, the law needs to specify the allocation and release mechanisms for resources needed to support designated entities in providing emergency care. The necessary resources to support or compensate those designated to provide emergency services have to be properly costed out, transferred to designated entities and accounted for, in accordance with government rules. It is critical for the law to specify the mechanisms that will facilitate the allocation and the release of these resources depending on the urgency of the situation (e.g., mass casualty events). The role of social health insurance financing also needs to be specified in the delivery of emergency services beyond hospital care.

87 In 2014, DOH issued Administrative Order No. 2014-0007 or the National Policy on the Establishment of Pre-hospital Emergency Medical Service System (EMSS). This issuance aims to institutionalize a comprehensive, accessible, and integrated system of pre-hospital emergency medical services (EMS) from the scene of accident to the appropriate health care facility or hospital at the national and local levels. Currently, the DOH is spearheading the drafting of an EMSS Law. The law seeks to put in place regulatory mechanisms in terms of minimum standards for capacity building of the EMS personnel and minimum requirements for ambulances, equipment and facilities of the service providers. The law will also require PhilHealth coverage for the provision of pre-hospital care, including ambulance services. Current bills (SB 583, SB 1573, HB 539, HB 1605 and HB 3529) submitted in the 17th Congress include provisions regarding the institutionalization of a pre-hospital emergency medical care system through a National Pre-hospital Care Council who are designated to formulate policies on pre-hospital emergency care, set up a system of networking and coordination among facilities, develop standards of operations for facilities, equipment and vehicles, training and certifications of medical professionals and preparing the annual budget of the council for inclusion in the annual GAA; creation of plantilla positions for emergency medical technicians in all government hospitals; preparation of an annual budget and adoption of a national emergency number to access medical services. In addition House Bill 720 seeks to identify and set the requirements for designated trauma centers and the establishment of a Clearinghouse that will develop policy and standards for emergency medical care as well as enter into contracts or agreements to designate and establish trauma care networks, among others.

122 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Lastly, the law also needs to provide the necessary powers and mandates for the designated entities to effectively exercise their functions. These include the mandate to enter into contracts or agreements with various parties involved in the delivery of emergency services.

Assign National and Regional Accountabilities during Disasters and Emergencies

The Philippines, being located in the typhoon belt and the Pacific Ring of Fire, is naturally exposed to disasters. Disasters have pervasive social impacts brought about by the destruction of houses, displacement of populations, and damage to infrastructure, farms, and other means of livelihood. Responding to disasters and emergencies, therefore, requires a multidisciplinary and multi-sectoral approach with the various government and international agencies as well as the private sector performing different but coordinated roles.

Specifically, the health sector is tasked with addressing the immediate health effects of disasters, i.e., preventing injuries and death, and controlling the spread of diseases. However, a major challenge is that the fragmented health care delivery and financing system makes it more difficult to organize and coordinate the appropriate response especially as the intensity and scope of the disaster expands. Moreover, local responders, as well as facilities, can be rendered incapable in the case of large disasters.

RA No. 10121 that created the National Disaster Risk Reduction and Management Council (NDRRMC) provides for coordination mechanisms, accountabilities and delegation of tasks especially between LGUs and the regional and national councils. This law needs to be reviewed and clarified to address operational gaps that were exposed with a mega disaster like Typhoon Haiyan.

Philippines is highly vulnerable to natural hazards

The 2014 World Risks Report of the United Nations ranked the Philippines as the second most vulnerable country in the world for natural hazards (UNU-IEHS, 2014). The geographic location of the Philippines periodically exposes the country to typhoons, earthquakes, and volcanic eruptions as shown in Figure 12.2. Typhoons cause flooding, landslides, heavy winds and storm surges. Earthquakes destroy structures as well as cause fires. Volcanic eruptions cause lava flows and release pyroclastic materials that destroy property even in areas that are far away.

From 1970 to 2010, a total of 137,020 people suffered physical injuries, trauma, or an illness requiring immediate medical assistance as a result of a disaster (CRED, 2016). In the same period, earthquakes killed 8,412 people. From 1970 to 2013, major disasters accounted for over 30,000 deaths and at least 50,000 injuries.

The primary task of the public health delivery system is to address the immediate health effects when disasters occur. This task includes preventing injuries and death, and controlling the spread of diseases such as trauma care and the provision of medical emergency services. However, a major limitation of local disaster response is when local capacity is rendered ineffective by a catastrophic event. As the magnitude of the disaster increases, the local capacity to respond to health needs can be easily overwhelmed by the rapid increase in case load. Local health facilities can be damaged, and health workers themselves can become victims (WHO-WPRO, 2014).

