Data Collection Survey on Social Health Protection System in Kingdom of Cambodia

DATA COLLECTION SURVEY

UNIVERSAL HEALTH COVERAGE

THE PHILIPPINES

DECEMBER 2016

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA)

GLOBAL LINK MANAGEMENT, INC.

16-077

Exchange Rate

US$ 1 = ¥ 104.76

1 Philippine Peso = ¥ 2.16

(JICA Rate in November 2016)

LIST OF ACRONYMS/ABBREVIATIONS

Acronyms/

Abbreviations

Standard Nomenclature

ADB

Asian Development Bank

ANC

Antenatal Care

ANC01

Antenatal Care Package

AOP

Annual Operational Plan

ARMM

Autonomous Region in Muslim Mindanao

BEmONC

Basic Emergency Maternal Obstetrics and Newborn Care

BHS

Barangay Health Station

BHW

Barangay Health Worker

BMC

Bicol Medical Center

BRTTH

Bicol Regional Training and Teaching Hospital

CAR

Cordillera Administrative Region

CCT

Conditional Cash Transfer

CEmONC

Comprehensive Emergency Maternal Obstetrics and Newborn Care

CHT

Community Health Team

CHTF

Common Health Trust Fund

Camarines Sur

DBM

Department of Budget and Management

DHS

Demographic and Health Survey

DMO

Development Management Officer

DOF

Department of Finance

DOH

Department of Health

DSWD

Department of Social Welfare and Development

European Union

EVRMC

Eastern Visayas Regional Medical Center

FBD

Facility-based Delivery

FGD

Focus Group Discussions

FHSIS

Field Health Service Information System

FIES

Family Income and Expenditure Survey

GDP

Gross Domestic Product

GIDA

Geographically Isolated and Disadvantaged Areas

GNI

Gross National Income

GSIS

Government Service Insurance System

HMO

Health Maintenance Organization

ILHZ

Inter-Local Health Zone

IRA

Internal Revenue Allotment

Information and Technology

I3QUIP

The Impact of Incentives and Information on Quality and Utilization in

Primary Care

JICA

Japan International Cooperation Agency

KII

Key Informant Interview

KOICA

Korea International Cooperation Agency

Kalusugan Pangkalahatan

LGC

Local Government Code 1991

IMR

Infant Mortality Rate

LGU

Local Government Unit

LHSD

Local Health Support Division

LIPH

Local Investment Plan for Health

MCH

Maternal and Child Health

Acronyms/

Abbreviations

Standard Nomenclature

MCP

Maternal Care Package

MDGs

Millennium Development Goals

MDR

Medical Data Record

MMR

Maternal Mortality Ratio

MNCHN/FP

Maternal, Neonatal, Child Health and Nutrition/ Family Planning

MNDR

Maternal and Newborn Death Review

MSW

Medical Social Worker

NBB

No Balance Billing

NCP

Newborn Care Package

NDHS

National Demographic and Health Survey

NEDA

National Economic and Development Authority

NGO

Non-Governmental Organization

NHIP

National Health Insurance Program

NHTS-PR

National Household Targeting System for Poverty Reduction

NSD

Normal Spontaneous Delivery

OBGYN

Obstetrics and Gynecology

ODA

Official Development Assistance

PCB1

Primary Care Benefit 1

PCPT

Per Capita Poverty Threshold

PhilHealth

The Philippine Health Insurance Corporation

PHRD

Policy and Human Resources Development

Poverty Incidence

PMRF

PhilHealth Member Registration Form

PMT

Proxy Means Test

PNC

Postnatal Care

POC

Point of Care

PSPI

Population Services Philipinas, Inc.

PRISM2

The Private Sector Mobilization for Family Health Project – Phase 2

PSA

Philippine Statistics Authority

RHMPP

Rural Health Midwives Replacement Program

RHU

Rural Health Unit

SAEs

Small Area Estimates

SBA

Skilled Birth Attendant

SDGs

Sustainable Development Goals

SDN

Service Delivery Network

SSS

Social Security System

SSV

Supportive Supervision

TBA

Traditional Birth Attendant

TCL

Target/ Client List

TseKaP

Tamag Serbisyo para sa Kalusugan ng Pamilya

UHC

Universal Health Coverage

UNFPA

United Nations Population Fund

UNICEF

United Nations Children’s Fund

USAID

United States Agency for International Development

WHO

World Health Organization

ZFF

Zuelling Family Foundation

iii

DATA COLLECTION SURVEY

ON UNIVERSAL HEALTH COVERAGE

IN THE PHILIPPINES

TABLE OF CONTENTS

List of Acronyms/Abbreviations ................................................................................................ i

Table of Contents ...................................................................................................................... iii

Attachments ................................................................................................................................v

List of Figures, Tables and Boxes ..............................................................................................v

Executive Summary ...................................................................................................................1

Chapter 1 Overview of the Survey ..........................................................................................2

1-1 Background ...................................................................................................................2

1-2 Objectives .....................................................................................................................3

1-3 Scope of the Survey ......................................................................................................3

1-4 Survey Areas .................................................................................................................4

1-5 Methodology .................................................................................................................5

(1) Literature review ...................................................................................................5

(2) Field data collection ..............................................................................................5

1-6 Survey Team .................................................................................................................8

1-7 Survey Schedule ............................................................................................................8

Chapter 2 Socio-Economic Situation in the Philippines ...................................................... 10

2-1 Geography, Ethnicity and Religion ............................................................................. 10

2-2 Population Statistics and Future Projections ............................................................... 10

2-3 Poverty and Economic Disparity ................................................................................. 13

2-4 Industrial Structure and Labor Market ........................................................................ 15

Chapter 3 Overview of the Health Sector ............................................................................ 16

3-1 Health System with a Focus on Maternal and Child Health ........................................ 16

(1) Health Governance ............................................................................................. 16

(2) Health Policies .................................................................................................... 17

(3) Health Financing ................................................................................................. 20

(4) Health Facilities and MCH Service Delivery ...................................................... 31

(5) Health-related Information .................................................................................. 33

3-2 Maternal and Child Health Conditions ........................................................................ 35

(1) Maternal conditions ............................................................................................ 35

(2) Child mortality .................................................................................................... 36

(3) Teenage Pregnancy ............................................................................................. 36

3-3 Assistance of Development Partners ........................................................................... 37

(1) Development Partners in the Philippine Health Sector ....................................... 37

(2) Trends of the Assistance by Development Partners in the Philippine Health

Sector .................................................................................................................. 38

(3) Details of Assistance by Development Partners .................................................. 39

Chapter 4 National Health Insurance Program (NHIP) – Overview and Utilization ............ 51

4-1 Current Framework of NHIP ....................................................................................... 51

4-2 PhilHealth ................................................................................................................... 51

4-3 Goals for the Philippine Health Agenda ...................................................................... 52

4-4 Membership Category ................................................................................................. 52

4-5 Enrollment Procedures ................................................................................................ 54

4-6 Premium Contributions ............................................................................................... 55

4-7 Payment Mechanisms .................................................................................................. 56

4-8 Benefit Packages ......................................................................................................... 57

(1) Inpatient Benefit Package ................................................................................... 57

(2) Outpatient Benefit Package ................................................................................. 58

(3) Z Benefit Package ............................................................................................... 59

(4) MDG related package ......................................................................................... 60

4-9 Claim Procedures ........................................................................................................ 62

4-10 Accreditation Processes............................................................................................... 63

(1) Health Facilities .................................................................................................. 63

(2) Professionals ....................................................................................................... 64

4-11 Funding for PhilHealth ................................................................................................ 64

4-12 Cross Subsidy among PhilHealth members ................................................................. 65

4-13 Enrollment and Utilization .......................................................................................... 66

(1) Population Coverage ........................................................................................... 66

(2) NHIP Utilization ................................................................................................. 67

4-14 Supporting Indigents ................................................................................................... 67

(1) Facilitating Enrollments for Indigent Members .................................................. 67

(2) No Balance Billing Policy................................................................................... 68

(3) Point-of-Care Enrollment Program ..................................................................... 69

(4) Conditional Cash Transfer .................................................................................. 70

Chapter 5 Maternal and Child Health Services in Bicol and Eastern Visayas Regions ... 73

5-1 Bicol Region (Region V) ............................................................................................. 73

(1) Regional Profile .................................................................................................. 73

(2) Overview of Study Sites ..................................................................................... 75

(3) Study Findings .................................................................................................... 76

5-2 Eastern Visayas (Region VIII) ..................................................................................... 87

(1) Regional Profile .................................................................................................. 87

(2) Field Study .......................................................................................................... 91

(3) Study Findings .................................................................................................... 93

Chapter 6 Good Practices and Challenges of JICA Projects ............................................ 107

6-1 Surveyed Projects ...................................................................................................... 107

6-2 Interview Sites........................................................................................................... 107

6-3 Survey Findings ........................................................................................................ 108

(1) Good Practices .................................................................................................. 108

(2) Challenges ........................................................................................................ 111

Chapter 7 Recommendations for JICA’s Future Assistance ............................................ 113

7-1 Points to be Considered ............................................................................................. 113

7-2 Recommendations for JICA’s future activities .......................................................... 113

(1) Access to Quality Essential Health-Care Services ............................................ 113

(2) Financial Risk Protection .................................................................................. 116

7-3 Project Sites .............................................................................................................. 118

7-4 Enhancement of Project Up-scaling Mechanism ....................................................... 118

