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FINANCING THE TRANSITION TO UNIVERSAL HEALTH COVERAGE IN BARMM THE TRANSITION TO Public Disclosure Authorized UNIVERSAL HEALTH COVERAGE IN BARMM Delivering and Financing Health Services in the Public Disclosure Authorized Bangsamoro Autonomous Region in Muslim Mindanao Public Disclosure Authorized Public Disclosure Authorized 1 © 2020 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: [email protected]. 2 FINANCING THE TRANSITION TO UNIVERSAL HEALTH COVERAGE IN BARMM TABLE OF CONTENTS Acknowledgements 11 Abbreviations and Acronyms 13 A note on the geographic focus of this report 14 Executive Summary 16 Chapter One: Introduction 23 Chapter Two: The Philippines National Context 26 Summary 26 The Health Sector 31 Overview 31 Health service delivery 33 Health governance and regulation 34 PhilHealth 35 Philippines National Health Plans and Legislation 36 Health Financing 37 Health Sector Performance and Status 39 Focus – Contrasting Stories in the Philippines and China 43 Fuure Directions 44 Chapter Three: The Historical, Political and Health-Specific Context of the BARMM Region 45 Summary 45 Historical and Political Context 45 The GPH-MILF Comprehensive Agreement on the Bangsamoro 47 BARMM and the BOL 48 The Bangsamoro Transition Authority: Challenges and Opportunities for Health 49 Regional Poverty and Inequity 51 Focus – Immunization in BARMM illustrates the challenge to address poverty and inequity in sub-national regions 54 The BARMM Health System 59 Future Directions 60 Chapter Four: Financing Health in BARMM 61 Summary 61 Introduction 62 Findings and Results 63 Funding Streams 63 Health Funding Allocated for ARMM, 2013-2017 64 3 TABLE OF CONTENTS Locus of Control 66 Flow of Funds 68 Use of Funds 69 Discussion 74 Chapter Five: Access to Basic Health Services in BARMM – Results and Analysis of a Household Survey 81 Summary 81 Rationale 82 Methodology 82 Findings 85 The Population of the BARMM Sample 85 Household economic conditions 87 Health 95 Immunization Coverage 105 Nutrition, Breastfeeding and Perceptions on Stunting 117 Conclusions 125 Chapter Six: Supply-Side Readiness of Primary Health Care in BARMM 127 Summary 127 Analytic Approach 127 Overview 127 Data Overview 128 The SARA Framework 128 Findings 130 General Service Availability 130 General Service Readiness 122 Specific Service Readiness Overview 137 Conclusions 147 General Trends 147 BARMM in the National Context 149 FIndings and Recommendations 152 Chapter Seven: Immunization Program in the Philippines and Immunization Coverage in BARMM 154 Summary 154 Overview 155 Immunization Financing 157 Immunization Service Delivery 160 4 FINANCING THE TRANSITION TO UNIVERSAL HEALTH COVERAGE IN BARMM TABLE OF CONTENTS Program Management and Service Provision 160 Vaccine Inventory Management Distribution and Supply 163 Cold Chain/Stock Management 165 Discussion 166 Chapter Eight: Preparing for Effective and Robust Governance of Health in BARMM - Financial Management 168 Summary 168 Introduction 169 Context 169 Legal and regulatory arrangements for Public Financial Management 169 Institutional arrangements for Public Financial Management 170 Fiscal planning, budget preparation and allocation 171 Fiscal and fiscal risks 171 Budget preparation 172 Budget allocation 173 Revenue Collection and Management 174 ARMM/BARMM Revenue 174 LGU Revenue 175 Fiscal and budgetary trends 176 Budget execution 177 Cash management 177 Operational and program expenditure 177 Health and Social Services 178 Procurement 179 Controls on budget execution 180 Internal Audit 180 Accounting and financial reporting 181 External audit and oversight 181 Cross-cutting Issues 182 Cohesion and integration within and across tiers of government 182 Capacity and capability 182 Transparency 183 Autonomy and accountability 183 Health service delivery impact 184 Conclusions and Recommendations 185 5 TABLE OF CONTENTS Chapter Nine: Preparing for Effective and Robust Governance of Health in BARMM - Organizational Development 187 Summary 187 Background & Rationale 187 A Functional Structure for the MOH 188 Considerations for Further Strengthening of BARMM-MOH Functional Structure 191 Structure refinements: Options for the Future 192 Discussion and Policy Options 195 Summary 195 References 205 ANNEXES Annex A. Discussion of BARMM Health Financing Streams Annex B. Health Funding Allocations: Source, Allocating Authority, and Disbursing Authority by Level of Government Annex C. Assumptions on Expense Class Categories Annex D. Assumptions on