123 Figure 12.2 Major Disasters from 1970 to 2013

Typhoon Kate (Titang) 1970 1,551 dead

Moro Gulf Earthquake 1976 4,791 dead, 9,928 injured, 2,288 missing

Typhoon Ike (Nitang) 1984 1,422 dead

Luzon Earthquake Typhoon Mike (Ruping) 1990 2,412 dead 748 dead

Typhoon Thelma (Uring)/ Pinatubo Eruption 1991 Ormoc Landslides 722 dead 5,956 dead

Mindoro Earthquake 1994 78 dead, 430 injured

Typhoon Nina (Sisang) Typhoon Angela (Rosing) 1995 812 dead 882 dead

Tropical Depression 2004 Winnie 1,619 dead

Typhoon Durian (Reming) 2006 1,399 dead

Typhoon Ketsana (Ondoy) 2009 464 dead, 529 injured, 37 missing

Typhoon Bopha (Pablo) Typhoon Washi (Sendong) 2012 1,901 dead, 2,666 injured, 1,259 dead, 6,071 injured, 834 missing 182 missing

Bohol Earthquake Typhoon Haiyan (Yolanda) 2013 222 dead, 976 injured, 6,300 dead, 28,688 injured, 8 missing 1,062 missing

Sources: National Disaster Risk Reduction and Management Council (NDRRMC), 2014a; NDRRMC, 2014b; NOAA, n.d.; Larson, 2014; Bueza, 2016

124 The Challenge of Reaching the Poor with a Continuum of Care:A 25-year Assessment of Philippine Health Sector Performance

Secure investments for effective emergency health care delivery system

The key recommendation of this Report is to review and amend RA No. 10121 in order to strengthen mechanisms and secure investments to build an effective emergency health care delivery system for disasters that cuts across jurisdictions and ensure resilience of the system.88

First, the amended law should clarify in no uncertain terms when regional and national councils can or should take over the responsibility of providing disaster response. The law should also define the roles of LGUs if and when regional or national councils take over. The lack of operational specification regarding the accountabilities of various LGUs as stated in Section 15 of the Law, and Rule 11 of the Implementing Rules and Regulations (IRR) of RA No. 10121, led to confusion in terms of the role of national agencies with that of LGUs in the immediate response phase. The Law assigns the mandate to lead in preparing for, responding to, and recovering from the effects of any disaster depending on the number of areas affected to the different disaster councils. For example, the NDRRMC can take the lead89 when two or more regions are affected by a disaster. However, the same provision states that LGUs are primarily responsible as first responders to disasters.

In terms of providing emergency medical response, the lack of specification on when and how national agencies can take over from local governments was highlighted during Typhoon Haiyan. Proclamation No. 682, s. 2013 was issued declaring a state of national calamity. This provided the legal mandate for DOH to take over local health systems pursuant to the Local Government Code. However, the lack of specific rules as to when and how the national government can take over from the LGU prevented the DOH from fully exercising this mandate. This resulted in ad hoc arrangements between local health staff and response teams in delineating responsibilities and assigning accountabilities, such as when DOH took over the operations of some public and private hospitals in the region. In the same manner, foreign medical teams worked out their own arrangements with local authorities (Albukrek, Mendlovic, & Marom, 2014).

Second, an amended law should identify the source, as well as define the trigger mechanisms for the release of special funds that would be made available when regional or national councils take over the responsibility of disaster response. The law could also specify the allocation rules governing such funds as to reflect priority actions from search and rescue to trauma care. The law and the IRR do not specify the mechanisms on how the regional and national disaster councils can mobilize local resources including personnel, facilities, and equipment, if and when they assume leadership. The regional and national councils are mainly composed of different national agencies with no staff and budget of its own, and rely on resources from each member agency. Moreover, RA No. 10121 does not provide for a quick response fund (QRF) for the DOH. In the meantime, the DOH relies on a special provision in the annual General Appropriations Act (GAA) for it to be able to secure and utilize a QRF. Based on assessment of how calamity funds have been utilized, alternative approaches to securing emergency funds can be considered, such as a system that triggers the realignment of available budgets if and when disaster levels are declared to have reached certain thresholds.