ReferenceS 120

ATTACHMENTS

1. The Schedule of the First Field Survey (Manila) ....................................................... A-1

2. The Schedule of the Second Field Survey (Bicol) ...................................................... A-2

3. The Schedule of the Second Field Survey (CAR & Eastern Visayas) ........................ A-3

4. The Schedule of the Third Field Survey (Manila) ...................................................... A-5

5. The LGU Health Score Cards .................................................................................... A-6

6. Family Assessment Form ........................................................................................... A-8

LIST OF FIGURES, TABLES AND BOXES

CHAPTER 1

FIGURE 1- 1 MAP PF THE PHILIPPINES ......................................................................................... 4

FIGURE 1- 2 THE WORK FLOW OF THE DATA COLLECTION SURVEY ON UHC IN THE PHILIPPINES9

TABLE 1- 1 SCOPE OF THE SURVEY .............................................................................................. 4

TABLE 1- 2 SELECTION CRITERIA OF THE FIELD DATA COLLECTION TAGET AREAS ...................... 5

TABLE 1- 3 LIST OF DATA TO BE REVIEWED DURING THE SURVEY................................................ 6

TABLE 1- 4 LIST OF KEY INFORMANTS DURING THE FIELD DATA COLLECTION ............................ 8

TABLE 1- 5 SURVEY TEAM MEMBERS ........................................................................................... 8

CHAPTER 2

FIGURE 2- 1 POPULATION PYRAMID OF THE PHILIPPINES, 2015 (IN THOUSANDS) ....................... 11

FIGURE 2- 2 NATIONAL AND REGIONAL POPULATION IN THE PHILIPPINES (2000-2015) ............ 11

FIGURE 2- 3 TRENDS OF POVERTY HEADCOUNT RATIO AT NATIONAL POVERTY LINES (% OF

POPULATION) IN ASEAN COUNTRIES IN 1997-2014 ............................................................. 14

FIGURE 2- 4 TRENDS OF POVERTY GAP AT NATIONAL POVERTY LINES (%) IN ASEAN COUNTRIES

IN 1997-2012 ...................................................................................................................... 14

FIGURE 2- 5 TRENDS OF GINI INDEX (WORLD BANK ESTIMATE) IN SOUTHEAST ASIAN

COUNTRIES IN 1981-2012 .................................................................................................... 15

CHAPTER 3

FIGURE 3- 1 HEALTH GOVERNANCE STRUCTURE IN THE PHILIPPINES ........................................ 16

FIGURE 3- 2 HEALTH EXPENDITURES, TOTAL (% OF GDP) ........................................................ 21

FIGURE 3- 3 OUT-OF-POCKET HEALTH EXPENDITURE (% OF TOTAL HEALTH EXPENDITURE ON

HEALTH) ............................................................................................................................. 21

FIGURE 3- 4 2014 HEALTH EXPENDITURES BY FACTORS OF HEALTH CARE PROVISIONS .............. 22

FIGURE 3- 5 2014 HEALTH EXPENDITURES BY HEALTH SERVICES AND HEALTH FINANCING

SCHEMES (IN MILLION PESOS) .............................................................................................. 22

FIGURE 3- 6 HEALTH EXPENDITURES BY INCOME QUINTILE GROUP: THE PHILIPPINES,

2012-2014 (IN MILLION PESOS) ........................................................................................... 23

FIGURE 3- 7 HEALTH EXPENDITURES BY INCOME QUINTILE GROUP AND HEALTH FINANCING

SCHEMES: THE PHILIPPINES, 2012-2014 (IN MILLION PESOS) ............................................... 23

FIGURE 3- 8 HEALTH EXPENDITURES BY DISEASE GROUPS AND HEALTH FINANCING SCHEMES:

THE PHILIPPINES, 2014 (IN MILLION PESOS) ......................................................................... 24

FIGURE 3- 9 HEALTH EXPENDITURES BY SPECIFIC DISEASE GROUPS AND HEALTH FINANCIAL

SCHEMES: THE PHILIPPINES, 2014 (IN MILLION PESOS) ........................................................ 25

FIGURE 3- 10 BUDGET AND BREAKDOWNS OF HEALTH BUDGET, 2011-2015 (IN PESOS) ............ 26

FIGURE 3- 11 REVENUE SOURCES AND FLOWS WITHIN THE PUBLIC HEALTH SYSTEM IN THE

PHILIPPINES ........................................................................................................................ 31

FIGURE 3- 12 TRENDS OF TOTAL FERTILITY RATE AND THE TEENAGE FERTILITY OUT OF TOTAL

FERTILITY RATE FROM 1973 TO 2013 IN THE PHILIPPINES .................................................... 37

vii

FIGURE 3- 13 DONOR CONTRIBUTIONS IN PHILIPPINE HEALTH SECTOR AS OF THE END OF

DECEMBER 2015 .................................................................................................................. 38

FIGURE 3- 14 AREAS OF ASSISTANCES BY DONORS AS OF THE END OF DECEMBER 2015 .............. 38

FIGURE 3- 15 DOH BUDGETS AND AMOUNT OF DONOR ASSISTANCES (1998-2016).................. 39

TABLE 3- 1 20 HIGH POVERTY SITES ......................................................................................... 20

TABLE 3- 2 HEALTH FINANCING IN THE PHILIPPINES ................................................................. 20

TABLE 3- 3 DISTRIBUTION OF SIN TAX INCREMENTAL REVENUE IN FY 2016 DOH BUDGET

PROPOSAL ........................................................................................................................... 27

TABLE 3- 4 IRA DISTRIBUTION VS. ESTIMATED SHARE OF DEVOLVED FUNCTIONS..................... 28

TABLE 3- 5 LOCAL TAXES .......................................................................................................... 29

TABLE 3- 6 2003-2007 CASE STUDIES OF VISAYA AND LUZON: LGU ANNUAL INCOME

BREAKDOWNS...................................................................................................................... 29

TABLE 3- 7 PUBLIC HEALTH FACILITIES ...................................................................................... 31

TABLE 3- 8 BASIS FUNCTIONS OF HEALTH FACILITIES................................................................ 32

TABLE 3- 9 MAJOR MCH SERVICES BY VARIOUS HEALTH FACILITIES ........................................... 32

TABLE 3- 10 TARGET REGIONS AND PROVINCES FOR THE USAID ASSISTED MNCHN/FP

PROGRAMS .......................................................................................................................... 42

BOX 3- 1 PHILIPPINES HEALTH AGENDA 2016-2022 ................................................................. 18

BOX 3- 2 THE 10-POINT SOCIOECONOMIC AGENDA OF PRESIDENT DUTERTE ........................... 19

CHAPTER 4

FIGURE 4- 1 ORGANIZATIONAL CHART OF PHILHEALTH ............................................................ 51

FIGURE 4- 2 REIMBURSEMENT FLOWS UNDER CASE RATE FOR PNEUMONIA II (HIGH RISK) ........ 57

FIGURE 4- 3 PREMIUM CONTRIBUTION TO PHILHEALTH BY MEMBERSHIP CATEGORIES (IN PESOS)

........................................................................................................................................... 65

TABLE 4- 1 PHILHEALTH MEMBERSHIP CATEGORY.................................................................... 53

TABLE 4- 2 ENROLLMENT PROCEDURES BY MEMBERSHIP CATEGORY ........................................ 54

TABLE 4- 3 PREMIUM PAYMENT PROCEDURES ........................................................................... 55

TABLE 4- 4 CASE RATE PAYMENT INTRODUCED IN 2011 – CASES AND RATES (IN PESOS) ............ 56

TABLE 4- 5 PRIMARY CARE SERVICE OFFERED UNDER TSEKAP PROGRAM ................................. 58

TABLE 4- 6 OUTPATIENT BENEFIT PACKAGES OFFERED BY PHILHEALTH (OTHER THAN TSEKAP)

........................................................................................................................................... 59

TABLE 4- 7 Z BENEFIT PACKAGE: YEAR OF INTRODUCTION AND CASE RATES (IN PESOS) ........... 59

viii

TABLE 4- 8 CONTRACTED HOSPITALS FOR ELECTIVE SURGERY FOR CORONARY ARTERY BYPASS

GRAPH ................................................................................................................................ 60

TABLE 4- 9 MATERNITY CARE PACKAGE (IN PESOS) ................................................................... 61

TABLE 4- 10 NCB PACKAGE (IN PESOS) ..................................................................................... 62

TABLE 4- 11 OTHER MDG RELATED PACKAGES (IN PESOS) ....................................................... 62

TABLE 4- 12 INSTITUTIONAL PROVIDERS WITH PHILHEALTH ACCREDITATIONS ........................ 64

TABLE 4- 13 NUMBER OF ACCREDITED OUTPATIENT CLINICS, NUMBER AND PERCENTAGE OF

CITIES AND MUNICIPALITIES WITH ACCREDITED OUTPATIENT CLINICS ............................... 64

TABLE 4- 14 PREMIUM CONTRIBUTIONS AND BENEFIT CLAIMS FOR 2015 BY NHIP MEMBERS ... 65

TABLE 4- 15 NUMBER OF COVERED MEMBERS AND COVERAGE RATIO FROM 2010 TO 2015 ....... 66

TABLE 4- 16 NHIP UTILIZATION FROM 2012 TO 2015NHIP ..................................................... 67

TABLE 4- 17 PATIENT CATEGORIES BASED ON THE ABILITY TO PAY AND RESPECTIVE PAYMENT

AMOUNTS ........................................................................................................................... 70

