Table of contents ▪ List of acronyms ▪ List of tables ▪ List of figures

THE MISAMIS OCCIDENTAL PROVINCIAL HEALTH INVESTMENT PLAN

▪ Executive summary

PART I: BACKGROUND AND SITUATIONAL ANALYSIS

A. Overview..……..…………………………………………………………………4

B. Introduction …..………………………………………………………………..8

C. The Province of Misamis Occidental…………………………………….10

D. The Province Health Situation…………………………………………….11

D.1 Health Needs D.2 Delivery System D.3 Health Financing D.4 Enrollment in Social Health Insurance D.5 Drug Management System D.6 Governance

PART II: THE INVESTMENT PLAN

E. MAJOR GAPS AND CHALLENGES………………………………………….30

E.1 Health Needs and Delivery System E.2 Health Care Financing E.3 Enrollment in Social Health Insurance E.4 Drugs B.5 Governance

F. PROPOSED INTERVENTIONS AND INVESTMENT OPTIONS...... 35

F.1 Health Service Delivery F.2 Health Care Financing F.3 Enrollment in Social Health Insurance F.4 Drugs Management Systems and Procurement F.5 Governance F.6 Start-Up Funds

G. CRITICAL TARGETS, ACTIVITIES AND OUTCOMES………………..48

2 List of Acronyms

APP Annual Procurement Plan BEMOC Basic Emergency Management of Obstetric Care BHS Barangay Health Station BHW Barangay Health Worker CAP Capitation CBR Crude Birth Rate CDR Crude Death Rate CEMOC Comprehensive Emergency Management of Obstetric Care CGMP Current Good Manufacturing Processes CHD Center for Health Development CHO City Health Office COPD Chronic Obstructive Pulmonary Disease CPG Clinical Practice Guidelines CPR Cardiopulmonary Resuscitation CVD Cardio Vascular Disease DCW Day Care Worker DMIS Drug Management Information System DOTS Directly Observe Treatment Short – Course Chemotherapy DR Delivery room EBM Evidence Based Medicine EC European Commission EKG Electro Cardiogram FIC Fully Immunized Children GIS Geographic Information System GSO General Service Officer GTC German Technical Cooperation HSRA Health Sector Reform Agenda HSRP Health Sector Reform Project HSRTAP Health Sector Reform Technical Assistance Program ICHSP Integrated Community Health Services Project ILHZ Inter-Local Health Zone IMR Infant Mortality Rate IPHO Integrated Provincial Health Office IP Integrated Program IPP Individually Paying Program IRA Internal Revenue Allotment IV Intravenus LCE Local Chief Executives LEAD Local Enhancement and Development LGU Local government Unit MD Doctor of Medicine MLGU Municipal Local Government Unit MMR Maternal Mortality Rate MOPH Misamis Occidental Provincial Hospital NDF National Pharmaceutical Foundation NDHS National Demographic Health Statistics NGO Non Government Organization NSO National Statistic Office

3 OPD Out Patient Department OR Operating Room O2 Oxygen PALS Philippine Australia Local Sustainability PPI Parallel Drug Information PLGU Provincial Local Government Office PLHIS Philippine Local Health Information system PHB Provincial Health Board PHIC Philippine Health Insurance Corporation PHN Public Health Nurse PHO Provincial Health Officer II PO People’s Organization PPF Provincial Pharmaceutical Foundation RHU Rural Health Unit RDF Revolving Drug Fund SEC Securities and Exchange Commission SS Sentrong Sigla STG Standard Treatment Guidelines TB Tuberculosis TC Therapeutic Committee WB World Bank WHO World Health Organization WRA Women of Reproductive Health

4 List of Tables

Table 1 Health Statistics, Misamis Occidental, 2004

Table 2 Top Causes of Illness, Misamis Occidental, 2005

Table 3 Misamis Occidental Inter-Local Health Zones, 2004

Table 4 Summary Assessment of Facilities in Misamis Occidental

Table 5 Capabilities in RHUs, by ILHZ,Misamis Occidental, 2004

Table 6 Capability Profile of Core (First Level) Referral Hospitals, Misamis Occidental, 2002

Table 7 Clinical Vignette Scores by Level of Care and Province

Table 8 Utilization of Facilities by Provincial Income Decile, 1998*

Table 9 Percentage Expenditure for Medical Care across Income Classes, 2000

Table 10 Current Sources and Used of Health Care Funds, Misamis Occidental 2002

Table 11 Projected enrollment and IP premium Requirements, Misamis Occidental 2003-2009

Table 12 Total Drug Budget and drug Needs of Misamis Occidental, 2003

Table 13 Proposed Networks of Facilities in Misamis Occidental

Table 14 Allocation of the Start up Funds*

Table 15 Critical Parameters for the Misamis Occidental Plan

5

List of Figures

FIGURE 1: Misamis Occidental Provincial Health Investment Plan Requirements (2006 – 2010)

FIGURE 2: Leading Causes of Mortality in Misamis Occiderntal

6 Executive Summary

The Five-Year Investment Plan of Misamis Occidental focuses on the five reform areas consistent with the Health Sector Reform Agenda (HSRA) being implemented under the Fourmula I framework, namely: (1) Health Service Delivery; (2) Health Care Financing; (3) Social Health Insurance; (4) Drugs Management Systems and Procurement; and (5) Governance.

The average life expectancy in Misamis Occidental is estimated to be 67.2 years or 4.4 years shorter than the national average of 71.6 years. Maternal mortality rate was 0.45 per 1,000 live births. Infant mortality rate was 0.455 per 1,000 live births, 60 percent lower than the national figure. The leading causes of mortality in Misamis Occidental are: degenerative diseases are becoming more common causes of mortality while infectious diseases continue to run high. Diseases of the heart, cardiovascular system, cancers, accidents or traumas and other diseases associated with an aging population and changing lifestyle are increasing significantly and will most likely take over as the leading causes of mortality within the next ten years. Inadequacy of the health care delivery system is evident in the large number of unattended deaths and the equally large number of preventable deaths from illnesses such as pneumonia and diarrhea. This implies of a poor preventive care that is inadequately linked to a similarly deficient curative care capability. Moreover, lack of budget for both rural health units and hospitals has lead to inadequacy of supplies and being unable to maintain its facilities. As a result, patients tend to bypass lower level facilities in favor of the higher referral centers, thus swamping them with mostly primary cases.

In terms of financing, out-of-pocket spending still accounts for 25 percent of total health expenditures. This burden is unusually heavy for the poor. This undue burden is aggravated by other factors including the lack of drugs and supplies in government facilities, the restrictive ceilings of PhilHealth benefits and the high cost of health goods in the private sector. Government facilities also remain to be heavily dependent on direct subsidies. The current set up does not provide enough incentive for government facilities to improve efficiency in operations in the light of inadequate budgets.

In terms of social health insurance, while the indigent program coverage of 63 percent of the bottom 50 percent of the population is higher than the national average, it is still below universal coverage targets. Variations in coverage are also wide across municipalities. There is no mechanism for routinely estimating the different PhilHealth member groups and for monitoring coverage rates for each group over time. National data sets are not readily suitable for identifying eligible members for various PhilHealth programs or for identifying who are current members of various programs.

7 Infectious diseases still dominate the morbidity profile (85 percent of all illnesses) but degenerative diseases already dominate its mortality profile (53 percent of all deaths). However, drugs for degenerative diseases like heart disease, hypertension, and COPD are not procured in sufficient quantities. A likely cause of this selection inequity is the lack of a systematic needs- and evidence-based drug selection and procurement process.

The administrative stratification as a result of devolution and financial fragmentation (since budgets were allocated per LGU), affected the smooth dynamic of a centralized governance system in that costs, risks and responsibilities were not internalized in a single system but in smaller geographically defined political spheres that fail to make use of collective resources. Among the more obvious effects include the lack of a linked information system which leaves health information largely inaccessible and the lack of a unified procurement system to make use of economies of scale in the market. To address such challenges, the following strategies will be implemented to improve service delivery: (1) Enable primary care facilities to deliver the complete package of primary preventive and curative services in order to rid hospitals of unnecessary load; (2) Provide adequate essential diagnostic and treatment services in local hospitals; (3) Develop comprehensive training and re-training plans for medical and paramedical personnel; (4) Establish support systems to ensure appropriate, efficient and quality patient care; (5) Implement a financing scheme that can further reduce out-of-pocket by the poor and shift LGU spending to public health; and (6) Develop and implement a health economic enterprise strategy plan for the health system.

In terms of financing, the following measures will be implemented: (1) Increase revenue generation so as to increase the overall budgetary fund of the province; (2) Identify revenue centers in public facilities that could benefit from improving user fees without necessarily compromising social objectives; and (3) Identify a specific portion of the annual budget that will be used for premium payments of indigents as a more efficient investment strategy.

In the area of social health insurance, the main goal in the various ILHZs in Misamis Occidental is the enrollment of all the indigents, defined as the 50percent poorest of the population (bottom 25 percent for cities). Likewise there is consensus that identification of those eligible for the Indigent Program and Individually Paying Program will be done through a community-based information system, and that the RHU will be the center for enrollment. To improve coverage, community-based baseline and periodic household surveys, will give local health systems multiple advantages, among which are: (a) Providing the data base for social insurance enrollment; (b) Opportunity for more precise client identification and planning for public health programs or follow-up care and epidemiologic investigation; (c) Basis for population/needs-based budget allocation or investment plans; and (d) More efficient monitoring and evaluation of community health.

8

Misamis Occidental will use evidence-based drug selection based on epidemiological risk profiles (morbidity and mortality). Drug selection provides the framework and dictates the architecture of all the other options. Pooled procurement and distribution through Parallel Drug Imports1) will be based on the selected drugs. Rational drug use is also reliant on the development, maintenance, and use of treatment guidelines and formularies, both of which are tools of drug selection. Under the Province-wide Pooled Procurement, the revolving drug fund (RDF) of all four ILHZ and (including the hospitals) will be pooled to purchase the pooled drug requirements of all ten of these institutions. The large volumes and amounts being included in the bidding will allow the province to attract regional and even national drug suppliers.