88 Several bills have been filed in the 17th Congress seeking to address some issues regarding the current RA No. 10121. Senate Bill 73 and House Bill 4203 seeks to establish an Emergency Response Department which will take over the present functions of the NDRRMC and OCD, and task bureaus with specific mandates and roles to enforce accountability and enhance capacity; establish disaster response activities in case of total/ considerable breakdown of authority resulting from a disaster, which goes beyond the capacity of the LGU; strengthen coordination with other government departments and agencies; creation of a Humanitarian Emergency Assistance Disaster Fund and increasing penalties for corruption; authorizing visitorial powers to ensure funding is used appropriately; commandeer private property for public purpose and authorizing emergency and contingency powers to commandeer and call out AFP/PNP in disaster stricken areas. In addition Senate Bill 1553 mandates the Department to set-up permanent and typhoon-resilient evacuation centers and facilities and to consolidate the existing evacuation infrastructures in the country. On the other hand, Senate Bills 287 and House Bill 108 also has provisions that further mandate for the purpose of disaster management that the LGUs to formulate their own local ordinances and possibly unite with other LGUs that have common borders as a joint local government. 89 Even if NDRRMC can take over, a council-structure has limited authority, resources, and staff capacity to address the impact, scale and rapidly evolving DRM issues. Thus, there is a need to establish a National Disaster Risk Reduction and Management (NDRRM) agency with stronger mandate to coordinate, plan, finance, implement, and monitor all DRRM interventions (World Bank, 2017). One proposal to address this issue is the creation of an Emergency Response Department (ERD) as proposed in Senate Bill 73 by Sen. Alan Peter Cayetano this 17th Congress.

125 Third, the law should also secure resources to sustain investments for emergency medical response capacity that will be installed in strategic locations nationwide. Such locations might be chosen in terms of its proximity or accessibility to areas that are frequently hit by disasters. These national emergency response units should not be prepositioned in disaster-prone areas, but rather be set up where it can easily reach affected areas through several alternative modes of transport. The primary responsibility of operating these strategically-located disaster response centers could be given to the Armed Forces of the Philippines, in partnership with other agencies and private organizations.90

90 A new Philippine Red Cross ship named Amazing Grace, a 195-foot military prototype vessel, can serve as an ambulance and disaster response ship. It can accommodate “120 passengers, 20 vehicles, and has a 35-ton overall freight capacity” (redcross.org.ph, 2017).

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A Commentary on Philippine Health Sector Review

The health sector in the Philippines stands out in at least two ways from other countries. Over the past 25 years, six governments and 14 secretaries of health, the policy advisers to government have remained constant. Thus, with modifications, national policies have been linked to each other ranging back to The Health Sector Reform Agenda of Alberto Romualdez in the 1990s to Kalusugan Pangkalahatan (KP) in this decade. Second, most governments do not take the opportunity to look back across a generation and critically reflect on their accomplishments and missed opportunities. The 25-Year Assessment of the Philippine Health Sector Performance, from its well–written Executive Summary—which should be required reading for anyone interested in improving health care in the Philippines—to the carefully selected subjects detailed in the full report, is an opportunity seized.

Even more importantly is the Filipino culture and capacity to look introspectively, to learn from the past and, as so ably expressed by the former Secretary of Health, Paulyn Ubial in her insights, to harness critical self-reflection into more strategic policies and better structural reforms to make the country’s long term health objectives a reality.

In the Philippines, evidence-based policies have been perennially challenged by rapid population growth, national and global economic crises, and some of the worst natural disasters facing any country. Poverty, however, remains the most fundamental challenge to improving health outcomes in the Philippines and it is an axiom that runs throughout this analysis. Ultimately the poor, who account for 25% of the population, do not receive adequate insurance or provisional subsidies and have remained vulnerable to disease and trauma. KP or Universal Health Care, through national targeting and premium subsidy policies, has aspired to decrease the financial burden of the poor. Analysis in this report shows, however, that this goal has been elusive with, perversely, higher income groups benefiting more from public subsides than the poor. One of the most urgent analysis herein, is for resources and subsidies to be re-organized if they are to be properly allocated.

Devolution, which the report clearly argues as not been a success for the health sector, has inhibited consistent implementation of policies and services; it has also obstructed equitable distributions of capital and other resources. As a result, local government units (LGUs) have failed to upgrade facilities, national technical coordination in the country is best described as ad hoc, and face serious distortions in funds flow with unacceptably high transactions costs. Although nascent, the report shows the evidence of the counterfactual: centrally managed and financed funds for investment, the deployment of centrally-hired doctors and nurses, and national purchasing of drugs and medical supplies can reverse some of devolution’s consequences. Similar to other countries and large health care systems elsewhere in the world, these policy directions should continue as a matter of national policy prioritization.