CHAPTER 5

FIGURE 5- 1 TREND OF MATERNAL DEATHS AND MMR IN BICOL ............................................... 74

FIGURE 5- 2 RURAL HEALTH UNIT IN CAMARINES SUR ............................................................. 77

FIGURE 5- 3 BRTTH ................................................................................................................. 79

FIGURE 5- 4 PHILHEALTH BICOL REGIONAL OFFICE ................................................................. 80

FIGURE 5- 5 BARANGAY HEALTH STATION IN CAMARINES SUR ................................................... 81

FIGURE 5- 6 GROUP DISCUSSION WITH PREGNANT AND LACTATING WOMEN ............................ 82

FIGURE 5- 7 MCP UTILIZATION AMOUNT IN BICOL (UP TO JUNE IN 2016).................................. 84

FIGURE 5- 8 BARANGAY HOUSES IN CAMARINES SUR ................................................................ 84

FIGURE 5- 9 MMR AND IMR OF EASTERN VISAYAS .................................................................... 88

FIGURE 5- 10 RHU STAFF OF CAN-AVID MUNICIPALITY IN EASTERN SAMAR ............................... 95

FIGURE 5- 11 INTERVIEW WITH MAYOR ..................................................................................... 96

FIGURE 5- 12 BHS DESTROYED.................................................................................................. 96

FIGURE 5- 13 MCP BENEFIT PAYMENTS IN EASTERN SAMAR AND NORTHERN SAMAR ................ 99

FIGURE 5- 14 PHILHEALTH NORTHERN SAMAR OFFICE ........................................................... 99

FIGURE 5- 15 RURAL HOUSEHOLD INTERVIEWED BY THE STUDY ............................................ 102

TABLE 5- 1 PROVINCIAL POPULATIONS IN BICOL REGION (IN THOUSAND) ................................. 73

TABLE 5- 2 NUMBER OF MATERNAL DEATHS AT TERTIARY HOSPITALS ........................................ 74

TABLE 5- 3 PROPORTION OF FBD (%) BY PROVINCE/CITY ......................................................... 74

TABLE 5- 4 IMR BY PROVINCE/CITY........................................................................................... 75

TABLE 5- 5 REGISTERED NUMBER OF PUBLIC AND PRIVATE HOSPITALS (2015-2016) .................. 75

TABLE 5- 6 STUDY SITES AND COMMUNITY INTERVIEWEES ......................................................... 76

TABLE 5- 7 NHIP COVERAGE BY SECTOR AND BY PROVINCE IN BICOL AS OF JUNE 2016 .............. 84

TABLE 5- 8 PROVINCIAL POPULATIONS IN EASTERN VISAYAS REGION (IN THOUSAND) ............... 87

TABLE 5- 9 PROVINCIAL FBD RATES IN EASTERN VISAYAS ......................................................... 88

TABLE 5- 10 REGISTERED HEALTH FACILITIES IN PROVINCES OF EASTERN VISAYAS (AS OF

AUGUST 2, 2016)................................................................................................................. 89

TABLE 5- 11 DELIVERIES AND MATERNAL DEATHS AT EVRMC ................................................. 90

TABLE 5- 12 MATERNAL AND CHILD HEALTH INDICATORS IN NORTHERN SAMAR ...................... 91

TABLE 5- 13 FACILITY BASED DELIVERY IN MUNICIPALITIES OF NORTHERN SAMAR PROVINCE .. 92

TABLE 5- 14 MATERNAL AND CHILD HEALTH INDICATORS IN EASTERN SAMAR.......................... 93

TABLE 5- 15 FACILITY BASED DELIVERY RATE IN EACH MUNICIPALITY OF EASTERN SAMAR

PROVINCE (2012 – JUNE 2016） .......................................................................................... 93

TABLE 5- 16 STUDY SITES AND COMMUNITY INTERVIEWEES ...................................................... 94

TABLE 5- 17 NUMBERS OF NHIP MEMBERS IN EASTERN VISAYAS (AS OF JUNE 2016) ................. 98

BOX 5- 1 STORY OF RHU MEDICAL DOCTOR OUTSIDE CASILI ZONE ....................................... 78

BOX 5- 2 BRTTH LEADERSHIP (STORY OF DOH REGIONAL OFFICER) ..................................... 79

BOX 5- 3 STORY OF PROVINCIAL HEALTH OFFICER ................................................................... 80

BOX 5- 4 HOME DELIVERY CASES .............................................................................................. 83

BOX 5- 5 EXPERIENCE OF A 35-YEAR-OLD WOMAN ................................................................. 103

BOX 5- 6 EXPERIENCE OF A 35-YEAR-OLD WOMAN ................................................................ 105

BOX 5- 7 EXPERIENCE OF A 19-YEAR-OLD WOMAN ................................................................. 105

CHAPTER 6

FIGURE 6- 1 BHS SUPPORTED BY JICA .................................................................................... 108

FIGURE 6- 2 BHS STAFF INTERVIEWED ..................................................................................... 111

FIGURE 6- 3 MCP-ACCREDITED BHS ...................................................................................... 111

TABLE 6- 1 LIST OF INTERVIEWEES .......................................................................................... 108

TABLE 6- 2 OUTCOME OF THE JICA PROJECT IN CORDILLERA ................................................. 109

TABLE 6- 3 OUTCOME OF THE JICA PROJECT IN EASTERN VISAYAS .......................................... 110

CHAPTER 7

FIGURE 7- 1 SDN HOUSEHOLD PROFILING .............................................................................. 117

FIGURE 7- 2 RECOMMENDED JICA NEW PROJECT AND PROJECT UPSCALING MECHANISM ....... 119

EXECUTIVE SUMMARY

Although the national infant mortality rate and under-five mortality rate have declined steadily,

the maternal mortality ratio and neonatal death remain high and regional disparities exist in the

Philippines. In the Philippine Health Agenda 2016-2022, President Duterte announced that the

new administration would guarantee good health for all life stages by setting effective Service

Delivery Networks and providing universal health insurance.

In 1995, the National Health Insurance Program (NHIP) was established, and as of the end of

June 2016, 90 percent of Filipinos were enrolled in NHIP. However, the out-of-pocket

expenditure rate is more than 50 percent, which is higher than many other Southeast Asian

countries. Moreover, the knowledge of the LGU staff, the health care providers and the people

is still limited and utilization rate remains low at 12 percent. The government budget increased

substantially in 2014 due to increased tax revenue from the Sin Tax Reform Law of 2012 and

about 40 percent of the indigent and near-indigent population are now sponsored by the national

government. Nonetheless, the total health expenditure for the richest quintile is more than twice

as much as that of the poorest quintile. The total health expenditure as a percentage of the Gross

Domestic Product (GDP) in the Philippines is lower than most developed countries, however,

comparable to other Southeastern Asian countries.

The Philippine health system is devolved and public health service providers are primarily local

government units (LGUs). The public health services are financed by central government

subsidy and the LGU budget. The LGU budget consists of local government tax revenues, user

fees at health facilities, and payments from health insurance corporations. Health service quality

highly depends on leadership of the executives of LGUs. Functional health service networks are

indispensable particularly for emergency obstetric care. However, coordination between the

primary health facilities and the referral hospitals within the multiple LGUs has been a

challenge in the devolved Philippine health system.

While institutional delivery has been increasingly popular in the Philippines, quite a few women

still prefer home delivery. There are geographical and cultural factors that affect their

preference; however, the important factor is financial. When a woman delivers at a facility, she

has to pay for medicine not in stock, some examinations, transportation fees, food for the

attendant family members, payment of the child care-takers, and loss of income while

hospitalized. These expenditures are a huge burden on poor families.

The survey team would recommend JICA to pursue the new technical assistance project, “UHC

enhancement in the MCH services” with two approaches: improved access to quality essential

health-care services and financial risk protection. Furthermore, a mechanism to fully up-scale

the good results of the project to the entire country should be also sought in the new project.

Chapter 1 Overview of the Survey

1-1 Background

The Aquino administration launched the national Universal Health Care policy (Kalusugan

Pangkalahatan, known as KP) in December 2010 to provide every Filipino with affordable and

quality health services particularly the most vulnerable and remote populations through three

strategic goals: 1) financial risk protection, 2) improved access to quality hospitals and health

care facilities, and 3) the attainment of health-related Millennium Development Goals (MDGs).

The first goal, financial risk protection, is intended to insure all citizens through the

implementation of the National Health Insurance Program (NHIP) by the Philippine Health

Insurance Corporation (PhilHealth).

The new President Duterte recently introduced the Philippine Health Agenda 2016-2022 with

the theme “All for Health towards Health for All.” The Agenda aims at attaining Health-Related

Sustainable Development Goal (SDG) Targets, Financial Risk Protection, Better Health

Outcomes and Responsiveness, and guarantees (1) All Life Stages & Triple Burden of Disease,

(2) Service Delivery Network, and (3) Universal Health Insurance.

According to PhilHealth, 92,624,502 people or 90 percent of the total population

had become

eligible beneficiaries of the NHIP by the end of June 2016 and the enrollment rate has been

increasing somewhat.

Since the Sin Tax Law (RA 10351) was passed in December 2012, the

increased tax revenue has enabled many of poor families to be enrolled as indigent members.

On the other hand, household out-of-pocket spending has increased by 150 percent from 2000 to

2012.