The proposed governance structure for the local health system is the inter-local health zone that is registered with the Securities and Exchange Commission (SEC) as a non-stock, nonprofit corporation or a foundation. The overall coordinating board or council for the four zones will be similarly registered. This strategy is simply for the consolidation of strengths and resources of the individual LGUs in Misamis Occidental. By taking on a corporate nature, the health delivery system can have more flexibility in the sourcing and use of funds, as well as hire additional personnel beyond the government ceilings for personnel services.

The total investments required to address the challenges with various strategies mentioned above as identified in Misamis Occidental PHIP 2006- 2010 amounts to almost Php 269 million. The Service Delivery component has the highest share at Php 129 million (48 percent), followed by Financing at Php 121 million (45 percent), Governance at Php 14 million (5 percent) and Regulation at Php 4.6 million (2 percent). These funds will be used to upgrade facilities, procure services and equipments, strengthening of referral system, improve identification and enrollment for social health insurance, identification of drug needs, establishment of procedures for drug procurement and sale, and establishment of appropriate governance structures, among others.

In terms of fund sources, EC (86 Php million) and MLGU (80 million) are the biggest sources of funds followed by PLGU (Php 34 million), other donors (Php 26 million) and DOH (Php 23 million). Other sources of funds are: Philippine-Australia Local Sustainability Program (Php 20 million), ILHZ pooled fund (450,000), National Dairy Authority (286,000) and LEAD (84,000).

1 Parallel drug imports (PDI) are drugs imported from a third country where it is cheaper and is usually done without the authorization of the manufacturer.

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10

MISAMIS OCCIDENTAL PROVINCIAL INVESTMENT PLAN FOR HEALTH

A. OVERVIEW

Philippines health indicators show that while the health situation in the country is at par with that of the rest of the developing world, there has been a marked slowing down in the rate of decline of critical health indicators such as maternal and infant mortality rates in the past decade.

This could be due to several factors that include inadequate and inappropriate spending for health care, the fragmentation of the delivery system and weak regulatory environment in the country. Health accounts analysis show that every peso spent in health, nearly 50 cents is borne by patients and their family as out of the pocket spending in 2003. Social health insurance accounts for mere 7.8 percent of expenditures National Health Accounts 2003.

In the public sector, 70.4 percent health budgets are spent by hospitals in 2003, thus leaving little for public health spending. Of the said government budgets, 56.7 percent is spent for personnel services leaving just 41.2 percent for operating expenses and only 2.1 percent for capital outlay Audited Financial Statement, (COA) 2003. This could explain why even with increasing government expenditures, particularly that by local governments, hardly any dent is felt by the public since very little money is allocated to buy drugs and supplies and even less money is available to procure or maintain equipment as well as renovate and construct buildings.

The devolution of health services to local government units (LGU) has also caused the fragmentation of the health care delivery system. Prior to devolution, the management of health facilities and health human resource development was internalized by a single system, hence benefiting from efficiency gains, scale economies as well as from a seamless and unified health planning, management and implementation system.

The inadequate spending in health and the fragmentation of the system have also contributed to the weakening of the regulatory environment such that government can hardly exert enough leverage to influence the pricing and quality of health goods and services in the market. Also, regulatory agencies do not have enough field personnel, largely owing to its centralized nature.

Considering these challenges and the various lessons learned in managing the health system, the Department of Health launched the Health Sector Reform Agenda (HSRA) in 1999. This comprehensive plan seeks to intervene through five interrelated and interdependent components that need to be implemented as a package, namely: a) public health reforms with DOH exercising technical leadership in public health and in securing multi-year

11 budgets or sustained financing for priority public health interventions; b) hospital reforms by making government hospitals as corporate entities that will promote self-sufficiency without necessarily negating its social obligations; c) local health systems reform by promoting inter-LGU cooperation through inter-local health zones that will address concerns on networking and referrals, facility rationalization, and internalization of costs and benefits to maximize efficiency gains and scale economies in health service delivery; d) regulatory reforms that seek to ensure quality and cost-containment of health goods and services; and lastly, e) health financing reforms through the achievement of universal coverage through social health insurance.

In order to implement these reforms nationwide, the Philippine government estimates a requirement of Php 212 billion based on DOH Health Sector Reform Agenda. Due to the lack of financial, technical and political capital for the reforms, the Department of Health (DOH) issued Administrative Order No. 37 in 2001 which provided for the shifting of the implementation strategy of the HSRA from a national to that of a provincial or convergence site level. The convergence approach will seek to implement reforms in key geographic areas that will serve as a field laboratory to test if reform interventions have the potential for nationwide implementation. This will be accomplished by supporting LGU health systems in keeping with the goals of devolution.

Initial convergence efforts in key sites nationwide were done by the DOH with the support of the Health Sector Reform Technical Assistance Program (HSRTAP) up until 2002. Likewise, the German Technical Cooperation (GTZ) and the Integrated Community Health Services Project (ICHSP) were also initiating reform-related activities in their respective project sites. Experiences from these initiatives led the DOH to pursue further expansion of the reform implementation and subsequently seek funding for its various programs under an HSRA framework.

In June 2002, the Government of Japan released a grant of USD 1.03 million to conduct preparatory studies for the Health Sector Reform Project (HSRP), under the auspices of the World Bank (WB). The preparatory phase is intended to produce a project proposal for the Philippine government that will be submitted for loan support by the Bank. Recently, European Countries get into the program and give financial support as grant to make this plan into reality.

Originally, four convergence sites were chosen based on the extent of their reform activities, their willingness to participate in the project and their likelihood of success during implementation. These sites were the provinces of Pangasinan, Capiz, Misamis Occidental and Agusan del Sur. Presently, these four convergence sites were expanded to another 12 sites, giving a total of 16 convergence sites for the whole country for this program.

12 In all of these sites, the core interventions in terms of governance, delivery system, health financing and drug systems reforms will be studied. Also, critical investment needs and their corresponding costs will be determined.

B. Introduction

This health investment plan for the Province of Misamis Occidental was made for the purpose of Health Sector Reform Project (HSRP) Preparatory Phase. At first it was a loan project of the Province of Misamis Occidental and the Department of Health (DOH) that will be submitted to the World Bank for funding. However, when the amount of amortizations was discussed the Province found it too expensive. Fortunately, DOH-Central Office was able to find new funding source through the European Commission.

This document is derived from a set of technical studies done on health reform in general and for Misamis Occidental in particular. There were investment options offered and options included herewith were product of an iterative and broadly representative planning process, spanning several consultations and workshops with the various stakeholders on the health prospects for Misamis Occidental.

As the Misamis Occidental component is only one among four convergence sites covered by the project, more detailed discussions found on the situational analysis of the province and the technical options mentioned are explained later within the document.

This document consists of 11 major parts. The first part is summary that provides an overview of the document followed by introduction. The introduction part cites what the document is all about as well as the reasons for and process involved in the developing the plan.

The third part discusses the province demographic and socio-economic profile. In this part, we will understand the economic situation of the province, its major source of income and other sources of livelihood of Misamisnon.

Part IV discusses the current situation in Misamis Occidental in terms of health needs (discusses current health status indicators and top causes of morbidity and mortality, etc), delivery system (provides information on count by facility, quality of rural units, quality of hospitals, service utilizations, drug management system, among others), health financing ( illustrates local health accounts and provides information on the enrollment in social health insurance), governance (discusses structures and systems that governs the local health system within the province, i.e. ILHZ, information system, financial and procurement systems, etc.).

The next part identifies the various gaps and deficiencies observed based on the categories tackled in part IV. Part VI cites strategies that would address

13 the problems identified under the previous section based on framework provided for in the Health Sector Reform Agenda/Formula One.

Part VII provides a matrix of the target, activities and outcomes for each strategy or intervention area. The matrix indicates the critical or priority targets for the province. This is followed by Part VIII which provides a realistic costing for each strategy/intervention. This shows the annual breakdown of priority investments for each strategy. It also provides breakdown of sources of funding to finance the implementation of the 5-year investment plan. It shows the timed phasing of project interventions (phasing of investments).

C. The Province of Misamis Occidental

Misamis Occidental is located in the eastern tip of Zamboanga Peninsula. The land consists of rice fields, rolling planes, hills and rugged terrain. Wet season starts from November to December, followed by dry season from January to April.

The total land area is 193,932 hectares with a total population of 527,405 in 2004. There are three cities, 14 municipalities, and 490 barangays. The population density is 139 person/ sq. km with a population growth rate of 1.2 percent.

Dependency ratio is 69 percent with an average family income per capita of 16,177. The number of families below poverty threshold is 51 percent and literacy rate of 92 percent.

The major crops are coconut, rice, root crops, fruits and nuts. The major products are ceramics, pottery, house-wares, textiles, ornamental plants, loom woven placements, handicrafts, wood/shell-crafts and furniture.

Tourist spots are also developed both in the sea areas such as Misamis Occidental Aquamarine Park at Sinacaban and mountainous areas like the Mount Malindang National Park at Don Victoriano.

14 D. Misamis Occidental Health Situationer

D.1 Health needs

The average life expectancy in the Northern Mindanao Region (Region 10), to which Misamis Occidental belongs, is estimated to be 67.2 years based on the _____ Census (?) or 4.4 years shorter than the national average of 71.6 years. In 2004, the province of Misamis Occidental had a birth rate of 14.81 and a crude death rate of 14.56 per 100,000 population. Maternal mortality rate was 0.45 per 1,000 live births, which is 20 percent lower than the national rate of 0.65 per 1,000 live births. Infant mortality rate was 0.455 per 1000 live births, 60 percent lower than the national figure.

Table 1. Health Statistics, Misamis Occidental, 2004

CBR (per 100,000) 14.81

CDR (per 100,000) 14.56

IMR (per 1,000 live births) 0.455

MMR (per 1,000 live births) 0.45 Underwt Children 0-5 years old 6.3% Source: Annual FHSIS Report 2004

The leading causes of mortality for the general population of Misamis Occidental reflect the nationwide trend since the 1990’s: degenerative diseases are becoming more common causes of mortality while infectious diseases continue to run high. Diseases of the heart, cardiovascular system, cancers, accidents or traumas and other diseases associated with an aging population and changing lifestyle are increasing significantly and will most likely take over as the leading causes of mortality within the next ten years (see Figure 2).

