THE CHALLENGE OF REACHING THE POOR WITH A CONTINUUM OF CARE A 25-Year Assessment of Philippine Health Sector Performance Carlo Irwin A. Panelo Orville Jose C. Solon Rebecca M. Ramos Alejandro N. Herrin Corresponding author: Carlo Irwin A. Panelo Telefax: +632-5254098 Mobile: +639189199467 Email: [email protected] The mention (if any) of specific companies or of certain manufacturer’s products does not imply that they are endorsed or recommended by the publisher in preference over others of a similar nature. Articles may be reproduced in part for non-profit purposes without prior permission, provided credit is given to the individual authors for original pieces. A copy of the reprinted or adapted version will be appreciated. Suggested citation: Panelo, C. I .A., Solon, O. J. C., Ramos, R. M., Herrin, A. N. The Challenge of Reaching the Poor with a Continuum of Care: A 25-Year Assessment of Philippine Health Sector Performance. Quezon City, 2017. This document is made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of Cooperative Agreement No. AID-492-A-12-00016. HPDP is a five- year USAID health policy project implemented by the UPecon Foundation, Inc. that supports the Department of Health (DOH)-led policy formulation process for scaling up Universal Health Care. The contents are the sole responsibility of authors and do not necessarily reflect the views of HPDP, UPecon Foundation, Inc., USAID or the United States Government. The Challenge of Reaching the Poor with a Continuum of Care: A 25-year Assessment of Philippine Health Sector Performance Carlo Irwin A. Panelo Orville Jose C. Solon Rebecca M. Ramos Alejandro N. Herrin Includes a commentary by John Peabody, MD, PhD and Diana Tamondong-Lachica, MD, and insights from Manuel M. Dayrit, MD, MSc, and Paulyn Jean B. Rosell-Ubial, MD, MPH, CESO II In memory of Mario M. Taguiwalo and Alberto G. Romualdez Jr. TABLE OF CONTENTS Acknowledgments i Foreword iii List of Tables v List of Figures viii Acronyms and Abbreviations ix Executive Summary xiii Overview xix PART I: CHALLENGES, FUNDAMEntaL WEAKNESSES, AND 1 StratEGIC RESPONSES 1. The Challenge of Improving Health Outcomes of the Poor 3 2. Managing a Highly Decentralized Health Delivery and Financing System 11 3. Reducing Variations in Access and Quality of Care to Improve Health Outcomes 19 4. Consolidating Public Finances to Secure the Needs of the Poor 37 5. Reducing Fragmentation and Expanding Capacity to Implement Reforms 53 PART II: FUNDAMEntaL PROBLEMS AND StratEGIC 63 RESPONSES to SPECIFIC HEALTH PROBLEMS 6. Ensuring a Continuum of Care to Improve Maternal and Neonatal Health 65 7. Intensifying Tuberculosis Control in High Burden Areas 79 8. Adopting a Programmatic Approach to HIV and AIDS Prevention and Control 89 9. Adopting a Set of Cost-Effective Interventions to Reduce Mortality and Morbidity 97 from Non-Communicable Diseases 10. Investing in Capacity to Respond to Threat from Emerging and Re-Emerging 105 Infectious Diseases 11. Strengthening the Process of Accountability to Reduce the Burden of Vaccine- 111 Preventable Diseases 12. Investing in Inter-Jurisdictional Emergency Services for Injuries and Disasters 119 References 127 Commentaries and Insights A. “A Commentary on the Philippine Health Sector Review” by John W. Peabody 155 B. “Insights on Philippine Health Sector Performance” by Manuel M. Dayrit 157 C. " Insights on Strengthening the Continuum of Healthcare in the Philippines" 159 by Paulyn Jean B. Rosell-Ubial ACKNOWLEDGMENTS The authors would like to acknowledge with gratitude the following people who made this Report possible. Aleli D. Kraft, Ermi Amor T. Figueroa Yap, Carlos Antonio R. Tan, Jr., Maryann A. Evangelista, Jhiedon L. Florentino, Miharu M. Kimwell, Kathryn U. Roa, Maria Christina C. Langit-Bagro, Jan Aura Laurelle Llevado, Patricia B. Miranda, Faith Obach, Leanne Elaine L. Lu, and Xylee A. Javier, for writing drafts and providing data analysis. The authors also acknowledge the excellent advice, comments, and information given by the following experts and resource persons: Department of Health current and former officials Francisco T. Duque III, Paulyn Jean Rosell-Ubial, Enrique T. Ona, Esperanza I. Cabral, Manuel M. Dayrit, Lilibeth C. David, Mario C. Villaverde, Roger P. Tong-an, Herminigildo V. Valle, Achilles Gerard C. Bravo, Vicente Y. Belizario Jr., Kenneth Y. Hartigan-Go, Teodoro J. Herbosa, Rhais M. Gamboa, Myrna C. Cabotaje, Enrique A. Tayag, Gloria J. Balboa, Elvira S.N. Dayrit, Crispinita A. Valdez, Socorro P. Lupisan, Joyce U. Ducusin, Anna Marie Celina G. Garfin, Ronald P. Law, and Jaime Y. Lagahid; Philippine Health Insurance Corporation officials Ramon F. Aristoza, Jr., Ruben John A. Basa, Johnny Y. Sychua, Francisco Z. Soria, Oscar B. Abadu, Jr., and Walter R. Bacareza; Juan Antonio A. Perez III (Commission on Population); Ella G. Naliponguit (Department of Education); University of the Philippines School of Economics professors Emmanuel S. De Dios, Toby Melissa C. Monsod, Joseph J. Capuno, Stella A. Quimbo, and Maria Socorro Gochoco-Bautista; University of