Although the out-of-pocket spending rate out of the total health expenditures has been

decreasing lately, household out-of-pocket spending was still as high as 44 percent, and NHIP’s

utilization rate

remains low at 12 percent as of December 31, 2015.

In addition, it is reported

that 7.7 percent of the households experienced catastrophic health expenditure in 2012 and the

proportion had increased three-fold from 2000.

6,7

This data reveals that NHIP enrollment has

not necessarily resulted in the improvement of access to health services and financial risk

protection.

On the basis of the Philippine 2015 Population Census, the total population of the Philippines as of

August 1, 2015 is 100,981,437.

PhilHealth. (2016). Stats and Charts, December 31, 2015.

Bredenkamp C. & Buisman L. R. (2016).

Utilization rate = unique member claims reimbursed/ total eligible members

PhilHealth. (2016). Stats and Charts, December 31, 2015.

ibid

Bredenkamp C. & Buisman L. R. (2016).

The government of Japan stated promotion of universal health coverage (UHC) as a vision of

Japan’s Strategy on Global Health Diplomacy in 2013. The government also declared that Japan

would take the lead in addressing global challenges including UHC, formulating international

goals and guidelines, and making active efforts to achieve the goals in the Development

Cooperation Charter in 2015.

Japan International Cooperation Agency (JICA) has been providing assistance to the Philippines

for the improvement of maternal and child health (MCH) especially in remote and poor areas,

such as the Cordillera Administrative Region and Eastern Visayas Region. While the evidence

has shown that the JICA projects have improved the MCH service delivery in the target areas, it

is suggested that mothers are still dying in childbirth due to personal, family and community

factors as well as healthcare system factors that hinder their accessibility to health services.

order for JICA to continue the efforts of MCH development in the context of the new

Sustainable Development Goal (SDG) 3, aiming at reduction of maternal and neonatal mortality

and improved access to sexual and reproductive health-care services, and start contributing to

the new administration’s health agenda, JICA dispatched the data collection survey team to

clarify current issues affecting access to MCH services, particularly for the poor, and to explore

JICA’s future assistance in the Philippines to promote UHC in the area of MCH.

1-2 Objectives

The data collection survey had the following objectives:

1) To understand the current status of NHIP implementation in the Philippines and identify

issues preventing access to basic health services with a particular focus on MCH services

for the poor; and

2) To identify possible areas for JICA’s future assistance in strengthening MCH services and

promoting UHC in the Philippines.

1-3 Scope of the Survey

Based on the situation analysis and objectives described earlier, data collection activities of the

survey were undertaken within the scope described in Table 1- 1.

Saniel, O. P. & Bermudez, A. N. C. (2016, August). Why do mothers die? A Maternal Death Review

in Camarines Norte.

Table 1- 1 Scope of the Survey

1-4 Survey Areas

The JICA survey team reviewed the overall status of UHC

and MCH efforts of the Philippines in Manila, and drew

lessons learned from the currently conducted MCH project

in the Cordillera Administrative Region (CAR).

Moreover, the Bicol Region and Eastern Visayas Region

were selected as field data collection sites based on the

following criteria (see Table 1- 2):

 Unsuccessful MCH indicators including facility- based

delivery (FBD), antenatal care (ANC) from skilled

providers and postnatal care (PNC) in the first two days

after birth according to National Demographic and

Health Survey (NDHS) 2013

 20 High Poverty Sites announced by the Duterte

Administration as priority provinces

 High ratio of geographically isolated and

disadvantaged area (GIDA), according to the

Department of Health (DOH)

 Large population

 Accessible from Manila

 Acceptable security level based on JICA’s standards

(1) Heath sector analysis

Status and issues concerning the overall health sector especially MCH

Regional progress in achieving MCH indicators

Status of health system at regional level

Donor assistance

Health sector priorities under the new administration

(2) Status of basic health service provision and access for the poor through the NHIP

Basic information about the NHIP

Size of population covered by the NHIP

Health services covered by the NHIP

Proportion of costs covered by the NHIP

(3) Analysis of factors affecting access to health services particularly economic access

Systems of DOH and PhilHealth to address the issue of economic access

Situation of out-of-pocket health expenditure paid by pregnant women

Implementation status of the No Balance Billing Policy at health facilities

(4) Suggestion of JICA’s future cooperation program

Means of transportation and transportation fees for pregnant women’s access and referral

to health facilities including hospitals, RHUs and BHS

Psychological barriers for pregnant women at the time of referral to health facilities

including hospitals, RHUs and BHS

Level of awareness of patients and service providers on the MCH service package and

primary care benefits

Figure 1- 1 Map pf the Philippines

Table 1- 2 Selection Criteria of the Field Data Collection Target Areas

Region

2015

Population

１

FBD

ANC

PNC

GIDA(％)

High

Poverty

Sites

％

Rank

％

Rank

％

Rank

Mimaropa - 4B

2,963,360

―

Soccksargen - 12

4,545,276

〇

Zamboanga Peninsula - 9

3,629,783

〇

Northern Mindanao - 10

4,689,302

〇

Caraga - 13

2,596,709

9.5

―

Cagayan Valley - 2

3,451,410

―

Bicol Region - 5

5,796,989

9.5

〇

Eastern Visayas - 8

4,440,150

〇

Davao Region - 11

4,893,318

〇

10.

Western Visayas - 6

4,477,247

〇

11.

Calabarzon - 4A

14,414,774

〇

12.

Ilocos Region - 1

5,026,128

〇

13.

Central Luzon - 3

11,218,177

―

14.

Central Visayas- 7

6,041,903

〇

15.

CAR

1,722,006

〇

Source:

The Philippine Population Census (2015),

National Demographic and Health Survey (2013),

Bureau of Local Health Development, DOH,

DOH

1-5 Methodology

The survey consisted of a literature review and field data collection to derive situation analysis

and strategic recommendations for JICA’s future assistance in the Philippines:

(1) Literature review

Existing academic research papers and reports by government, donors and

non-governmental organizations (NGOs) on the subjects mentioned in Table 1- 1 were

collected and analyzed throughout the survey period.

(2) Field data collection

The JICA survey team conducted interviews and collected materials at the Philippine

Government offices, including the Department of Health (DOH), PhilHealth, the

Department of Social Welfare and Development (DSWD), the Department of Interior and

Local Government (DILG) and the Philippine Statistics Authority (PSA), and development

partners at the national level. At the sub-national level, the survey team collected

information through key informant interviews (KIIs) and focus group discussions (FGDs)

at the DOH/PhilHealth Regional Offices, other government offices, local government units

(LGUs), health facilities, NGOs, community members and any other relevant parties.

National Capital Region and ARMM are not included in the table as they are not likely to be JICA

project target sites. NIR is also not included as it was newly created in 2015.

Table 1- 3 shows categories and sub-categories, sources and collection methods of data

collected in the survey.

Table 1- 3 List of Data to be Reviewed During the Survey

Data Category

Data Sub-Category

Data Source

Data

Collection

Method

Status and issues of

the health sector

especially MCH

 Overview of the health sector

 Achievements and challenges

pertaining to MCH

 Online

 Statistical data

 Japanese experts

 Desk

review

 KII

Regional Progress in

achieving MCH

indicators

 MMR

 IMR

 MCH service utilization rates

 Online

 Statistical data

Status of health

system at regional

level

 System of health service provision

 Human resources

 Budget

 Number of NHIP-accredited facilities

 Online

 Statistical data

 Japanese experts

Donor assistance

 Status of assistance in health financing

 Status of assistance in MCH

 Status of assistance in health system

 Online

 Japanese experts

New administration’s

health sector priorities

 Priority issues on MCH

 Other priority issues on health

 Online

 Japanese experts

Basic information

about the NHIP

 Organization and structure

 Financial resources and budget

 Payment mechanisms

 Accreditation system

 Awareness-raising activities

 Online

 DOH and PhilHealth

 Experts

 Desk

review

 KII

Size of population

covered by the NHIP

 Enrollment and utilization rates of

each program (particularly for

indigents)

 Online

 DOH and PhilHealth

 Beneficiaries

including indigents

 Desk

review

 FGD

 KII

 Enrollment rates in each region

 DOH and PhilHealth

 Desk

review

 KII

 Reasons for not enrolling

 Community members

not enrolled in the

NHIP

 FGD

 KII

 Characteristics of NHIP populations

 PhilHealth

 KII

Health services

covered by the NHIP

 Details of benefits and packages

 Online

 PhilHealth

 Desk

review

 KII

Proportion of costs

covered by the NHIP

 Details of out-of-pocket spending

 DOH and PhilHealth

 NHIP members

 Details of costs covered by LGUs

 DOH/LGU and

PhilHealth

 Health facilities

 Measures for indigents not enrolled in

the NHIP

 Health facilities

 PhilHealth

 Indigents who are not

enrolled in the NHIP

 Desk

review

 FDG

 KII

Data Category

Data Sub-Category

Data Source

Data Collection

Method

Means of

transportation and

transportation fees

for pregnant

women’s access and

referral to health

facilities

 Distance and conditions of

infrastructure between facilities at

different levels

 DOH/LGU

 Healthcare

providers/BHWs

 Pregnant and

lactating women

 Barangay councilors/

Chairmen

 Donors/NGOs

 PhilHealth

 Community members

 Desk review

 KII

 FGD

 Transportation options and time

required

 Transportation costs and household

income sources/levels

 Existing transportation support by

government/donors

Psychological

barriers for pregnant

women at the time of

referral to health

facilities

 Images/perceptions of health facilities

and staff

 DOH/LGU

 Healthcare providers/

BHWs

 Pregnant and

lactating women

 TBAs

 Traditional leaders

 Donors/NGOs

 Actual experiences at or feedback on

health facilities (including what they

heard from families and friends)