Type of Health Care Function Annex E. BARMM Appropriations for Ministry of Health Annex F. Details about Sampling of Barangays, 2019 BARMM Household Survey Annex G. Immunization Findings, Children Age 0–11 Months, 2019 BARMM Household Survey Annex H. Immunization Findings, Children Age 12–23 Months, 2019 BARMM Household Survey Annex I. Nutrition and Anthropometric Results and Discussion, 2019 BARMM Household Survey Annex J. Additional Figures and Tables from 2017 BARMM Supply Side Readiness Assessment Annex K. Rationale for Proposed Changes in the BARMM Ministry of Health Functional Structure Annex L. Cross-Functional Groups for Decision Making and Coordination in the BARMM MOH Annex M. Number of Positions in the Proposed BARMM MOH Structure http://bit.ly/BARMMHFSAAnnexes 6 FINANCING THE TRANSITION TO UNIVERSAL HEALTH COVERAGE IN BARMM FIGURES Figure 1.1. BARMM Health Financing System Assessment Components 25 Figure 2.1. Philippine Population Age Pyramid, 2015 28 Figure 2.2. Philippines GDP Growth, 1980-2015 29 Figure 2.3. Average Yearly Growth in the Philippines of Various Economic Measures, 2006–2015 29 Figure 2.4. Income Inequality: Philippines versus Select East Asian Countries, 2006 – 2015 30 Figure 2.5. Leading Causes of Death, Philippines, 2018 31 Figure 2.6. Changing Burden of Disease in the Philippines, 1990 versus 2017 32 Figure 2.7. Current Health Expenditures by Financing Agent, Philippines, 2018 37 Figure 2.8. Out-of-Pocket Spending as Percentage of Current Health Expenditure, 2014-2017 39 Figure 2.9. Domestic General Government Health Expenditure as Percentage of Current Health Expenditure, 2014-2017 39 Figure 2.10. Under-5 Mortality Rates (per 1,000 live births), Philippines, 2008-2018 40 Figure 2.11. Under-5 Mortality Rates, by Region, Ten-Year Period Preceding 2017 NDHS (Per 1,000 Live Births) 41 Figure 2.12. Prevalence of Underweight, Select East Asian countries, 2010-2018 41 Figure 2.13. Maternal Mortality Ratio per 100,000 Live Births, Philippines versus Select East Asian Countries, 2005-2015 42 Figure 3.1. Poverty Incidence among BARMM Families over time 52 Figure 3.2. PhilHealth coverage by Region, 2017 52 Figure 3.3, Panel A: Infant and Child Mortality (per 1,000 population), Philippines versus BARMM, 2017 53 Figure 3.3, Panel B: Under-5 Stunting Prevalence (per 100 population), Philippines versus BARMM, 2019 53 Figure 3.4. Maternal Health Indicators, Philippines versus BARMM, 2017 53 Figure 3.5: Socioeconomic indicators, BARMM, Mindanao and Philippines overall, 2017 54 Figure 3.6. All Basic Vaccination Coverage by Region in the Philippines 55 Figure 3.7. All Basic Vaccination Coverage by Selected Southeast Asian Countries and Region Therein 55 Figure 3.8. Percentage of Children with No Vaccination by Selected Southeast Asian Countries 56 Figure 3.9. Polio vaccination coverage in Philippine Regions Source: DHS 2008, 2013 and 2017 56 Figure 3.10. Polio3 Vaccination Coverage by Selected Southeast Asian Countries 57 Figure 4.1a. Health Funding Allocations for ARMM, by Funding Source, 2016 to 2017 65 Figure 4.1b. Health Funding Allocations for ARMM, by Funding Stream, 2016 to 2017 65 Figure 4.2. Locus of Source, Allocation, and Disbursement of ARMM Health Funds, 2016–2017 (PhP13.3 billion) 67 Figure 4.3. Flow of Funds of Health Resources for ARMM 69 Figure 4.4. Health Expenditures by Health Care Function, ARMM, 2016-2017 71 Figure 4.5. Type of Health Spending by Funding Stream and Health Care Function, 2016-2017 72 Figure 4.6. Locus of Allocation of Health Funds, Variation 75 7 FIGURES Figure 4.7. Shift in Allocation Authority under Three Scenarios 79 Figure 5.1. Distribution of households per income quartile, BARMM provinces, 2019 87 Figure 5.2. Monthly Expenditures versus Average Monthly Income, BARMM, 2019 90 Figure 5.3. Proportional Breakdown of Medical Expenditure by Category, BARMM, 2019 91 Figure 5.4. Home and Land Ownership, BARMM, 2019 92 Figure 5.5. Matrix of Access Category by Indicator, BARMM 2019 95 Figure 5.6. Vaccine coverage, BARMM and Philippines, 2017 and 2019 106 Figure 5.7. Provincial Variation in Vaccine Coverage, BARMM, 2019 107 Figure 5.8. Vaccine coverage and timeliness, BARMM, 2019 108 Figure 5.9. Messages about Vaccination, BARMM, 2019 114 Figure 6.1. Analysis Overview 129 Figure 6.2. The Location of RHUs across BARMM 131 Figure 6.3. RHU and BHS Density 131 Figure 6.4. General Service Readiness, by Province 134 Figure 6.5. Facility-Based Delivery 2013–2016 139 Figure 6.6. Immunization Service Readiness 140 Figure 6.7. Stock-outs of NIP Vaccines 141 Figure 6.8.