the Philippines Manila College of Medicine professors Carmencita D. Padilla, Ernesto O. Domingo, Agnes D. Mejia, Mary Ann D. Lansang, Antonio L. Dans, Raul V. Destura, and Ma. Asuncion A. Silvestre; Ben S. Malayang III (Silliman University); Philip P. Padilla (University of the Philippines Visayas); Soonman Kwon (Seoul National University); Edwin M. Mercado (Qualimed Healthcare); Diana R. Tamondong-Lachica (QURE Healthcare); and John W. Peabody (University of California San Francisco and QURE Healthcare). The Report likewise gained from the comments and suggestions from partners in the health sector: Susan P. Mercado, Ben Lane, and Lluis Vinyals Torres of the World Health Organization (WHO); Teresita Marie P. Bagasao (UNAIDS); Michael D. Singh (UNFPA); Raoul A. Bermejo III and Johanna S. Banzon (UNICEF); Eduardo P. Banzon (Asian Development Bank); Rouselle F. Lavado and Robert Oelrichs (World Bank); Loyd P. Norella (HIVOS Southeast Asia Hub); Thelma E. Tupasi (Tropical Disease Foundation); Daniel T. Tan (HealthJustice); Ann Claire K. Reyta and Von Ryan Ong (Philippine National Red Cross); Karen K. Klimowski, Bryn A. Sakagawa, Maria Paz G. de Sagun, Yolanda E. Oliveros, Belfrando Cangao Jr., Mariquita J. Mantala, and Maria Kathrina D. Olivarez of the USAID and Cooperating Agencies; and independent experts Gelia T. Castillo, Loraine Hawkins, Lorelie C. De Dios, Ricardo J. Mateo Jr., Maricar G. Bautista, Albert E. Domingo, Julie Marie Christi de la Gente, Ma. Victoria C. Villareal, and Oscar F. Picazo. Technical notes were prepared by Gerry Lyn E. Alcantara, Riza Halili, Jason Alacapa, Consuelo D. Aranas, Bernardino M. Aldaba, Luis Aldaba, Ma. Caroline Belisario, Flory Ann Dycoco, Joyce Encluna, Napoleon S. Espiritu III, Jocelyn I. Ilagan, Maurice Liwag, Marvin Marquez, Allan O. Millar, Nathaniel Orillaza, Immanuel Razon, Dante Salvador, and Rhodora A. Tiongson. Research assistance was provided by Donna Faye Bajaro, Kaye De Ramos, Pamela Crosby, and Danica Galvan. Style and copy editing was done by Victoria V. Quimbo, and cover design and lay-out by Isobel Angelita F. Yap for earlier drafts, and Drink Editorial and Design, Inc. for the final version. i The authors acknowledge the different institutions where parts of the Report were presented to the public: Silliman University School of Public Affairs and Governance Seminar "25 Years of the Philippine Health Care and Delivery and Financing System: A Performance Review" on March 12, 2016 at Silliman University in Dumaguete City where Orville C. Solon presented the sections on Health Care Financing and Service Delivery; Ayala-UPSE Economic Forum “Who Pays and Who Benefits From Health Care Reforms? (A quick look at the last 25 years)” on April 7, 2016 at The Mind Museum Auditorium in Taguig City where Alejandro N. Herrin and Orville C. Solon presented the summary of the section on Health Care Financing. A paper from this presentation was published in a special issue of the Public Policy Journal Volumes XVI and XVII of the University of the Philippines; Pharmaceutical and Healthcare Association of the Philippines (PHAP) Forum “Health for Juan and Juana: Moving Forward with the Philippine Health Agenda” on May 4, 2016 at the Asian Institute of Management in Makati City where Rebecca M. Ramos and Carlo Irwin A. Panelo presented findings from the section on Maternal and Neonatal Health; Philippine Institute for Development Studies 2nd Annual Public Policy Conference “Risks, Shocks, Building Resilience” on September 22, 2016 at the Marco Polo Hotel in Ortigas Center where Alejandro N. Herrin and Orville C. Solon presented the overview and highlights of the Fundamental Challenges and Strategic Responses section; and, Series of Health Sector Review Discussion Fora were also held to consult and validate findings with various regional stakeholders. A total of nine fora were held in the following regions: Ilocos, Albay, Iloilo, Cebu, Leyte, Zamboanga, Northern Mindanao, and Davao. These events were organized in partnership with the UP Visayas Foundation, Inc. and the various Regional Health Research Development Councils supported by the DOH and DOST. Earlier drafts were likewise presented to the USAID Office of Health and other Cooperating Agencies; the DOH Operations, Planning, and Health Services Cluster; and the PhilHealth Executive Committee. The authors are grateful for the funding support of the Health Policy Development Program of the UPecon Foundation, Inc. and the USAID Philippines. The contents of this Report are the sole responsibility of the authors. The Report does not necessarily reflect the views of the HPDP, the UPecon Foundation, Inc., the USAID or the US government and the American people. ii ƌĂĨƚĂƐŽĨƉƌŝůϲ͕ϮϬϭϳ Republic of the Philippines Department of Health OFFICE OF THE SECRETARY FOREWORD The Report entitled “The Challenge of Reaching the Poor with a Continuum of Care: A 25-Year Assessment of the Philippine Health Sector”, comes at a timely juncture after two decades since the devolution of the health system and the shift to social health insurance financing.