15 Fugure 2: Leading Causes of Death in Misamis Occidental, 2000, 2002 and 2005

CV D

Pneumonia

Cancer

PTB

Renal Disease

Peptic Ulc er Dis

Diabetes Mellitus 2005 Accidents/Violence 2002 2000 Septicemia

Malnutr ition

0 100 200 300 400 500 600 700 800 900 rate per 100,000 Annual FHSIS Report, 2004

The leading causes of illness are mainly infectious agents. Upper respiratory tract infection, bronchitis, pneumonia, wounds/accidents and influenza were the five top causes of OPD consultations in 2005 (see Table 2).

Table 2. Top Causes of Illness, Misamis Occidental, 2005

Acute Respiratory Infection 1 (18,961/100,000) 2 Bronchitis (12,609/100,000)

3 Pneumonia (6,046/100,000) Wounds/Accidents 4 (5,091/100,000) 5 Influenza (4,815/100,000)

16

Leading causes of deaths in Misamis Occidental in 2004

1. CVD 2. Pneumonia 3. Cancer, all forms 4. Hypertension 5. Renal Failure Annual FHSIS Report, 2004

D.2 Delivery System

D.2.1 Count by facility

At the primary level, there is an average of 27,713 population for every RHU. The recommended ratio in developing countries is 1 clinic per 20,000 population. However, there are currently 55 private clinics owing to the large number of private practitioners in the Ozamiz zone. If these were to be included, the ratio would drop to 1 clinic per 6,833 population.

Private hospital facilities consist of 180 beds for tertiary care, 142 beds for secondary care and 220 beds for primary care. The main concentration of hospitals is in Ozamiz City. Government hospital beds for tertiary care have 250, secondary care 125 beds while primary have 25 beds with a total of 400 beds. These are distributed unevenly across the province’s four health zones, with the Ozamiz and Oroquieta zones getting most of the beds.

Table 3. Misamis Occidental Inter-Local Health Zones, 2004

Calamba Oroquieta Ozamis Tangub Total

LGUs (*lead Baliangao, Aloran, Clarin, Bonifacio LGU) Calamba*, Jimenez, Ozamiz *, Don Concepcion Lopez City*, Victorian , Plaridel Jaena*, Sinacaba o and and Oroquieta n and Tangub Sapang City and Tudela City Dalaga Panaon

Population 92,445 142,771 193,993 96,396 527,405

OP clinics: 5 544 18 RHU 4 5 41 5 55

17 Private Hospitals: 1 231 7 Gov’t

4 794 Private 24 Misamis Occidental Accomplishment 2004.

The public sector referral network as described is composed of the Barangay health stations that are staffed by midwives and nurses which provide basic preventive and curative care. These BHS are under the supervision of a rural health unit that is staffed by a physician, a team of nurses, a medical technologist and other health personnel. These rural health units in turn belong to a facility network under the ILHZ framework.

Within their respective ILHZs, a core hospital is designated. Usually, this core hospital is a 1st level referral (secondary) hospital by classification. The network is supposed to practice a two-way referral system where a patient is formally referred up the referral chain and upon discharge, the patient is supposed to be formally referred back down. In the Calamba zone, the core referral facility is the Calamba District Hospital, in the Ozamiz Zone the SM Lao Memorial Hospital is the core referral center, in Tangub zone it is the Tangub District Hospital while in the Oroquieta Zone, the core referral hospital is the MOPH.

Among this group of ILHZs, the MOPH has also been designated as the end referral facility for the convergence site, even if a higher level facility is present inside the zone. Compliance to referral chain is poor as many patients tend to bypass lower level facilities in favor of higher level centers, which in this case is MOPH.

The summary assessment of the current facility network in the convergence site is shown below (see Table 4). The said matrix also shows the proposed outcome after consultation with stakeholders in the site:

18

Table 4. Summary Assessment of Facilities in Misamis Occidental

Facility Service Utilizat Patient Private Political Proposed capabili ion preferen sector preferenc outcome ties rate ce hospital e (not (%) presence license)

Oroquieta zone MOPH 3 >100 preferred 4 primary; Core Equipment 2 referral upgrading secondary and capacity expansion Economic Enterprise Jimenez 1 <50 Bypassed Status quo Upgrading as Primary for MOPH satellite of Hospital MOPH Calamba zone Calamba 2 39 4 primary Referral Upgrading District hospital dependent Hospital on service statistics; provision of lying in facility within hospital and become CEMOC Tangub zone Tangub 2 48 4 primary; Referral Upgrading to District 1 hospital become Hospital secondary CEMOC

Ozamiz Zone

19 MHARRSGEN Regional 67 Preferred 6 primary; Regional Upgrading medical and 1 medical dependent center accepts secondary center on DOH less and 2 policy and severe tertiary networking cases arrangement s with govt. hospitals as well as negotiations with private sector SM Lao 2 Preferred Referral Upgrading Hospital hospital dependent on negotiations with private sector Tudela 1 Bypassed Status quo Negotiation Community for SM to merge Hospital Lao and with Tudela Sinacaban MHARRS Operated RHU and Birthing center GEN by RHU become RHU personnel and to become BEMOC Health Facility Survey, 2003

The initial consultation process revealed that there are at least three major facility providers in the site: the MOPH, MHARRSGEN and the SM Lao Hospital. The rest of the facilities tend to get bypassed in favor of these three major government centers or the private sector facilities. No facility was willing to get closed down.

D.2.2 Quality of Rural Health Units

There are 18 RHUs in Misamis Occidental. The average distance of RHUs from their respective zone’s core referral hospital is 14 kilometers. Only 15 out of the 18 RHUs are served by a full time medical doctor. Fourteen (14) are able to provide standard primary laboratory services; 13 are able to provide minor surgical services; nine have ambulances, and only seven have communication facilities. Only one can provide life-saving cardio-pulmonary resuscitation with oxygen supplementation. In terms of meeting accreditation standards, only the Ozamiz ILHZ has its entire complement of RHUs accredited by PHIC.

20 It is in the Oroquieta and Ozamiz health zones where the majority of RHUs meet the services of 71 percent. This is followed by Tangub ILHZ which complies with 60 percent of requirements and lastly by the Calamba ILHZ with 51percent compliance. In Tangub ILHZ, the deficiencies in emergency care can theoretically be offset by the presence of five primary hospitals (all private) distributed in the different LGUs within the ILHZ. In the Calamba ILHZ, there are four privately-run primary hospitals in the ILHZ that can provide emergency services which are lacking in the RHUs.

Consultation work and preventive services appear to be heavy at Ozamiz and Tangub zones. Except for the low full immunization rate of infants in Oroquieta ILHZ and the need to look further into the TB case treatment coverage per community, preventive care in the different zones seems to be adequately provided and the clinics are highly utilized.

Table 5. Capabilities in RHUs, by ILHZ, Misamis Occidental, 2004

Misamis Calamba Oroquieta Ozamiz Tangub Occidental Zone Zone Zone Zone Population 527,405 92,445 142,771 193,993 96,396 No. of RHUs 18554 4 RHU with full- 15354 3 time MD RHU providing 13154 3 minor surgery RHU with 14334 3 standard laboratory2 RHU with 9 322 2 ambulance RHU with CPR 1 010 0 and O2 RHU with 7 222 1 communication facility SS/PHIC- 16454 3 accredited Average 382 60 86 108 127 outpatient

21 visits/day Proportion of 88% 81% 91% 88% 91% infants who are fully immunized Pregnant women 66% 59% 83% 66% 57% with adequate prenatal care TB cure rate 91% 84% 86% 99% 94% Family Planning 55% 51% 59% 55% 54% CPR Health Facility Survey 2004 1 A standard primary laboratory has the following: routine hematology, routine urinalysis, routine fecalysis, blood typing, sputum microscopy and quantitative platelet determination (DOH A.O. 59, s. 2001)

D.2.3 Quality of hospitals

Each of the ILHZs in Misamis Occidental is served by a core referral hospital with the capabilities of at least a 1st level (secondary) hospital. The Misamis Occidental Provincial Hospital (MOPH) in Oroquieta Zone is the tertiary provincial hospital and end referral center for the province. However, the third level (regional medical center) referral center, the Mayor Hilarion A. Ramiro General Hospital (MHARRSGEN) in the Ozamiz zone, also shares in this function.

All core referral hospitals are served by adequate number of medical staff, except for the requirement in the number of nurses. All hospitals also provide radiographic services, but not one offers bacteriologic services, except the DOH–retained MHARRSGEN. Of the designated core referral hospitals, only the MOPH Zone has an adequate information system for referral, billing and laboratory. No hospital is currently computer-linked with any of the RHU units at present.

Table 6. Capability Profile of Core (First Level) Referral Hospitals, Misamis Occidental, 2002

Misamis Calamba Oroquieta Ozamiz Tangub Requirements Occidental Zone Zone Zone Zone Number of Core Hospitals with at least secondary 4 1 1 1 1 health care capabilities Number with at least 4 GPs 4 1 1 1 1 Number with at least 1 3 0 1 1 1 Specialist Number with 1 nurse/2.5 bed 0 0 0 0 0 Number with x-ray services 4 1 1 1 1

22 Number with microbiology 0 0 0 0 0 lab Number doing blood 4 1 1 1 1 transfusion Number with adequate 1 0 1 0 0 information system Number with computerized 0 0 0 0 0 linkage with ILHZ units Number of beds 250 50 100 50 50 Facility survey Misamis Occidental 2002 1 A standard primary laboratory has the following: routine hematology, routine urinalysis, routine fecalysis, blood typing, sputum microscopy and quantitative platelet determination (DOH A.O. 59, s. 2001)

A more detailed assessment of government health care facilities for each of the four zones show that the core hospitals in Ozamis, Calamba and Tangub are relatively underutilized while that of Oroquieta is operating at an excess capacity. Occupancy rates of private hospitals in this zone are undetermined.

Table 7. Clinical Vignette Scores by Level of Care and Province

PNEUMONIA All CS Misamis Occ Primary level n=21 59% n=7 54% Secondary level n=11 59% n=0 none Tertiary level N=18 66% n=2 72%

DIARRHEA All CS Misamis Occ

Primary level N=14 49%

Secondary level N=11 50%

Tertiary level N=16 53% NONE NONE

PREECLAMPSIA All CS Misamis Occ

Primary level N=12 46% n=7 46%

Secondary level n=2 38% n=0 none

Tertiary level n=6 57% n=2 50%

Several studies claim that one of the most common reasons for facility bypass other than the lack of drugs and supplies is the perception of quality care. Usually the bias is towards higher level facilities where health personnel are said to be more competent to handle cases. This finding is somewhat validated by the result of clinical vignette scoring where higher level facility personnel tend to score higher compared to their counterparts in lower level

23 facilities. It can also be observed from this matrix that compared to four project sites, Misamis Occidental practitioners tend to score lower than the average, except for pneumonia in a tertiary setting.