This report starkly describes enormous variations in the access and quality of care for the poor. Access, remarkably, is still done 60% of the time through RHUs, BHUs, (dating back to policy decisions in the 1950’s) and along with private clinics are efficient places to provide primary, preventive and chronic care. Likewise, 80% of all care for the poor is through publicly funded RHUs and BHUs. Impressively, these facilities are staffed by doctors and typically have a midwife, and an improving drug supply. Poor quality threatens this jewel. The 25-year review identifies that the threat to national access through RHUs and BHU’s for the poor will erode if better diagnostic capacity and basic primary and secondary preventive services are not a priority focus of upcoming policies.

155 Many needed analyses in this report are not done because data is simply not available. In the 21st century, it should be considered a national failure that the Department of Health has not been given the resources to put in place a modern data and informatics system. Against the backdrop of inadequate sectoral data, the exception is a wealth of data on the quality of hospital care given to children. These data come from the rigorous 10+ year Quality Improvement Demonstration Study, widely known as QIDS. QIDS already stands out in international policy circles as an example of how to measure and improve health policy. QIDS was not a pilot—it was a measurement and feedback study done throughout the Visayas and it showed quality could be improved in a very short period of time. The bottom line is that when QIDS improved quality, fewer Filipino children died. There is an irony that these remarkable policy lessons, hailed in the international community to form the basis for national level health sector reforms (for example) in Mexico, Rwanda and the United States, have been largely ignored in the Philippines. The takeaway, described herein, is that the Philippines should embrace their own results and expertise by re-invigorating the pursuit of quality and measurement as a matter of national policy.

Beyond fragmentation of delivery and financing, the 25-year Review highlights the constraints of human capacity and limitations in technology acquisition. There has been a serious lack of investment on expanding the pool of managers and scientific experts creating unfilled gaps and inefficiencies needed to deal with evolving health issues. Increased coverage and spending from social health insurance, accompanied by increased out of pocket expenditures and the inability of the health ministry to effectively utilize its higher budget have widened the inequity in access to services. Quality and equity are the takeaway requisites for evaluating future service delivery and the financing effectiveness.

Notwithstanding, there are bright spots across many disease areas. Evidence-based policies have been extremely effective in redefining access to drugs and the importance of primary care. Passage of important legislations such as the Sin Tax and Responsible Parenthood and Reproductive Health have opened up centralized financial and strategic opportunities for program expansion. Compared to other countries, however, major challenges exist with inadequate improvements in maternal and neonatal mortality, tuberculosis, and highly effective vaccine-preventable diseases. Prevalence issues in HIV, injuries and disaster, emerging and re-emerging infectious diseases demand a closer look at data (or the lack of it) and greater emphasis on inter-agency and inter-locality collaboration.

Health outcomes over the past 25 years are better. That is good news. The bad news is that the improvements are far less than would be expected from the enormous budget and spending increases over the same time period. Compared to other countries in South East Asia, when 25 years ago the Philippines was in the middle as measured by Life Expectancy (LE), the Philippines now ranks last with the shortest LE among five comparable countries. The same last place position is true for maternal mortality. Perhaps more sobering is that the trends in these and other metrics have been flat or nearly flat for over a quarter of a century.

As much as this report will provoke both a demand for better care, better policy, and more equitable financing, it should also produce an acknowledgment of the hard work and honest commitment of the thousands of people working to improve the healthcare of Filipinos. More centralization of purchasing and policies, expanded training, technical capacity and data systems for an increasingly complex sector and a concerted effort to find and train better managers should be the simple message of this important national review.

John W. Peabody, MD, PhD University of California San Francisco and QURE Healthcare

Diana R. Tamondong-Lachica, MD QURE Healthcare

156 Insights on Philippine Health Sector Performance

Reading this Report has for me been both a stimulating intellectual and emotional experience. I say this from the vantage point of a public health professional who has witnessed the evolution of the country’s health system over the last 40 years. Through those years, my driving mission has always been “health for all Filipinos”. This was and still is a common vision shared with many who have sought to contribute to the creation of a better health system ̶ one that ensures quality, accessible, affordable and equitable health care for our countrymen. Among these kindred spirits were health visionaries like Mario Taguiwalo and Alberto Romualdez to whom this Report has been dedicated. (Let me return to them later.)

In my view, this Report which covers the last 25 years beginning with the passage of the Local Government Code, lucidly lays out the “long-standing fundamental structural weaknesses” of the Philippine health system, foremost of which is its fragmentation brought about by the Local Government Code. Having personally experienced these weaknesses at work, it riveted me to see them described in print. The Report deconstructs the workings of the system, describes them, and provides data to use as windows and handles to understand very complex processes. For example, how many of us fully comprehend the significance of out-of-pocket (OOP) payments as the largest and fastest growing source of expenditures for health care? Most of us know about OOP payments in our daily lives as patients and consumers. But how many can explain to what extent OOP promotes inequity among our people who belong to various income groups or how as a national phenomenon, it causes the nation to miss out on the efficiencies of pre-paid resources for health and risk-pooling?