 Determining factors for referral

 Household decision-making on referral

 Coping strategies when referral is not

utilized

DOH and

PhilHealth’s systems

to address the issue

of economic access

 DOH and PhilHealth’s measures to

address the issue

 Online

 DOH and PhilHealth

 Community members

 DOH’s measures to improve economic

access to health services other than the

NHIP (such as through social security

and anti-poverty systems)

 Online

 DOH and PhilHealth

 Desk review

 KII

 DOH’s systems and mechanisms on

referral and emergency transport

 LGU’s systems to support

transportation fees

 DOH/LGU

 KII

 Details of PhilHealth’s benefits and

packages (in relation to economic

access)

 PhilHealth

 Desk review

 KII

Out-of-pocket

expenses paid by

pregnant women

 Fees paid at health facilities for ANC,

delivery and PNC services

 Women who gave

birth in the past year

 DOH and PhilHealth

 Health facilities

 KII

 FGD (during

PNC and at

community)

 Reimbursements from the NHIP for

healthcare expenses related to ANC,

delivery and PNC services

 Women who gave

birth in the past year

 PhilHealth

 KII

 FGD (during

PNC and in

community)

Implementation

status of the No

Balance Billing

Policy at hospital

level

 Healthcare providers’ level of

awareness of the No Balance Billing

Policy

 Healthcare providers

 KII

 Implementation status of the No

Balance Billing Policy

 Health facilities

 DOH/LGU

 Patients

 KII

 FGD

Awareness levels of

patients and

healthcare providers

regarding the MCH

service package and

primary care benefits

 Awareness levels of pregnant women

and healthcare providers on the MCH

service package

 Healthcare

providers/BHWs

 Pregnant and

lactating women

 Patients

 Barangay councilors/

Chairmen

 Donors/NGOs

 Awareness levels of patients and

healthcare providers on the primary

care benefits

The key informants interviewed in the survey are listed in Table 1- 4.

Table 1- 4 List of Key Informants During the Field Data Collection

Informants

Government

DOH (national/regional officers)

LGU (provincial/city/municipal health officers)

Healthcare providers at DOH’s

regional/provincial/district/municipal hospitals, medical

centers, RHUs and BHS

BHWs

Barangay Chairmen and Councilors

Community Health Team (CHT)

PhilHealth (national and LGU levels)

DSWD (national/regional/provincial/municipal

officers)

Development

partners

WHO, UNICEF, UNFPA, World Bank, ADB, EU,

USAID

NGOs

Community

Pregnant and lactating women

TBA

Traditional/religious leaders

Patients at health facilities

Community-based organizations/women’s groups

Other

Private hospitals and clinics covered by PhilHealth in

survey areas

Private insurance companies

JICA Office, JICA Experts and the Embassy of Japan

Ambulatory service providers (such as Lifeline Rescue)

Universities and think tanks

1-6 Survey Team

The survey team consists of the members in Table 1- 5.

Table 1- 5 Survey Team Members

Name

Area of work

Affiliation

Ms. Haruyo Nakamura

Team Leader/UHC

Global Link Management, Inc.

Ms. Akiko Hirano

MCH /Health System Analysis

Global Link Management, Inc.

Ms. Nami Takashi

MCH /Needs Analysis

Global Link Management, Inc.

Mr. Shizuma Yokozawa

Health Financing

Deloitte Tohmatsu Financial Advisory LLC

1-7 Survey Schedule

The survey was conducted from July to December 2016. During this period field data

collections were executed in the Philippines for three times. Please see Attachments 1-4 for the

detailed schedules of the first to third field data collections. The work flow of the entire survey

is shown in Figure 1- 2.

Figure 1- 2 The Work Flow of the Data Collection Survey on UHC in the Philippines

Month

Deliverable Tasks in Japan Tasks in the Philippines

JUL

AUG

SEP

OCT

NOV

DEC

・Develop and finalize the inception report

・Desk review on the health sector situation

・Prepare for the field data collection

(1) Preparation

Inception

Report

・Brief JICA Philippines, DOH etc. on the inception report

・Interview DOH, PhiliHealth, donors etc. on the system of health

care and MCH service delivery and access for the poor

(2) First Field Data Collection

・Interview LGUs, health facilities and communities in target

regions (CAR, Eastern Visayas and Bicol Region) on factors

affecting economic access to MCH services

・Analysis and documentation of the first field survey

・Prepare for the second field survey

(4) Second Field Data Collection

Summary

of Results

Final

Report

Reporting to

JICA HQ

(3) Documentation and Preparation

・Discussion with JICA Philippines and DOH on the summary

・Follow-up data collection

(5) Drafting of a Summary of Results from the Field Data Collection

・Finalize the result summary

・Devise JICA’s future assistance

(7) Documentation and Analysis

・Develop a final report

(8) Finalization

Consultation

with JICA HQ

(6) Third Field Data Collection

Chapter 2 Socio-Economic Situation in the Philippines

2-1 Geography, Ethnicity and Religion

The Philippines is an archipelago comprised of 7,107 islands in Southeast Asia. Its terrain is

primarily mountainous with narrow to extensive coastal lowlands. It has a tropical and maritime

climate, characterized by relatively high temperatures, high humidity and abundant rainfall.

Because of its location in the typhoon belt of the Western Pacific, the Philippines experiences

an average of twenty typhoons annually during its rainy season, from June to November. In

addition, the country is along the “Pacific Ring of Fire,” where large number of earthquakes and

volcanic eruptions occur. These factors combine to make the Philippines one of the most

disaster-prone countries on the globe.

According to the 2010 Census of Population and Housing, 92.6 percent of the Filipinos are

Christian, 80.6 percent of which are Roman Catholic, 5.6 percent are Muslim and 0.05 percent

are Buddhist. There are approximately 180 ethnic groups which have their own languages. The

largest linguistic group is Tagalog, which accounts for 24.4 percent of the population. Other

ethnic groups include Cebuano, Ilocano, Hillgaynon (Ilongo), Bisaya, Bicol and

Lineyte-Samarnon (Waray). The official language of the Philippines is Filipino, derived from

Tagalog and English.

2-2 Population Statistics and Future Projections

The total population of the Philippines was 76,506,928 in 2000, 92,337,852 in 2010 and

100,981,437 in 2015 (see Figure 2- 1). The average population growth rate during the period

varies from the highest in Calabarzon Region at 2.85 percent to the lowest in Negros Island

Region at 1.14 percent (see Figure 2- 2).

The population in 2016 is estimated to be

102,250,133 (population growth rate: 1.54 percent, population density: 343 persons per km

)

and projected to continuously increase to 148,260,478 by 2050.

Kwon S. & Dodd R. (Eds.). (2011). The Philippines Health System Review, WHO Health Systems in

Transition.

The Philippine 2015 Population Census.

https://psa.gov.ph/content/highlights-philippine-population-2015-census-population.

Worldometers (www.Worldometers.info) Elaboration of data by United Nations, Department of

Economic and Social Affairs, Population Division. World Population Prospects: The 2015 Revision.

(Medium-fertility variant).

Source: Department of Economic and

Figure 2- 1 Population pyramid of the Philippines, 2015 (in thousands)

Social Affairs, Population Division, United Nations

Figure 2- 2 National and Regional Population in the Philippines (2000-2015)

Source: The Philippine 2015 Population Census. https://psa.gov.ph/content/highlights-philippine-population-2015-census-population.

0 2,000 4,000 6,000

02,0004,0006,000

0-4

10-14.

20-24

30-34

40-44

50-54

60-64

70-74

80-84

Men Women

0 4,000,000 8,000,000 12,000,000 16,000,000

REGION XIII (Caraga)

AUTONOMOUS REGION IN MUSLIM MINDANAO (ARMM)

REGION XII (SOCCSKSARGEN)

REGION XI (DAVAO REGION)

REGION X (NORTHERN MINDANAO)

REGION IX (ZAMBOANGA PENINSULA)

REGION VIII (EASTERN VISAYAS)

NEGROS ISLAND REGION (NIR) 1

REGION VII (CENTRAL VISAYAS)

REGION VI (WESTERN VISAYAS)

REGION V (BICOL REGION)

REGION IV-B (MIMAROPA)

REGION IV-A (CALABARZON)

REGION III (CENTRAL LUZON)

REGION II (CAGAYAN VALLEY)

REGION I (ILOCOS REGION)

CORDILLERA ADMINISTRATIVE REGION (CAR)

NATIONAL CAPITAL REGION (NCR)

TOTAL POPULATION 1-Aug-15 TOTAL POPULATION 1-May-10 TOTAL POPULATION 1-May-00

0 4,000,000 8,000,000 12,000,000 16,000,000

REGION XIII (Caraga)

AUTONOMOUS REGION IN MUSLIM MINDANAO (ARMM)

REGION XII (SOCCSKSARGEN)

REGION XI (DAVAO REGION)

REGION X (NORTHERN MINDANAO)

REGION IX (ZAMBOANGA PENINSULA)

REGION VIII (EASTERN VISAYAS)

NEGROS ISLAND REGION (NIR) 1

REGION VII (CENTRAL VISAYAS)

REGION VI (WESTERN VISAYAS)

REGION V (BICOL REGION)

REGION IV-B (MIMAROPA)

REGION IV-A (CALABARZON)

REGION III (CENTRAL LUZON)

REGION II (CAGAYAN VALLEY)

REGION I (ILOCOS REGION)

CORDILLERA ADMINISTRATIVE REGION (CAR)

NATIONAL CAPITAL REGION (NCR)

TOTAL POPULATION 1-Aug-15 TOTAL POPULATION 1-May-10 TOTAL POPULATION 1-May-00

The proportion of age categories 0-14 years, 15-64 years and 65+ years are 31.9 percent, 63.5

percent and 4.6 percent, respectively, in 2015. The child dependency ratio

is 50.3, the old-age

dependency ratio

is 7.2, and the total dependency ratio is 57.5.