D.2.4 Public – Private Partnerships

At present there is no formal service arrangement or contract relationship between government and private hospitals that can be invoked to maximize the health facilities available in the convergence site.

While some private practitioners also practice in these government centers, these are done on an individual basis and is not part of a formal arrangement between facilities. In terms of diagnostics however, the government has entered into a sharing arrangement with the Misamis University Medical Center in the purchase of a CT scanner. As the government is a co-owner of such machine, case referrals from government facilities are provided a special discount in the user fee. Other types of equipment are currently being negotiated between the two parties.

D.2.5 Service Utilization

Greater proportions of those belonging to the bottom 50 percent in terms of income decile utilize public facilities (Table 8). Rural health units are also utilized even by those who belong up to the 8th income decile, implying that either these are competitive with their private sector counterparts especially that 16 out 18 health facilities are SS certified with PhilHealth accreditation or that these are the only facilities available in certain areas. Public hospitals are likewise utilized by those in the upper half of the income distribution.

Table 8. Utilization of Facilities by Provincial Income Decile, 1998*

Provincial Barangay Income Government Private Private Rural Health Health Other Decile Hospital Hospital Clinic Unit Station Facilities 1 0.16 0.10 0.08 0.49 0.17 0.00 2 0.26 0.09 0.14 0.28 0.24 0.00 3 0.07 0.03 0.33 0.40 0.14 0.04 4 0.22 0.28 0.19 0.22 0.09 0.00 5 0.18 0.06 0.08 0.49 0.19 0.00 6 0.15 0.14 0.34 0.20 0.12 0.03 7 0.23 0.10 0.25 0.34 0.00 0.08 8 0.15 0.11 0.14 0.28 0.32 0.00 9 0.23 0.27 0.14 0.04 0.34 0.00 10 0.11 0.42 0.37 0.07 0.05 0.00 *Proportion visiting specific health facility out of those who visited any facility in the last six months

24 From this table, it appears that for outpatient services, the poor of Misamis Occidental mainly utilize the rural health units. The picture is less equivocal for inpatient services. While utilization data from surveys indicate greater proportions utilizing public facilities, indigent claims data indicate that at the primary level at least, private hospitals are mainly utilized. Only at the secondary and tertiary levels are public hospitals mainly utilized by the poor population.

However, looking at the claims data, it would appear that a greater proportion of indigents are utilizing private hospitals. Only slightly more than one-third of indigent claims are from public hospitals, the rest are from private hospitals. More than 50 percent of indigent claims are accounted for by primary private hospitals3. Meanwhile, nearly equal proportions of claims are accounted for by public secondary and private secondary hospitals. More than one-fourth of the claims are from tertiary public hospitals. Thus, it appears that at least at the secondary and tertiary levels, public hospitals are the preferred providers of indigents.

D.3 Health Care Financing

Household spending for health care in the Northern Mindanao region in 2000 was estimated to be 1.9 percent or an average of Php 10,563 per year per family which translates to an estimated per capita expenditure of Php 2,112 based on a household of five Family Income and Expenditures Survey, National Statistics Office.

In terms of income classes, the distribution of health expenditures relative to income classes show that the poor are still disproportionately paying more than their richer counterparts, although the region is much better off compared to the national average (see Table 9). This is so because the poor have very little disposable income and medical expenses are not usually anticipated and therefore, are not being prepared for.

Table 9. Percentage expenditure for medical care across income Classes, 2000

Income Regional Below 20,001- 30,000- 40,000- 50,000- 60,000- 80,000- 100,000- 250,000 group Average 20,000 29,999 39,999 49,999 59,999 79,999 99,999 249,999 and above Northern 1.9 0.7 0.9 1.0 1.8 0.9 1.1 1.0 2.0 2.8 Mindanao

Philippines 1.9 1.1 1.0 1.1 1.3 1.3 1.5 1.6 1.9 2.3

Source: Family Income and Expenditure Survey, National Statistics Office.

3 Anecdotal evidence suggests that one of the reasons for the high claim rates for private hospitals in Misamis Occidental may be fraudulent cases.

25 The total health care expenditure in Misamis Occidental in 2002 amounted to Php 635.5 million. Government expenditure accounted for almost half, or 47.4 percent, of the total, while social health insurance contributed for 20.44 percent of total. Households accounted for more than a quarter, or 25.3 percent of total health care expenditures through out-of-pocket payments for personal health care services. More than three-fourths, or 77 percent of health expenditure was used to pay for personal health care, while a little over 15 percent was spent on public health care provision. Table 10 below shows the detailed health accounts for the province of Misamis Occidental in 2002.

Table 10. Current Sources and Uses of Health Care Funds, Misamis Occidental, 2002

SOURCES OF FUNDS (Expenditures in Php million) USES OF Per- FUNDS GOVERNMENTSOCIAL PRIVATE TOTAL cent of HEALTH DOH PROVINCE MUN/ FAMILY Total INSURA INSURA CITY NCE NCE Personal Health 99.90 64.61 16.71 118.30 160.82 29.29 489.63 77.04 Public Health 8.52 9.97 75.98 2.51 0 0 96.98 15.26 Others 7.00 9.56 9.05 9.11 0 14.20 48.92 7.70 TOTAL 115.42 84.14 101.74 129.92 160.82 43.49 635.53 100.0 Percent 18.16 13.24 16.01 20.44 25.31 6.84 100.0 Audited Financial Statement, COA 2002

The Department of Health’s (DOH) contribution to total health care spending in Misamis Occidental in 2002 was a little over 18 percent at Php 115.4 million. This was mostly spent to support the operation of MHARRSGEN. A smaller amount of Php 8.5 million was spent to augment LGU resources for the delivery of priority public health services.

The provincial government spent Php 84.14 million, mostly (Php 64.6 million) on the delivery and provision of hospital services, while the municipal and city governments combined spending reached Php 101.7 million, which was given mostly for the operations of the rural health units and barangay health stations throughout the province. Another Php 16.7 million was spent to support hospital operations and maintenance. The combined spending of DOH, the provincial and municipal/city governments amounted to a little over Php 300 million, making government the biggest spender for health care in the province in 2002. Household out-of-pocket spending, however, still accounted for the biggest single source of health care spending, with social health insurance following closely behind.

26 Social health insurance contribution was estimated at 20.4 percent of total health care spending in the province. This is more than double that of the national average of less than 10 percent but is still below the HSRA national target of 35 percent for 2004. It is notable that the total PhilHealth reimbursement for personal health care worth Php 94.8 million is already more than the amount spent by the provincial government for the operation of its hospitals. More than 70 percent of these reimbursements, however, went to private hospitals. Nonetheless, the amount of PhilHealth reimbursement to government hospitals is approximately 43 percent of the total amount spent by the provincial government for hospital operations. A little over Php 2.5 million went to capitation payments to accredited rural health units and district hospitals which provide outpatient benefits to enrolled indigents in the province.

The most significant impact of social health insurance on the structure of health care spending in Misamis Occidental is on the marked reduction in the proportion of household out-of-pocket spending for health vis-a-vis the national average. At almost one-fourth of total health care expenditure, household out-of-pocket spending is markedly less than the almost one-half of total as observed nationally and in the other convergence sites.

Contribution from household out-of-pocket amounted to Php 317 per capita On the other hand, the per capita spending on public health is at Php 191, which is still below the recommended level Php 687.50 for low-income countries. This also reflects the extremely inadequate provision for essential health and medical care for the population at large. In per capita terms, health care expenditure in Misamis Occidental amounted to Php 1,222 in 2002. This is lower than the estimated amount spent per capita based on 2000 FIES data. While this amount may not be enough to cover for a single admission of CAP III pneumonia for children, it is more than enough to pay for the annual health insurance premium of one household that usually has around five members each.

D.4 Enrollment in Social Health Insurance

PhilHealth records in Region 10 showed that as of January 31, 2006, a total of 68,703 families were enrolled in the Indigent Program (IP), while another 32,746 families were enrolled in the Individually Paying Program (IPP) and 1,719 families were registered as non-paying members. Enrollment in the indigent and individually paying programs exceeded those of the formally employed.

Those enrolled in the Indigent Program exceeded the total population whose incomes fell below the poverty line, also exceeded the national target of enrolling the priority bottom 25 percent of the population. It is, however, not possible to validate that those enrolled were indeed in the bottom 25 percent since the general method of enrollment of indigents was not based on identifying this segment of the poor. The basis foe identifying the indigents to

27 be enrolled is there Annual Per Capita Income and physical structure of their houses determined through a “Means Test” where in enumerators is conducting Family Data Survey. These enumerators are mostly barangay workers (BHW and DCW) supervised by the City/Municipal Social Welfare and or health workers. Services of the enumerators are paid on piecework basis by PHILHEALTH. It is therefore necessary to do an actual client segmentation survey to validate this data and to determine other indigents for future enrollment.

Identification of the poor is done through LGU social welfare offices. The usual process is that the individual LGU and not the ILHZ, sets an enrollment target that is based on the allocated budget for premiums. With already an identified number of households to be covered, barangay officials and other political and community leaders are asked to identify the prospective enrollees in their respective areas. These people will now forward this list of indigents to the mayor’s office. This list will then be validated by the social welfare officer. In some cases, the provincial government also subsidizes the premium payments enrolled by individual LGUs.

In terms of enrolling indigents, the Province of Misamis Occidental would have to spend an amount that grows from 6.8 million in 2003 to 35.4 million in 2009 (see Table 11). The burden of these premium payments would be varied across LGUs depending on the number of their enrollees and the income classification of the LGUs.