The Report discusses several long-standing national health programs in turn – maternal and neonatal health, tuberculosis control, HIV/AIDS among others. It analyzes these programs and makes recommendations for their improvement. It however omits to discuss pharmaceuticals as a sector in itself, as medicines account for at least 30% of health expenditures; nor does it discuss the problems of blood transfusion services, a key service which depends on functioning clinical laboratories and blood banks. Nonetheless, the Report tackles the difficult issues of integrating the “service delivery network” (of which pharmaceuticals and laboratories are an integral part) and makes the plea for unlocking the potential to better synergize health services provided by the public and private sectors.

The messages of the Report resonate very well with a recent publication in the Lancet which was released on line on 19th April 2017 entitled: “Evolution and patterns of global health financing 1995-2014: Development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries”. A clear message that emerges from these two documents is that the Philippines has been underfinancing its health care. It has less health spending per capita and a lower share of financing from government than what might be expected based on statistical model(s) devised from the global experience.1

But financing health care is only one aspect of making health systems work. And this Report rightly raises the issues of the competence of human resources in the health sector to manage the complex system and to supply the scientific brain power to free the health system from its shackles and get it really going. For a

1 Global Burden of Disease Health Financing Collaborator Network 2017. Evolution and patterns of global health financing 1995-2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet. Published on line April 19, 2017.

157 country that produces thousands of health professionals – doctors, nurses, midwives, pharmacists, dentists– many of whom have difficulty finding decent-paying jobs so that they go abroad, it is an indictment that should incite the spirit of reform within the health sector.

For its overarching message, which for me was quite emotionally-charged, the Report proclaims that health outcomes “have [only] slightly improved, if not remained the same over the last 25 years.” OMG! This is a conclusion that should stoke the passions of health care reformers all over the country. Mario Taguiwalo and Alberto Romualdez possessed the fire which made them drive the health reform agenda during the years covered by this Report. As we dedicate this Report to them, we call on the new generation of health visionaries to come together, dialogue, figure out the way forward, and act decisively and in unity for the health of all Filipinos.

Manuel M. Dayrit MD, MSc Dean, Ateneo De Manila University School of Medicine and Public Health Secretary of Health of the Philippines, 2001 - 2005

158 Insights on Strengthening the Continuum of Healthcare in the Philippines

With the devolution of health services in 1992, the DOH turned over administrative and financial control over health facilities, personnel, and reforms and improved investments in health regulation and governance for health, as well as the social determinants for health not within control of the health system, to more than 2,500 local government units. While devolution stimulated innovations, it also widened the variation in effort and health outcomes. To pursue national health objectives, the DOH now had to exercise technical leadership, leverage local investments, and monitor the performance of municipalities, cities and provinces, the frontline implementers.

Since then, successive DOH administrations undertook reform initiatives to improve outcomes under a devolved system. The efforts were done in the face of formidable odds including economic and social challenges and threats from infectious disease outbreaks and disasters brought about by climate change.

This report entitled, “The Challenge of Reaching the Poor with a Continuum of Care, A 25-Year Assessment of Philippine Health Sector Performance” describes the problem of insufficient investments in health, and fragmentation in the delivery as major contributors to failure of attainment of the National Obectives for Health. It identifies the following strategies that contribute to this issue: (a) consolidate service delivery and financing, to include public and private provision into a service delivery network; (b) invest in the capacity of the scientific community supporting the health sector; and (c) strengthen the management of systems for health care reforms.

I hope that this report will stimulate discussion and debate that would inform what reforms the current administration needs to undertake in order to pursue long term national health objectives. I wish that the report could have covered more programs in its assessment to better illustrate how fundamental challenges affect the implementation of specific programs. In addition, I would have also wanted more discussion on health human resources. However, the lack of data prevented the writers from discussing the issue more extensively. I understand from the report that the DOH must pay attention to both urgent operational problems and the need to address fundamental weaknesses in the way we deliver and finance health services.

I wish to commend the United States Agency for International Development and the UPecon-Health Policy Development Program for this report. I would also like to thank everyone who contributed, including those who reviewed the report and offered valuable comments and suggestions. The review does not end with publication of a report. It must continue way after since improving the health system is a continuing process. Let us adopt a culture of continuous quest for excellence and improvement.

Paulyn Jean B. Rosell-Ubial, MD, MPH, CESO II Secretary of Health of the Philippines, 2016 – 2017

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