The total fertility rate is

3.04, the under-five mortality rate is 30 per 1,000 live births, and average life expectancy is

estimated to be 68 years.

The total fertility rate is similar to Japan’s in 1951-1952.

Life expectancy

and the

population proportions of 0-14 years and 15-64 years are similar to Japan in 1960; however, the

proportion of people 65+ years is lower than that of Japan in 1960 at 5.7.

Aging is slowly becoming an issue in the Philippines.

The Philippines is forecast to become

an aging society with 7 percent of aged people (65+ years) in 2030-2035 and an aged society

with 14 percent of aged people in 2070-2075. The doubling time

is projected to be 35 to 45

years,

which is much longer than that of Japan at 24 years.

It is predicted that the labor force ratio (15-64 years) will be 66.7 percent in 2055 at the highest

point and then will decrease, while the dependency ratio will be 33.3 percent at the lowest in the

same year and then will increase.

Japan experienced the same transition in the early 1990s.

The child dependency ratio is an age-population ratio of children under the age of 15 and those

typically in the labor force (the productive part). It is used to measure the pressure on the productive

population.

The old-age dependency ratio is an age-population ratio of those over the age of 64, not in the labor

force, and those typically in the labor force (the productive part). It is used to measure the pressure on

the productive population.

The Philippine 2015 Population Census.

https://psa.gov.ph/content/highlights-philippine-population-2015-census-population.

United Nations, Department of Economic and Social Affairs, Population Division. (2015). World

Population Prospects: The 2015 Revision. Volume II: Demographic Profiles.

National Institute of Population and Social Security Research. 2016. Population Statistics.

http://www.ipss.go.jp/syoushika/tohkei/Popular/P_Detail2016.asp?fname=T04-03.htm.

Ministry of Health, Labour and Welfare. Abridged life table.

http://kaiwa-kouza.com/contents/sub/statistics/longevity.html.

Statistics of Japan 2016, Statistics Bureau, Ministry of Internal Affairs and Communications.

http://www.stat.go.jp/data/nihon/02.htm

All the population estimates here are moderate-range estimates.

Number of years required for the proportion of the aged population to move from 7% to 14%. It is an

indicator that shows the speed of aging in each country.

United Nations, Department of Economic and Social Affairs, Population Division. Interactive data of

World Population Prospects, the 2015 Revision. https://esa.un.org/unpd/wpp/.

National Institute of Population and Social Security Research. 2012. Population Statistics.

http://www.ipss.go.jp/syoushika/tohkei/Popular/P_Detail2012.asp?fname=T02-18.htm

United Nations, Department of Economic and Social Affairs, Population Division. Interactive data of

World Population Prospects, the 2015 Revision. https://esa.un.org/unpd/wpp/.

Statistics of Japan 2016, Statistics Bureau, Ministry of Internal Affairs and Communications.

http://www.stat.go.jp/data/nihon/02.htm

In the Philippines, child dependency is currently much higher than old age dependency (child

dependency: 50.3, old-age dependency: 7.2), however, it will become equal in 2090 (both child

dependency and old-age dependency: 31.1) and then old-age dependency will become slightly

higher.

Japan experienced the same transition in the late 1990s.

2-3 Poverty and Economic Disparity

The Gross National Income (GNI) of the Philippines was US$357 billion

in 2015, GNI per

capita was US$3,540,

and the real GDP growth rate has been on average 6 percent from 2010

to 2015. The Philippines is categorized as a “lower-middle-income economy”

by the World

Bank.

In the Philippines, the poverty incidence

was estimated at 21.6 percent in 2015.

Although

the estimate was improved from 2012 at 25.6 percent, another poverty data, the poverty

headcount ratio, has not shown much change in the past decade in the country, while other

Southeast Asian countries, such as Cambodia, Thailand, Vietnam and Laos, have shown

progress (see Figure 2- 3). The Philippines’ poverty headcount ratio is in fact one of the highest

in the region today.

United Nations, Department of Economic and Social Affairs, Population Division. Interactive data of

World Population Prospects, the 2015 Revision. https://esa.un.org/unpd/wpp/.

Statistics of Japan 2016, Statistics Bureau, Ministry of Internal Affairs and Communications.

http://www.stat.go.jp/data/nihon/02.htm

At the time of the US$ market price.

Calculated using Atlas method of the World Bank (Converted to the current US$).

World Bank Open Data. http://data.worldbank.org/

The World Bank’s country classification by income level takes place in July every year and it uses

GNI per capita of the previous years as an indicator. For the current 2017 fiscal year, lower

middle-income economies are defined as those with a GNI per capita, calculated using the World

Bank Atlas method, of between $1,026 and $4,035.”

Poverty incidence is the proportion of people below the poverty line to the total population. The

poverty line refers to the minimum income required to meet food and non-food requirements. In 2015,

a family of five needed at least PhP 9,064, on average, every month to meet both basic food and

non-food needs. Source: Philippine Statistics Authority. https://psa.gov.ph/poverty-press-releases.

Philippine Statistics Authority. (2016). Philippine Poverty Statistics.

https://psa.gov.ph/poverty-press-releases

Figure 2- 3 Trends of poverty headcount ratio at national poverty lines (% of population)

in ASEAN countries in 1997-2014

Source: World Bank. The World Development Indicators

Figure 2- 4 Trends of poverty gap at national poverty lines (%)

in ASEAN countries in 1997-2012

Source: World Bank. The World Development Indicators

Whereas the poverty gap ratio

in 2012 was 5.1 percent, which had slightly improved since

2003, showing that the depth and incidence of poverty in the country has been somewhat

mitigated in the past decade. However, the country’s progress is still minimal as compared with

other Southeastern countries, such as Cambodia, Laos and Vietnam, and the Philippine poverty

gap ratio was second highest among these nations in 2012 (see Figure 2- 4).

The GINI Index, which measures the degree of inequality in the distribution of family income in

a country, shows that income is distributed quite unequally in the Philippines, at the highest

Poverty gap ratio is the mean shortfall of the total population from the poverty line (counting the

non-poor as having zero shortfall), expressed as a percentage of the poverty line. This measure reflects

the depth of poverty as well as its incidence.

1997 2000 2002 2003 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014

Philippines Cambodia Lao PDR Thailand Vietnam

1997 2002 2003 2006 2007 2008 2009 2010 2011 2012

Philippines Cambodia Lao PDR Vietnam

after 1996, and it has not improved over the past three decades. In fact, the Philippines’ family

income is the most unequally distributed in all of Southeast Asia (see Figure 2- 5).

Figure 2- 5 Trends of GINI Index (World Bank estimate)

in Southeast Asian countries in 1981-2012

Source: World Bank. The World Development Indicators

2-4 Industrial Structure and Labor Market

In the Philippines, the composition ratio by industry to GDP in 2014 was as follows:

manufacturing (20.6%), trade (17.7%), agriculture (11.3%), finance (7.8%), and construction

(6.6%). The composition ratio has not changed in the past three decades.

The labor force

(ages 15-64) of the Philippines in 2014 was 41,379,000 people. Among the

labor force, 38,651,000 people were employed and 2,728,000 were unemployed. The

unemployment rate among the labor force is 6.6%.

37, 38

Asia Development Bank 2015. Key Indicators for Asia and the Pacific 2015.

http://www.adb.org/sites/default/files/publication/175162/phi.pdf

All persons who are 15 years old and over and are reported as (1) without work, (2) currently

available for work, and (3) seeking work or not seeking work due to valid reasons.

Proportion of people who are both jobless and looking for a job.

Asia Development Bank 2015. Key Indicators for Asia and the Pacific 2015.

http://www.adb.org/sites/default/files/publication/175162/phi.pdf

1981 1985 1988 1990 1991 1992 1994 1996 1997 1998 1999 2000 2002 2003 2004 2006 2007 2008 2009 2010 2011 2012

Philippines Cambodia Lao PDR Thailand Vietnam

Chapter 3 Overview of the Health Sector

3-1 Health System with a Focus on Maternal and Child Health

(1) Health Governance

The Philippine health system is comprised of five administrative bodies. The Department

of Health (DOH) in the central government is in charge of the development of policies,

regulations and guidelines, and the provision of tertiary health care. The provincial

governments are responsible for secondary health care, and the municipal/city

governments are in charge of primary health care. The general term for a provincial

government and a municipal/city government is a local government unit (LGU). Each

municipality/city is divided into barangays and the barangay health station (BHS) provides

public health services as the closest facility to the people.

In principle, LGU health personnel are employed and deployed by the LGUs. However,

LGU health facilities also have human resources assigned by DOH, such as Development

Management Officers (DMOs) who provide technical assistance to the municipalities, and

monitor and report DOH programs, Nurses and Midwives posted at Rural Health Units

(RHUs) and BHSs.