Table 11. Projected enrollment and IP premium requirement, Misamis Occidental, 2003-2009

2003 2004 2005 2006 2007 2008 2009 Estimated IP eligibles to be funded IP eligibles (bottom 25 and 50% mix) 41,000 42,077 43,185 44,248 45,344 46,475 47,639

IP enrollment* 34,679 37,597 40,664 43,841 47,170 50,661 54,318

IP coverage (%) 0.85 0.89 0.94 0.99 1.04 1.09 1.14 Estimated IP premium (million pesos)

IP premium 51.29 (total) 41.615 48.638 8 55.436 59.055 62.846 66.814 IP LGU cost 6.898 8.068 9.301 10.583 11.930 13.344 14.828 IP cost as % of municipal health expenditures 8.1% 8.8% 9.5 %10.0% 10.4% 10.9% 11.3% Estimated return flow from IP premium paid (in million pesos)

28

Capitation 12.99 (RHUs) 10.405 12.160 5 13.859 14.764 15.711 16.703 Reimbursement for hospitalization 7.491 8.755 9.357 9.979 10.630 11.312 12.027 Total return as % of LGU IP cost 259% 259% 240% 225% 213% 203% 194%

These estimates were derived by assuming that LGUs who already surpassed the bottom 50 percent mark will maintain their enrollment and that those municipalities which are below the said mark would reach the target by 2009. These estimates also factored in that only the bottom 25 percent will be enrolled by the cities of Oroquieta, Ozamiz and Tangub . Furthermore, premium computations are based on the latest ruling that 4th to 6th class municipalities will have a 10-90 sharing with the national government in 2006-2007, with an increment of 5 percent thereafter until they reach a 50-50 sharing on the 10th year.

It can also be noted that the LGUs would earn more income by investing in premiums, at least in the first five years.

In terms of enrolling other types of members such as the non-paying and the informal sector, there are no fixed programs yet from both PhilHealth and the LGUs on how to increase enrollment from these sectors. Oftentimes, the LGUs are left to their own discretion on how best to invite these member groups to join the system. Also, while it has been proposed repeatedly, only a few LGUs were able to legislate the requirement of PhilHealth memberships for owners and employees of establishments that apply for business permits every fiscal year. Furthermore, all municipal LGUs will be required to put up a desk to serve as an information, membership and collection with the PhilHealth and provide accessibility to enroll members.

D.5 Drug Management System

The need to rationalize drug financing is critical since funds are not always enough to meet even the minimum needs for essential drugs. The case of Misamis Occidental, however, suggests that the province as a whole has enough fiscal resources to meet its drug requirements to treat the leading causes of morbidity and mortality in the province. As shown in Table 12, the combined drug budget of the provincial government and all the city and municipal governments is about Php 23.448 million. This amount is Php 1.205 million more than the required financing for the most essential drugs needed to treat the leading causes of illnesses and deaths in the province.

29 Table 12. Total Drug Budget and Drug Needs of Misamis Occidental, 2003

Drug Budget Drug NeedsA LGUs/ILHZs In pesos As % of In pesos As % of IRA* IRA* Total for the province 23,448,111 22,242,949 Provincial Government 13,547,028 4.51 22,242,949 7.41 Hospitals (incl. RDFs) 7,385,128 2.46 11,693,725 3.89 PHO 6,161,900 2.05 10,549,224** 3.51 ILHZ 1 3,637,638 0.84 3,935,893*** 1.92 ILHZ 2 769,482 0.74 1,899,195*** 1.80 ILHZ 3 4,663,136 0.99 2,843,746*** 1.57 ILHZ 4 830,827 0.55 1,870,390*** 1.29 Notes: The drug needs are based on a list of essential drugs (“wonder“ drugs) required to treat the leading causes of morbidity. *Average for the LGUs in the Inter-Local Health Zone. **If the provincial government alone bears the cost of public health drugs. ***If the ILHZs alone bear the cost of public health drugs. The share of the ILHZ in the total drugs needs is based on its population share. A - subject for recalculation as per suggestion of the international consultant.

In the case of the provincial government, the secondary sources of drug funds include revenues from parallel drug import (PDI) drugs and those drugs sold in hospital pharmacies paid directly by out-of-pocket means or through PHIC reimbursement. Supplementary drug transfers to the province, city and municipalities come from the CHD, other national government agencies, non- government organizations and national elected officials. These additional transfers are mostly in-kind and often irregular.

However, a closer look at the drug budgets and needs reveals a funding gap for hospital drugs, and for public health drugs in most interlocal health zones (ILHZs). In 2003, the drug budget for the provincial hospitals and the existing revolving drug funds for public pharmacies located in the provincial hospitals amounted to Php 7.385 million. This amount is Php 4.3 million short of the required financing for hospital drugs. Also, assuming that the provincial government alone will provide for public health drugs, the financing gap for these items is also large at Php 3.9 million.

If the ILHZs alone were to shoulder the public health drugs, the resulting funding gap at that level would be: Php 0.298 million for ILHZ 1 (Ozamiz), Php 1.13 million for ILHZ 2 (Calamba) and Php 1.039 million for ILHZ 4 (Tangub). Unlike the three other ILHZs, only ILHZ 3 (Oroquieta) appears to be spending more on drugs than what is required. However, this is misleading since Oroquieta City alone among five member LGUs of the ILHZ 3 has a financing surplus. In fact, the provincial-level financing surplus is largely due to the huge outlay of Oroquieta City and, to a lesser extent, of Ozamiz City.

30 To meet the funding requirements for the most essential drugs, the LGUs in Misamis Occidental will have to apportion twice the current share of their drug budgets in the IRA. Nominally, this would only entail allocating less than three percent of their IRA for drugs. In reality, however, this would entail a reduction in the provision of other public services, which are also mostly funded out of the IRA. Clearly, the enormity of the funding gap requires additional budget sources and, at the same time, the rationalization of drug expenditures.

Municipalities in the convergence site have their own separate procurement systems and schedules. The province-level drug procurement which consists of requests from the PHO and the hospitals are already in a pooled procurement setup.

Drug procurement is also limited by budgetary allocations which at times disregard the actual needs based on the requisition of health facilities. A common practice is that during the budget process, the annual procurement plan submitted by health facilities gets slashed depending on the availability of the allocation. In most cases, the slashing of the APPs is not consulted anymore with end users and hence, prioritization has not been made for the reduced procurement. There is also a considerably long lead-time between the purchase request and the purchase order which takes three months. Thus, even if the drugs are cheap, they are not getting to the hospitals in time. Some of the reasons cited for this include the numerous signatures required (40-50) to process the request and the inadequacy of funds (if not cash allocation) at the time of purchase.

While facilities have organized therapeutics committees, antibiotic prescription is found to be relatively high at 50percent of all curative encounters. Also, average stock out time, particularly in the tertiary hospitals is 31.7 percent. This means that one third of the time, essential drugs are out of stock. This further validates the claim that even with a zero co-pay policy in these facilities, substantial out of pocket spending still occurs among patients.

D.6 Governance

As prescribed in the Local Government Code of 1991, the health system is headed by the Governor through the Provincial Health Board. This Board which is composed by a core set of officials with the Governor as Chairperson, the Board Member for Health as Vice–Chairperson and the Provincial Health Officer (PHO), plus other local government officials and private individuals that the Board so desires to invite. The Provincial Health Board is the policy making body for health that endorses the budget proposal for health in the province. It also acts as oversight office for the health sector in a given province.

The PHO is in charge of day-to-day management of the provincial health system and reports directly to the Governor. The Provincial Health Office

31 primarily manages the network of hospitals owned by the province as well as attends to the public health concerns of the province in general. It also provides public health goods and services such as vaccines, TB drugs and family planning supplies to augment the support coming from the national government and those that were procured by its constituent LGUs. It also undertakes social marketing activities in health and for the case of Misamis Occidental, it has also been tasked to manage the revolving drug fund of the Province.

In some cases, there is an Assistant PHO and the hospital and public health functions are divided between them. In the case of Misamis Occidental, there is no Assistant PHO and the Chief of Hospital of the MOPH is also assisting the PHO in the management of the hospitals within its network.

As the health system is devolved, all the RHUs, and even some community hospitals are owned by their respective municipal or city governments. Similar to the provincial structure, the municipalities and cities also have a local health board which is chaired by their mayors and day to day management of the LGU health system is delegated to the City or Municipal Health Officer. These officers report directly to the Mayor and are primarily concerned with providing promotive, preventive and curative care RHU or CHO level. In the case of the Ozamiz zone, the core referral facility is owned by the City of Ozamiz and its Chief of Hospital also serves as an Assistant of the City Health Officer in an informal manner.

Under the convergence framework, the central authority for health care in Misamis Occidental is the Governor. Under him are three cities and 14 municipalities in the province that in 2002 pledged to work together as one convergence site for health sector reforms. Currently, there are 4 inter-local health zones (ILHZ) organized in Misamis Occidental. An ILHZ approximates the former district health system. It is composed of a cluster of geographically contiguous municipalities with well-defined population base that is served by a core referral hospital, from 3 to 5 RHUs and an average of 122 barangay health stations. In addition to government health facilities, the ILHZ also includes other stakeholders and sectors involved in the health care i.e., community-based nongovernmental organizations and the private sector.

At present, the Misamis Occidental convergence site is managed by the Provincial Health Board through a Secretariat that is headed by the PHO. Except for the core members of the Provincial Health Board, the secretariat and other members of the Board are sitting on an informal capacity that is not defined by a legal instrument. The other members now include the head mayor of each of the four ILHZs.

On the other hand, the ILHZ Board is the policy and governing body that provides direction to the different health units within the health zone. It facilitates inter-LGU cooperation and stakeholders’ coordination. Through a memorandum of agreement among stakeholders (provincial government,

32 municipal governments, Department of Health, Philippine Health Insurance Corporation, non-governmental organization, private sector, etc.), the ILHZs were formalized with the organization of the ILHZ Board and its technical management committee. This technical management committee is composed mainly of the municipal health officers and other assigned health personnel. Some private sector participation is present in some zones as this is discretionary to the ILHZ Board.

Unlike the provincial health board where only a few have legal voting powers, the ILHZ officials can define voting rights freely in their respective charters. Again, unlike the provincial health board, since the ILHZ was formed as a voluntary association not defined by law, its mandate to police its ranks is limited by the willingness of its members to submit to its directives.

Under the convergence set up, RHU and hospital personnel are now implementing common plans decided at the convergence site or ILHZ level. These institutions have also turned some of what used to be facility-specific committees or task groups into province-wide or ILHZ committees (i.e., ILHZ therapeutics committee, Technical Working Committees/Hospital Reform Groups/ Hospital Therapeutic Committees.

33 PART II: THE INVESTMENT PLAN

E. Major Gaps and Challenges

E.1 Health needs and delivery system

In the assessment of the local health situation discussed in the first part of this report, the following were found to be evident: 1) The number of health care facilities is adequate. In fact, there are from five to 12 hospitals and from eight to 43 out-patient clinics in each health zone. Similarly, there are from 87 to 495 hospital beds per zone, giving a bed to population ratio in the health zones of from 10 to 27 per 10,000 population. 2) Distribution of facilities is such that each zone has adequate primary and secondary care facilities. The number of tertiary care facilities located in two health zones is more than adequate for the entire province. 3) There are an adequate number of medical practitioners and distribution follows the distribution of health care facilities. There are however, not enough nurses at the core referral hospitals. 4) Range and quality of services in the different levels of care vary by zone. There is also no objective measure that is seen as a common standard across facilities to determine quality. 5) The availability of specific service facility, equipment and manpower determine the variation to a large extent. 6) There are much more private than government-owned health care facilities and practitioners. However, utilization of government hospitals is higher than that of the private hospitals. 7) The provincial government has initiated a meaningful partnership with private practitioners by way of sharing resources and responsibilities. 8) The level of social insurance enrollment is beginning to reduce the proportion of out-of-pocket expenditure. 9) Patient referral and information systems need to be coordinated and implemented province-wide. 10) Inadequacy of the health care delivery system is evident in the large number of unattended deaths and the equally large number of preventable deaths from illnesses such as pneumonia and diarrhea. This speaks of a poor preventive care that is inadequately linked to a similarly deficient curative care capability. 11) Relatively low vignette scores suggest that the management of index diseases may not be according to acceptable standards. 12) This may be due to the lack of budgets for both RHUs and hospitals that lead to these facilities to lack supplies and being unable to maintain its facilities. As a result, patients tend to bypass lower level facilities in favor of the higher referral centers, thus swamping them with mostly primary cases. A case in point is Zone 1 which uses the Provincial Hospital as its referral center, even for out-patient cases.

34 All these observations point to the need for a more coordinated health system that spans both private and public facilities. The current spread of service delivery points remains inequitable in that most clinics and doctors are located in the bigger cities and municipalities. Also, government facilities while utilized at sometimes in excess capacity do not have diagnostic and treatment facilities which are in adequate supply in the private sector.

There is an apparent need to redistribute and increase capacities in existing facilities rather than the need to add more facilities or increasing bed capacities.

The current shortfall in nurses can still be addressed by restructuring the human resource allocation of the province. However, it is also a possibility that with the massive migration of the nurses abroad (including doctors who are took nursing as a second degree) there could be an acute shortage in the next few years.

Given that ILHZs were already organized, there is now the need to come up with a management structure that will oversee ILHZs at the level of the convergence site. The existing provincial health board is seen to be deficient in that its composition is limited and voting rights are restricted. While the need to create a separate body that would subsume the health board’s functions appears necessary, it also presents several legal questions as to its personality, extent of powers and its implications relative to the Local Government Code of 1991.

Lastly, in the light of the planned health economic enterprise for the province’s health system, major data gaps for business planning as well as skill gaps for personnel who will eventually become business managers were identified. The move towards a health enterprise also calls for a major paradigm shift not only among clients but among providers as well. Investments are therefore needed to address these gaps.

35 F. Proposed Interventions and Investment Options

F.1 Health Service Delivery

The health system development needs in Misamis Occidental will be minimal on physical infrastructure and more on making the essential human resources available, and in making operational support health care management systems available in order for available infrastructure to function optimally. The recommended strategies for Misamis Occidental health development are [the items below are strategies, not goals; a goal is a situation/scenario/state of being/condition/etc that we want to reach within a considerable period of time]: 1) Enable primary care facilities to deliver the complete package of primary preventive and curative services in order to rid hospitals of unnecessary load. 2) Provide adequate essential diagnostic and treatment services in local hospitals: a. microbiology b. public health referral laboratory. c. electrocardiography d. ultrasonography e. hemodialysis f. isolation ward g. access to histopathology services 3) Develop comprehensive training and re-training plans for medical and paramedical personnel that are matched by a redeployment plan and incentive system. 4) Establish support systems to ensure appropriate, efficient and quality patient care: patient referral system, standard therapeutic guidelines, health information system, indigent participation in social insurance, public-private cooperation in health provision 5) Implement a financing scheme that can further reduce out-of-pocket by the poor and shift LGU spending to public health. 6) Develop and implement a health economic enterprise strategy plan for the health system

By matching the diseases and conditions primarily affecting the poor with DOH-recommended service protocols for the different health facilities4, a few areas to improve the current standard services were identified. These are:

4 Documents used for identifying DOH recommended health services for various health facilities are: Quality Standards List for Rural health Units and Health Centers-Level 1, October 2000; Quality Standards List for Hospitals-Level 1, October 2000; Manual of Procedures for the NTP, 2001; Reference Guide-Managing Malaria at the Local Level, 2002; National Rabies Prevention and Control Program-manual of Operations, 2001; Manual of Procedures-DOH National Leprosy Control Program, 2002; Guide Health Education on the Prevention and Control of Schistosomiasis in the Philippines, 1995; and, Guidelines in the Implementation of the National Filariasis Elimination Program.

36 a) Improve emergency services in RHUS by - Identifying a medical doctor on call for 24 hours per day with consultation with LCE - Allowing IV infusion for acute cholera-like diarrhea cases even prior to transfer to hospital - Ensure availability of ambulance or other appropriate transport services in RHUs that are 10 kilometers away or has a travel time of more than 15 minutes from the core referral hospital, - Communication facilities, i.e., cell phone, high frequency radio network or land lines that can link with higher referral units be made mandatory in all RHUs - Complete first-aid supplies, minor surgery instruments, obstetric packs, basic oxygen supplementation apparatus and cardio-pulmonary resuscitation services be available in RHUs with full-time medical doctors and in LGUs without a hospital facility. - Service arrangements with private practitioners shall be actively pursued in order to attract specialists to practice in public facilities as well as help augment current human resource capabilities, including having physicians on call especially in isolated areas or when ambulance service is not readily accessible. b) Services for WRA (women in the reproductive age), whether in the RHU or core referral hospital must include provision of an enclosed area or room where privacy and a reasonable level of sterilization of facilities and equipment can be maintained. This also includes emergency obstetric care facilities and functional referral networks consistent with accepted standards and principles of safe motherhood. This recommendation specifically includes the establishment of birthing facilities/wings in hospitals to help decongest the main OR/DR and ward complexes of the hospitals as well as rationalize human resource distribution in the facilities by making midwives the main providers for birthing services instead of doctors and nurses who are needed for more general health delivery. c) The core referral hospital must be able to provide access to an isolation facility where patients with relatively unknown and highly contagious disease, like SARS can be confined if warranted. d) Health education, patient counseling and disease prevention in general, are shared responsibilities by RHU and hospital technical staff. Core referral hospitals are in a good position to reinforce information and messages that promote health when patients are ‘captive’ audience while confined. Hospital out-patient services can include provision of missed immunizations among children and

37 women in the reproductive age and investigate children who are chronically malnourished.

e) As a diagnostic facility, the designated core referral hospitals must be able to provide x-ray examinations, EKG, ultrasound, and at least provide easy access to microbiology services for unknown, recalcitrant or suspected drug-resistant infections. If these cannot be efficiently and effectively provided, service arrangements with private providers are to be arranged and negotiated.

f) Return-referral by a hospital to the RHU should, apart from post- operative care, specifically include post-partum cases requiring home visits by a midwife or paramedic, TB cases needing continuation of D.O.T.S. (directly observed treatment with standard regimen for TB), and post-stroke cases needing monitoring of treatment compliance and health status. Sustained care for these three types of patients alone can have a significant impact in the reduction of illness and mortality in communities.

The basic recommendation is for Misamis local governments to continue financing and managing the bulk of primary and secondary levels of health care. It is the profit-generating private sector that can be encouraged to pursue the development and provision of the more costly tertiary services. The private hospitals in Misamis Occidental provide majority of advanced diagnostic studies in the province. Service arrangements can then be entered into between the province and these facilities particularly in terms of pricing and utilization of these services.

These service arrangements are particularly important in the health economic enterprise system that will be developed for the province.

Based on the criteria that will be defined later for accreditation and for assessing performance based bonuses, the corresponding capability building investments such as training, continuing education and access to medical literature need to be made as well.

An initial facility rationalization exercise was conducted using a mix of criteria such as: population-to-facility ratio, travel time, transportation flow, utilization rates, disease epidemiology, private sector presence and political preference and dynamics. This proposed configuration of the facility network is subject to further validation by the business planning TA and LGU preference:

38 Table 13. Proposed network of facilities in Misamis Occidental Facility Health Critical upgrading Category/Designation Facility requirements Infrastructure Equipment Third level referral MHARRSGEN Installation of Microbiology lab Psychiatric Cobalt machine Room Hemodialysis machine (subject to private sector negotiations) CS End referral facility MOPH Repair of Ultrasound and Oroquieta core OR/DR, CSR, Xray machine referral facility Kitchen, Water Blood chemistry Repiping analyzer(subject to private sector negotiations) Calamba core referral Calamba Conversion of OB equipments, District 25% of beds CEMOC Hospital to birthing Equipment, Film area Processor, Other equipments.

Ozamis core referral SM Lao Inputs are subject to private sector Hospital negotiations Tangub core referral Tangub Note: see below District Hospital Specialties facilities Tudela New building Infirmary for 10 bed facility with RHU* Sinacaban Refurbishing BEMOC equipment Birthing of existing facility structure RHUs Based on compliance to SS Level I Phase II standards, TB DOTS Accreditation and Maternity Care Package * final bed number subject to validation with business planning (Note: Table 13 under 1. Ozamiz ( Core Referral) SM LAO Laboratory/ Dietary CEMOC Equipment,other equipments, Anesthesia Machine, Generator 2.( Core Referral) Tangub Construction of Dormetory, ward, Anesthesia Machine , CEMOC Equipments.)