Figure 3- 1 Health Governance Structure in the Philippines

Source: Global Link Management

There are two types of health service networks in the Philippines, namely Inter Local

Health Zone (ILHZ) and Service Delivery Network (SDN). ILHZ was adopted in the

Philippines based on the District Health System

advocated by World Health

Organization (WHO) in 1986, aiming at promoting coordination between the primary

The means to achieve the end of an equitable, efficient and effective health system based on the

principles of the primary health care (PHC) approach.

DOH

DOH Regional

Offices

Provincial Health

Offices

Municipal/City Health Offices

Barangay

Policy formulation, Guidance, Tertiary

Health Care Providsion: Specialty,

Regional & Training Hospitals

Primary Health Care

Provision: BHS

Secondary & Primary &Health

Care Provision: Minicipality/City

Hospitals, RHU, Infirmary

Secondary Health Care Provision:

Provincial & Distrcit Hospitals

Development

Management Officers

Nurse/ Rural Health

MW Deployment

Program

health facilities and the referral hospitals within the multiple LGUs in order to ensure the

access of communities to better health services. Meanwhile, SDN was announced in

Administrative Order No. 2014-0046 in 2014 during the Aquino Administration as a health

service networking system established by the provincial or municipal government with the

participation of the private sector. DOH reportedly planned to redefine the detail roles and

functions of SDN in 2016 and scale up its implementation nationwide.

DOH uses the LGU Health Score Cards with 30 indicators (see Attachment 5) as a tool of

Monitoring & Evaluation on Equity & Effectiveness for each local health system. DOH

requires LGUs to develop a three-year plan called the Local Investment Plan for Health

(LIPH). The LIPH was introduced in 2014 to strengthen local health planning with

significant consideration for building the capacities of health managers in the local

government units (LGUs). The Annual Operational Plan (AOPs) is prepared every year of

the planning cycle and the Service Level Agreement is signed. The results of the LGU

Score cards are primarily used for the planning process. For LGUs whose scores of

selected LGU Score Card indicators are positive, performance based grants are provided

by the Bureau of Local Health Development, DOH. The data for LGU Score Cards are

collected by the Department of Interior and Local Government (DILG) staff that have

offices at the municipality/city level.

41,42

(2) Health Policies

Under the Aquino Administration, the Government of the Philippines placed Universal

Health Care (Kalusugan Pangkalahatan, known as KP) as a principle of national health

policy and promoted to achieve the Millennium Development Goals (MDGs).

The new Duterte Administration recently presented the Philippine Health Agenda

2016-2022, as shown in BOX 3- 1.

Interview with the Bureau of Local Health Systems Development, DOH (August 5, 2016).

Interview with the Department of Interior and Local Government (August 1, 2016).

Interview with the Bureau of Local Health Systems Development, DOH (August 5, 2016).

BOX 3- 1 Philippines Health Agenda 2016-2022

~ All for Health towards Health for All ~

Goals:

1. Ensure the best health outcomes for all, without socio-economic,

ethnic, gender and geographic disparities

2. Promote health and deliver healthcare through means that

respect, value and empower clients and patients as they interact

with the health system

3. Protect all families especially the poor and vulnerable against the

high cost of healthcare

Values: Equity, quality, efﬁciency, transparency, accountability,

sustainability and resilience

Guarantees:

1. Population- and individual-level interventions for all life stages

that promote health and wellness, prevent and treat the triple

burden of diseases,

delay complications, facilitate rehabilitation and provide palliation

2. Access to health interventions through functional Service Delivery Networks (SDNs)

***

3. Financial freedom when accessing these interventions through Universal Health Insurance

Strategy:

dvance Quality, Health Promotion and Primary Care

over all Filipinos against Health-Related Financial Risk

arness the Power of Strategic Human Resources for Health Development

nvest in eHealth and Data for Decision-Making

nforce Standards, Accountability, and Transparency

alue All Clients and Patients, especially the Poor and Vulnerable

licit Multi-sectoral and Multi-stakeholder support for Health

All Life Stages refers to services for pregnant women, children, adolescents, adults and older persons.

Triple Burden of Disease pertains to the (1) communicable diseases and neglected tropical diseases, (2)

non-communicable diseases, and (3) problems related to globalization, urbanization and

industrialization, including injuries and mental illness.

***

SDNs 1) consist of primary care networks (PCNs) linked to Level 3 hospitals, 2) ensure well-equipped

and fully-staffed network of health facilities, 3) render services that are compliant with clinical practice

guidelines and 4) practice gatekeeping and utilize telemedicine to expand specialty service.

Source: DOH Ofﬁce of the Secretary & DOH Health Policy Development and Planning Bureau. (2016).

Philippine Health Agenda 2016-2022 Healthy Philippines 2022.

The Philippine government agencies, including DOH, determine their agenda through the

cabinet secretaries for approval of the President based on his 10-point socioeconomic

agenda (see BOX 3- 2). This 10-point agenda is the basis for the Philippine Development

Plan, the country’s multi-sectoral development plan. The Philippine Health Agenda

contributes to numbers 7 and 10 of the 10-point agenda. The Philippine Health Agenda

STRATEGY

GOALS + VALUES

3 GUARANTEES

Service Delivery Network

All Life Stages &

Trip le Burden of Diseases

Universal Health Insurance

2016-2022 will be part of the Philippine Development Plan 2017-2022, under the Chapter

on Social Development.

BOX 3- 2 The 10-point Socioeconomic Agenda of President Duterte

1. Continue and maintain current macroeconomic policies, including fiscal, monetary, and trade

policies.

2. Institute progressive tax reform and more effective tax collection, indexing taxes to inflation.

A tax reform package will be submitted to Congress by September 2016.

3. Increase competitiveness and the ease of doing business. This effort will draw upon successful

models used to attract business to local cities (e.g., Davao) and pursue the relaxation of the

Constitutional restrictions on foreign ownership, except as regards land ownership, in order to

attract foreign direct investment.

4. Accelerate annual infrastructure spending to account for 5% of GDP, with Public-Private

Partnerships playing a key role.

5. Promote rural and value chain development toward increasing agricultural and rural enterprise

productivity and rural tourism.

6. Ensure security of land tenure to encourage investments, and address bottlenecks in land

management and titling agencies.

7. Invest in human capital development, including health and education systems, and match skills

and training to meet the demand of businesses and the private sector.

8. Promote science, technology, and the creative arts to enhance innovation and creative capacity

towards self-sustaining, inclusive development.

9. Improve social protection programs, including the government’s Conditional Cash Transfer

program, to protect the poor against instability and economic shocks.

10. Strengthen implementation of the Responsible Parenthood and Reproductive Health Law to

enable especially poor couples to make informed choices on financial and family planning.

Moreover, the new administration prioritizes the 20 High Poverty Sites (see Table 3- 1) for

development efforts and encourages development partners to provide assistance to the

selected provinces.

Information shared by Chief of Health Planning Division, Health Policy Development and Planning

Bureau, DOH (October 31, 2016).

Table 3- 1 20 High Poverty Sites

Source: Department of Health. (2016). 20 High Poverty Sites.

(3) Health Financing

Table 3- 2 shows the current circumstances surrounding health financing in the

Philippines.

Table 3- 2 Health Financing in the Philippines

Source:

World Population Prospects (2015),

World Development Indicator (2016),

Department of Budget and Management website (2016) and

Philippine Health Accounts Based on the 20111

System of Health Accounts for CY 2012, 2013 and 2014 (2016)

CAR: Apayao

Ilocos Region: Pangasinan

Carabarzon Region: Quezon

Bicol Region: Masbate, Camarines Sur

Western Visayas Region: Negros Occidental, Ilo-ilo

Central Visayas Region: Cebu

Eastern Visayas Region: East Samar, North Samar, North Leyte

Zamboanga Peninsula Region: Zamboanga Del Sur, Zamboanga Del Norte

Northern Mindanao Region: Camiguin

Davao Region: Davao Del Sur

Soccsksargen Region: North Cotabato, Saranggani

ARMM: Sulu, Maguindanao, Lanao Del Sur

1 Macroeconomic Indicator

Population (million)

96.0 97.6 99.1

GDP (100 million US$）

2,501 2,719 2,848

GDP per capita (US$)

2,605 2,787 2,873

2 Government Budget

Total Government Budget (100 million US$）

296 323 363

Total Government Budget as % of GDP 11.8% 11.9% 12.7%

3 Government Budget for Health

Govt Budget for Health (100 million US$）

10.2 12.0 19.0

Govt Health Budget as % of GDP 0.4% 0.4% 0.7%

% of Total Government Budget 3.4% 3.7% 5.2%

4 Government Expenditure on Health

Total Health Expenditure (THE) (100 milllion US$）

108.8 123.8 127.7

THE as % of GDP 4.4% 4.6% 4.5%

5 Disbursement of THE (100 million US$）

Share Share Share

Government 30.8 28.3% 38.0 30.7% 39.5 30.9%

Central Government 11.1 10.2% 15.2 12.3% 12.3 9.6%

LGUs 7.2 6.6% 8.5 6.9% 8.4 6.6%

Social Security 12.5 11.5% 14.3 11.6% 18.8 14.7%

Other Government 0.03 0.03% ― ―

Private Insurance 9.4 8.6% 10.8 8.7% 11.5 9.0%

Other Private Corporation 4.6 4.2% 5.0 4.0% 4.6 3.6%

Out-of-Pocket Expenditure 64.0 58.8% 69.9 56.5% 72.0 56.4%

2012

2013

2014

The substantial government budget increase in 2014 derives from the increased tax income

due to the Sin Tax Reform Law of 2012. From 2012 to 2014, the Social Security budget

steadily increased, while private insurance slightly increased. In 2014, about 30 percent of

total health expenditure was from the Government, 9.6 percent of which was the Central

Government, 6.6 percent LGUs and 14.7 percent Social Security, while 9.0 percent

accounted for private insurance, 3.6 percent for private corporations, and 56.4 percent from

household out-of-pocket expenditure. The total health expenditure as percentage of GDP in

the Philippines is lower than most developed countries; but is comparable to other

Southeastern Asian countries (see Figure 3- 2). The Philippines’ out-of-pocket expenditure

out of the total health expenditure was higher than many Southeast Asian countries from

2000 to 2014 and the proportion has not decreased over the years (see Figure 3- 3).