These facilities will now compose the Misamis Occidental Health Enterprise. A health enterprise entails the creation of a government-owned- and-controlled corporation that is mandated to provide sustained, appropriate and accessible healthcare especially for the poor.

39 The enterprise concept differs from the usual health service delivery system based on these following parameters:

1. Facilities are fiscally and administratively autonomous;

2. Uses business tools and principles in the planning, implementation and evaluation of activities;

3. Budgetary dependence is minimized to a level of meeting only the appropriate requirements of uninsured indigents; and

4. Shares costs and benefits among incorporator agencies/LGUs.

Some benchmarks for enterprise development include:

1. Progressive income retention and corresponding budgetary reduction;

2. Enforcement of performance based budgeting process; and

3. Facility development based on market forces.

The initial concept was for the enterprise to involve only the hospitals as a network of corporate and autonomous facilities. However, the stakeholders also wanted the RHUs to be part of the enterprise system.

It was proposed that the enterprise development be accomplished in a phased manner with the hospitals first, specifically with MOPH and then the RHUs following later.

Further details on the enterprise system and its mechanics will be tackled under the Business Planning consultancy package. Investments for other hospitals will also depend on the outcome of the Business Planning.

F.2 Health Care Financing

With a substantial portion of the provincial budget going to health services, the Province of Misamis Occidental is near the optimal point of spending for health given its current constraints. However, the way expenses are being incurred can still benefit from a more efficient allocation of health funds. Also there are restrictive audit ceilings such as the 60-40 rule for personnel services. Even if the LGU can still afford to hire more health staff, it is prohibited to allocate funds for this purpose once it hits the ceiling.

The LGU can apply the following interventions in order to address the chronic lack of funds: a. Increase revenue generation so as to increase the overall budgetary fund of the province. One way to accomplish this

40 would be to make the price structure of user fees market-based for PHilhealth and private payer and socialized for non-member indigents;

b. Identify revenue centers in public facilities that could benefit from improving user fees without necessarily compromising social objectives; and

c. Identify a specific portion of the annual budget that will be used for premium payments of indigents as a more efficient investment strategy.

On the other hand, the DOH can provide support through allocation of grants. It is important however, that any form of support by the DOH to LGUs need to meet specific project criteria and should be designed for performance- based releases. These fiscal reforms can be included in the general package of enterprise-related activities. Plans and investments towards a health enterprise system need to be further elucidated.

F.3 Enrollment in Social Health Insurance

For social insurance, the main goal in the various ILHZs in Misamis Occidental is the enrollment of all the indigents, defined as the 50 percent poorest of the population (bottom 25 percent for cities). Likewise there is consensus that identification of those eligible for PHIC’s Indigent Program and Individually Paying Program will be done through a community-based information system, and that the RHU will be the center for enrollment. In order to ensure sustained enrollment and participation of the indigent group in the local health system being developed, the LGUs will need to work out a delicate balance in using payments, revenues and budget between health service provision and payment of premiums for the increasing number of indigent enrollees.

Community-based baseline and periodic household surveys, on the other hand, will give local health systems multiple advantages, among which are:

a) Providing the data base for social insurance enrollment;

b) Opportunity for more precise client identification and planning for public health programs or follow-up care and epidemiologic investigation;

c) Basis for population/needs-based budget allocation or investment plans; and,

d) More efficient monitoring and evaluation of community health.

41 However, caution should be exercised by the LGUs in designating or allowing technical personnel of the RHU to assume the added responsibility for enrollment or registration or for assuming supervision of the community- based information system. Even if we did not factor in the effects of increased enrollment, there is bound to be dramatic increase in RHU utilization rates with the planned improvements in health infrastructure, diagnostic and curative services and patient referral system. Optimum performance level of current technical personnel is needed for providing the whole gamut of essential public health programs and curative services to the community.

For enrolment, the zones have committed to enroll all their indigents and their poor independently paying members (IPP-A) by the end of Year 5. Indigents here were defined as the bottom 50 percent of the population while the IPP-A are the next 25 percent. To identify the eligible members, a biannual enumeration of households shall be done in Misamis Occidental. Information gathered from this survey shall be made part of a convergence site-wide information system that will be interlinked across facilities and their Geographic Information System (GIS). Enrollment shall be supported with premium subsidies for enrollees that were beyond the target for that year.

All IPP-A will likewise be enrolled by intensifying social marketing efforts, particularly directed to organized groups and by setting up the necessary membership infrastructure and support systems in support of this objective.

F.4 Drug Management Systems and Procurement

The overarching choice for Misamis Occidental is evidence-based drug selection based on epidemiological risk profiles (morbidity and mortality). Drug selection provides the framework and dictates the architecture of all the other options. Pooled procurement and distribution through PDI, will be based on the selected drugs. Rational drug use is also reliant on the development, maintenance, and use of treatment guidelines and formularies, both of which are tools of drug selection. Thus, it is vitally important to get drug selection right.

A list should be compiled by every health facility based on catchment area epidemiology. These lists should then be collated and synthesized to come up with ILHZ and provincial lists. After compiling the quality effective drug lists, formularies and standard treatment guidelines should be developed for the province. These formularies and standard treatment guidelines should cover majority of the diseases encountered in all health facilities and should provide different regimens applicable for every medical setting from primary to tertiary care. Another method of selecting drugs is by simply adapting evidence-based standard treatment guidelines that have been approved by the PHIC or have been developed by the professional societies, the World Health Organization (WHO), or other bodies. Thus, the process of compiling this list should be participative and interactive, balancing the requirements of evidence-based medicine (EBM) and the experience of the prescribers. As a

42 motivator of compliance, hospitals whose physicians have a high compliance rate to the provincial standard treatment guidelines will receive their PHIC reimbursements faster.

Current good manufacturing practices (cGMP) are standards established by the BFAD to ensure the quality of manufactured drug products. These standards prescribe the way drug products should be compounded, packaged, stored, and distributed. They also prescribe the quality assurance methods that drug manufacturing plants should use. It is assumed that if drug plants adhere to these standards, the products coming from them would be of high quality.

The provincial board can issue a resolution making cGMP a minimum requirement for accreditation of drug suppliers.

Parallel drug imports (PDI) are drugs imported from a third country where it is cheaper and is usually done without the authorization of the manufacturer. Since these products are equivalent to the multinational brand products, the quality is assured. In addition, they are 50 percent cheaper than the locally sold branded equivalents.

Under the Province-wide Pooled Procurement, the revolving drug fund (RDF) of all four ILHZ and (including the hospitals) will be pooled to purchase the pooled drug requirements of all ten of these institutions. The large volumes and amounts being included in the bidding will allow the province to attract regional and even national drug suppliers. These suppliers will try to give deep discounts as they compete with each other. In addition, the middlemen are also cut out. The savings may be expected to be at least 47 percent.

To ensure maximum price reduction, the pooled procurement facility may adopt a reasonable “waiting period” after the winning bidder is selected to enable other suppliers offer a lower price for the same quality and quantity of drugs.

The use of Health Plus Outlets or the German Agency for Technical Cooperation—Philippines (GTZ) model of the Botika ng Barangay and is based on the concept of social franchising. A national drug procurement and distribution organization has been established called the National Pharmaceutical Foundation (NPF). Provinces are encouraged to form their own Provincial Pharmaceutical Foundations (PPF). In addition, nongovernment organizations (NGO) and people’s organizations (PO) are encouraged to establish Health Plus outlets.

If strategically located, these outlets will address the problem of scarcity of government or private dispensing facilities in some areas. A geographic information system (GIS) algorithm can be used to locate these facilities so that all Misamis Occidental residents are within at least half an hour away from a dispensing facility for essential medicines.

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The cost of establishing a PPF is about Php 2 million, while the cost for a single Health Plus outlet, inclusive of medicine supply for a quarter is about Php 38,000. Other details regarding the establishment of this system of dispensing facilities are available at the FAMUS office of the GTZ at the DOH.

Another alternative is to establish PHIC-Accredited Private Drugstores which are actually more geographically accessible than government dispensing facilities. There are 83 private-owned dispensing facilities, while there are only five government-owned dispensing facilities. However, the prices of these private entities are, on the average, 45 percent higher. If these private drugstores are willing to keep their prices within the PHIC Drug Price Reference Index when selling to PHIC members, then PHIC can accredit them and reimburse them for PHIC member purchases. A voucher system can be used for both in- and out-patients.

The drugstores also have to agree to purchase only from cGMP-compliant drug companies. To assist them in sourcing such products, private drugstores may also be allowed to buy from the pooled procurement system of the province.

The main function of Therapeutic or Drug Management Committees (TC) is to provide management support for the maintenance of drug supply. These committees should be organized at the provincial, hospital, and ILHZ levels. Their functions include development and maintenance of STGs and formularies, budget programming, monitoring of procurement, and conduct of rational drug use (RDU) activities.

All the members of the committees need to undergo a three-day training that may be conducted by either the regional TC trainors in the CHDs or by the National Drug Policy Staff.

To provide the TCs with sufficient authority to perform its duties effectively, they should be provided with the proper legal mandate. These may be a provincial or ILHZ resolution or a hospital chief’s order.

To maintain the functionality of the TC, the release of the RDF can be partially conditioned on the development and maintenance of formularies and standard treatment guidelines, on drug budget programming, on the conduct of drug use reviews by the TC.

The drug management information system (DMIS) should be integrated with a province-wide information system for monitoring and evaluating health sector reform-related activities.

In order to manage the drug system, a special section under the GSO shall be solely dedicated to drug procurement. Staff from this section will receive special training on drug management systems and procurement.

44 F.5 Governance

The proposed governance structure for the local health system is the inter- local health zone that is registered with the Securities and Exchange Commission (SEC) as a non-stock, nonprofit corporation or a foundation. The overall coordinating board or council for the four zones will be similarly registered. This strategy is simply for the consolidation of strengths and resources of the individual LGUs in Misamis Occidental.

The recommendation for SEC registration stems from the observation that corporatization allows for administrative and financial reforms in government- run institutions. Using the Local Government Code as legal basis, the LGUs can pass an ordinance authorizing the organization of LGUs into a corporation through registration with the SEC. The enabling ordinance can likewise be explicit in declaring the transfer of an amount for SEC registration, the specific nature of the corporation, and that the facilities managed by the corporatized ILHZ remain to serve public purposes.

By taking on a corporate nature, the health delivery system can have more flexibility in the sourcing and use of funds, as well as hire additional personnel beyond the government ceilings for personnel services.

As a non-stock, non-profit corporation, the ILHZ would have to be initially financed by its LGU members. Later, future funds from various sources could be funneled to it and it would enjoy tax exemption like other non-profit corporations and organizations.

Related to the DOH-European Commission Health Sector Reform Project, the SEC-registered Council will:

• oversee and approve joint health planning and budgeting, inter-LGU cost sharing and human resource pooling;

• access capital loan or grant from various sources including the European countries and decide on investment priorities;

• provide oversight over the integration of hospital and public health services; and

• represent the interest of the different member LGUs of the zone as a single provider, as far as practicable.

The ILHZ board is proposed to be composed of the Governor or his duly designated representative, the Mayors from the participating municipalities who will elect from among themselves a Chairperson, a representative from the Department of Health, a representative from the Philippine Health Insurance Corporation, a representative from the non-government

45 organization or the private sector, a representative from the Municipal Health Officers, and the Chief of Hospital.

The ILHZ Technical or Management Committee will handle the day-to-day affairs of the zone. It will provide technical advice and recommendations to the board and the catchment facilities in these aspects, among others:

• health information system;

• integrated health planning and health care financing;

• rational drug use;

• referral system;

• resource pooling: manpower sharing, health care financing, pooled procurement system, utilization of hospital income; and

• quality assurance standards for periodic assessment.

The Technical Committee could be composed of the chief of hospital, other hospital doctors, the municipal health officers of the participating municipalities, the chief nurse, the pharmacist, a representative form the midwives, DOH representative, some administrative staff and others that the board may include.

On the provincial level, it is proposed that the present Local Health Board will expand its membership, to include the chairman of each ILHZ, Philhealth representative and multi-sectoral representative.

During the course of the project preparation, several legal questions came up particularly in the issue of corporatizing the convergence site council. It was feared that the organization of such council will be in conflict with the presence of a Provincial Health Board which is an office created by law.

As the convergence site council is an expanded health board, one proposal was for the convergence council to make the decisions which the provincial health board concurs to and endorses if it requires the LGUs approval. Another alternative was for the provincial health board to delegate its powers and functions to this convergence site council at the beginning of each fiscal year. Under these proposals, ownership of facilities and the status of existing organic employees will retain their public sector character.

These legal personality issues did not concern ILHZs as there is no argument that they would need a legal personality which was not anticipated in the crafting of the Local Government Code.

46 F.6 Start up funds

In order to pump prime the process, Php 5 million worth of government funds has been allocated as a start up fund for Misamis Occidental. The purpose of the allocation was three-fold: a) to help the province set up the necessary support structures and mechanisms in support of the interventions listed in the Misamis Occidental Plan and b) to test the capacity of the DOH to do adequate and timely allocation of funding to LGUs using project criteria and c) to test the capacity of LGUs to plan and implement activities using project principles.

Table 14 below shows how the funds will be allocated across items. Priority items for funding include the seed funds for the drug revolving fund, the establishment of governance institutions and the procurement of equipment for various health facilities.

Table 14. Allocation of the Start Up Fund*

Type of Target Item Unit cost Quan TOTAL Expenditure Areas tity Capital Outlay Public health Panaon Centrifuge 90,000 2 180,000 Baliangao Sub Total 180,000 Hospital MOPH Electrolyte 1,500,000 1 1,500,000 Analyzer

SMLAO Anesthesia 600,000 1 600,000 machine Sub Total 2,100,000 Total CO 2,280,000 MOOE A. Capability building CHO, Chief Meals and Meals & P259,000.00 1. capability Nurse, Supplies Lodging enhancement of MHO, PHN health managers 2. Training on Meals and Meals- P58,000.00 Strengthening of supplies P36,000 Therapeutics Supplies/mats committee Honorarium- P4,000 B. Program Support

47 1. Registration of Registratio 50,000.00 50,000.00 ILHZ to SEC n cost 2.revolving drug 4 ILHZ 2,000,000.000 2million fund 3. Hiring of salaries/ 19,500.00 19,500.00 contractual admin wages 4. office supplies/materials 50,000.00 50,000.00 5.meetings/works hops/monitoring 63,000.00 63,000.00 MOOE Total 2,220,000 TOTAL 5,000,000 * subject for revision pending determination of final amount available from DOH

The RDF will be used to start up the RDF system in the convergence site. The Php 2.6 million administrative fund allocation will be used by the province to set up the necessary governance institutions, hire necessary consultants and conduct needed researches to set up the health enterprise of Misamis Occidental.

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G. Critical Targets, Activities and Outcomes

Project benchmarks serve to define milestones in implementation. For the Misamis Occidental Health Investment Plan in Fourmula One, the following critical targets, activities and outcomes are being proposed (see Table 15):

49 Table 15. Critical Parameters for the Misamis Occidental Plan Interven Targets Activities Outcomes Indicators Means of Assumption/Risk tion Area Verification

Service 1. Ensure that 1. Identification of target lResponsive 1. Improve- Hospital report Primary Delivery facilities facilities for upgrading and sustaina- ments of hospi cases are still entitled provide 2. Procurement of ble health deli- tal indicators- at the tertiary hospital adequate appropriate services very system Occupancy rate and and equipments for Misamis and others. appropriate 3. Critical upgrading of Occidental. 2. Reduction FHSIS Report quality care facilities IMR, MMR for the 4. Contracting of specific 3. Reduction Change of personal poor. service arrangements of infectious behavior is a big 2. Ensure that with the private sector. and lifestyle challenge. health 5. Institute measures to disease. delivery is address public health 4. Increased DOH might stop done at the priority programs Of fully immu- the supply of most reduction of infectious nized children vaccines. efficient and & life style diseases effective and maternal child manner. care. 6. Health manpower capability building thru training and support mechanism. 7. Disaster Preparedness /Emergency Management 8. Improvement of laboratory services. 9. Information, education, and Communication

1 services. 10. Monitoring and evaluation of the Outcomes Indicators Means of Assumption/Risk delivery system. Verification

Finance 1. Provide 1. Identification of target Universal cover- PHIC enrollment LGUs/LCES may not insurance clientele age of PhilHealth listing enroll because; support for 2. Enrollment of clientele sustained and 1. premiums will in- all indigents 3. Establishing an maintained. crease coming years and IPP-A. information system 2. change of adminis 2. Ensure that is interlinked with tration, some LCE appropriate other critical social insurance of PHIC intervention areas health not his/her membership 4. Developing a priority. managemen membership Presence of SP/SB Secretary Legal mandates are t management system Legal mandates IPHO Inventory of present but not his/ 5. Measures to maximize ordinances, ordinances and her implementation. utilization and MOAs, resolu- resolutions. expansion of PhilHealth tion support benefits. revenue gene- 6. Establishment of ration. Sources and Revenue Center 7. Enactment for Legal Mandates 8. Monitoring and Evaluation.

2 Regulator Ensure adequate Identification of drug needs Improved health No. of CHOs/ y and sustained Provision of sufficient indicators for RHUs SS Certi access of Misamis RDF/Drug Outlets Misamis Occ. fied I & II to Occidental to good Establishing operational Philhealth quality, safe, and procedures for Sustainable accreditated. Supervisory/monitor- effective medicines. drugprocurement and sale Health Delivery ing /evaluation Quality assurance , SS System in Mis. listing Certification/Philhealth Occ. Accreditation No. of BNB es- - do - BNB are too many Enactment for Legal tablished for the pharmacist Mandates-CGMP, No smoking to supervise. Clinical Practice Guidelines Legal mandates SB/SP Secretary/ No political will Workshop and Adoption ECMP no smo- IPHO Inventory of for implementation. Monitoring and Evaluation. king and etc. ordinances and reso- lutions.

CPG Adopted Hospitals/RHUs files Not all doctors Follow CPG

Governan 1. Ensure the 1. Establishment of effective, Representative Presence of In- Mis. Occ. Health Manpower pool- ce establishme accurate and timely and responsive formation sys- System present at encoder & retriever nt of information system governance of tem. Website. might seek for appropriate 2. Strengthening Referral the Mis. Occ. a greener pasture, governance System Health Enter- employment is structures in 3. Installation of Human prise. Misamis Resource Development Functional Return slips are filed Lack of health Occidental System Referral at the RHUs; or me- manpower will 4. Enhancing Management System nimal primary cases affect the Structure services. 5. Corporate restructuring of Identified at the MOPH to become Districts and hospi-

3 Economic Enterprise tals 6. Enhancing ILHZ Cooperation and Support Human Resource List of personnel No experience how 7. Strengthen GOs/ Development need trainings, is done, is risk but NGOs/POs Partnership Section Installed PES, etc are filed worth while trying 8. Measures to improve And put in data effective program SEC Registration Certification from A Public Entity in management Of ILHZ the SEC signature is a 9. Monitoring and evaluation. challenge

Fiscal Autonomy Functional records Ignite negative re Is piriscribe at marked as trust action from the MOPH fund in finance & Provincial Finance Nursing office committee.

Needs massive in- Formation cam- Paign.

Provincial Health EO of the Gover- Need massive Board is expan- nor. Information, Ded Education Cam- Paign.

Effective Health Management.

4 H. Implementation Management

In case the money will be flowed to the Provincial Government as part of the Internal Revenue Allotment (IRA) earmarked as EC Grant, the procurement process follows the Government Procurement Reform Act 1984 for the equipments and construction materials. Civil works/infrastructure implementation is through administration. General Service Office (GSO) personnel is assigned to focus solely for EC project implementation. At the provincial level, the Health Sector Reform Project Technical Working Group (HSRP-TWG) now becomes F1 TWG. Chaired by the Provincial Health Officer II (PHO II), the TWG oversees the implementation. It has administrative staff aided by the existing support staff of the province at the IPHO. Two technical staff is assigned to each inter-local health zone. They attend every meeting and serves as the link to the PHO II They also oversees the implementation of the F1. In return, the technical staff has assignment as to component Service Delivery, Financing, Regulations and Governance.

The PHO II reports to the Governor every week during every Monday meeting with the other Department Heads and to the Provincial Health Board every month.

1