Figure 3- 2 Health Expenditures, total (% of GDP)

Source: The World Bank. (2016). World Development Indicators.

Figure 3- 3 Out-of-Pocket Health Expenditure

(% of total health expenditure on health)

Source: The World Bank. (2016). World Development Indicators.

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

2000 2010 2014

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

2000 2010 2014

① Health Expenditure

Figure 3- 4 shows the breakdown of health expenditure in 2014. Pharmaceuticals account

for 44.4 percent, the largest portion, followed by compensation of employees, which

accounts for 26.4 percent, and these two categories account for over 70 percent of the total

health expenditures in the Philippines.

Figure 3- 4 2014 Health Expenditures by Factors of Health Care provisions

Source: Philippine Health Accounts Based on the 20111 System of Health Accounts

for CY2012, 2013 and 2014 (2016).

Figure 3- 5 shows Health Expenditures by Health Services and Health Financing Schemes

in 2014. Nearly 200 billion pesos was estimated to have been spent in pharmacies in 2014

and more than 99% of which was paid by household out-of-pocket. Similarly, a relatively

high portion, 82.5 percent, of ambulatory or outpatient health care services were paid by

household out-of-pocket. The high burden on the household out-of-pocket in these

expenditures can be explained by the fact that the NHIP does not cover these costs.

Figure 3- 5 2014 Health Expenditures by Health Services

and Health Financing Schemes (in million pesos)

Source: Philippine Health Accounts Based on the 20111 System of Health Accounts

for CY 2012, 2013 and 2014 (2016).

26.4%

44.4%

14.9%

14.3%

Compensation of exployees Pharmaceuticals

Other materials and services used Unspecified

50000

100000

150000

200000

250000

Government/NHIP Voluntary Insurance Household

Figure 3- 6 shows health expenditures by income quintile groups in the Philippines from

2012 to 2014. Over the three years, the health expenditures of all groups increased,

however, the health expenditure of the richest income group increased the most from 2013

to 2014. Moreover, throughout the three-year period, the lower three income quintile

groups accounted for less than their equal share, while the richest income group accounted

for more than twice its equal share.

Figure 3- 6 Health Expenditures by Income Quintile Group:

the Philippines, 2012-2014 (in million pesos)

Source: Philippine Health Accounts Based on the 20111 System of Health Accounts

for CY 2012, 2013 and 2014 (2016).

Figure 3- 7 Health Expenditures by Income Quintile Group and Health Financing

Schemes: the Philippines, 2012-2014 (in million pesos)

Source: Philippine Health Accounts Based on the 20111 System of Health Accounts

for CY 2012, 2013 and 2014 (2016).

0 50,000 100,000 150,000 200,000 250,000

Philippines

Not Specific

（

top

）

（

bottom

）

2014 2013 2012

0 50,000 100,000 150,000 200,000 250,000

2014

2013

2012

2014

2013

2012

2014

2013

2012

2014

2013

2012

2014

2013

2012

2014

2013

2012

2014

2013

2012

Philippines

Not

Specific

（top）

IV III II

(bottom)

Government／NHIP

Voluntary Insurance Household

Figure 3- 7 shows health expenditures by income quintile groups and health financing

schemes. The overall health expenditures in the Philippines have increased from 2012 to

2014; however, the health financing schemes for the increased amounts differ among the

income quintile groups. For the lowest quintile group, household out-of-pocket payment

has not changed and voluntary insurance has slightly increased, while the government

expenditures, including the National Health Insurance Program (NHIP), has substantially

increased. Although PhilHealth announced that it would increase the Indigent Members to

more than 40 percent of the total population in 2014,

the increase in the government

health expenditures for the second quintile group was not seen. On the other hand, the

government expenditure for higher quintile groups is not as much as the lowest quintile

group, and the level of increase in the government expenditure for the higher quintile

groups over the three years was also minimal. The increase in the higher quintile groups’

health expenditure derives from household out-of-pocket.

Figure 3- 8 Health Expenditures by Disease Groups and Health Financing Schemes:

the Philippines, 2014 (in million pesos)

Source: Philippine Health Accounts Based on the 20111 System of Health Accounts

for CY 2012, 2013 and 2014 (2016).

Figure 3- 8 shows health expenditures by disease groups and health financing schemes.

Expenditures for noncommunicable diseases took the largest share of health expenditures

in 2014 at about one-third, followed by infectious diseases and reproductive health. The

proportion of household out-of-pocket expenditure was generally high, but injuries were

mostly paid by households due to the fact that they are rarely covered by insurance. The

proportion of donor assistance is generally small and limited to infectious diseases and

reproductive health.

PhilHealth. (2014). 2014 Stats and Charts.

0 40000 80000 120000 160000 200000

Others

Non-disease Specific

Injuries

Non-communicable Diseases

Nutritional Deficiencies

Reproductive Health

Infectious Diseases

The Government／NHIP

Donor Voluntary Insurance Household

Figure 3- 9 Health Expenditures by Specific Disease Groups and

Health Financial Schemes: the Philippines, 2014 (in million pesos)

Source: Philippine Health Accounts Based on the 20111 System of Health Accounts

for CY 2012, 2013 and 2014 (2016).

Figure Figure 3- 9 shows health expenditures by specific disease groups and health

financing schemes in 2014. Expenditures for respiratory infections took the largest share

that accounts for 38 percent of the total health expenditures for infectious diseases. The

majority of expenditures for vaccine-preventable diseases came from the government, but

expenditures for other diseases were largely paid by household out-of-pocket. Regarding

reproductive health, the majority of health expenditures for maternal conditions are paid by

health insurance, but the household out-of-pocket payment rates are high for perinatal

conditions due to limited insurance coverage for new-born cares. Among the

non-communicable diseases, the household out-of-pocket rate is highest for endocrine and

metabolic disorders at 81.1 percent.

② Health Budget

[Central Government]

Government health expenditures are funded out of general tax revenues collected by the

Department of Finance (DOF). The DOH and the Philippine Health Insurance Corporation

(PhilHealth) are allotted annual budgets by the Department of Budget and Management

(DBM). The annual process of developing a DOH budget starts with the issuance of the

0 10000 20000 30000 40000 50000 60000 70000 80000 90000 100000

Others

Non-disease specific

Injuries

Other non-communicable diseases

Nephritis

Mental & neurological conditions

Cardiovascular diseases

Endocrine and metabolic disorders

Neoplasms

Unspecified reproductive health conditions

Perinatal Conditions

Maternal Conditions

Other infectious diseases

Vaccine preventable diseases

Neglected tropical diseases

Diarrheal diseases

Respiratory infections

HIV/AIDS, STD, TB & Malaria

Non-communicable

Diseases

Reproductive

Health Infectious Diseases

The government／NHIP

Donor Voluntary insurance Household

budget call and the budget ceilings by DBM around late February to the middle of March.

DOH then prepares the annual budget proposal based on these set ceilings. The DOH

proposal is consolidated into a national expenditure program, along with other line

ministries’ proposals, that is submitted to congress.

In 1991, the management of provincial, district, and municipal hospitals as well as primary

care facilities was transferred to LGUs. However, specialty hospitals, regional and training

hospitals, and sanitaria

were retained under the management of the central DOH. While

DOH-retained hospitals continue to be managed by the central DOH, they are also given

authority to set and collect user fees with a ceiling for mark ups to a maximum of 30

percent of actual cost.

Figure 3- 10 shows the health budget of 2011 to 2015 by the factors of health care

provision. The substantial government budget increase, particularly the budget for health

promotion and preventive medicine, since 2014 derives from the increased tax income due

to the Sin Tax Law of 2012. The reason that only the budget for health promotion and

preventive medicine increased was that health insurance subsidy is included in the budget

for health promotion and preventive medicine, rather than that for curative medicine.

Figure 3- 10 Breakdowns of Health Budget, 2011-2015 (in pesos)

Source: DOH Annual Budget 2011-2015.

The Philippines Health System Review 2011.

Health facilities for the recuperation and treatment of individuals with leprosy.

The Philippines Health System Review 2011.

0 20,000,000 40,000,000 60,000,000 80,000,000 100,000,000

2011

2012

2013

2014

2015

Health Promotion & Preventive Medicine Curative Medicine

Health Administration

Table 3- 3 Distribution of Sin Tax Incremental Revenue

in FY 2016 DOH Budget Proposal

Prescribed

Allocation

Detail of Prescribed Allocation

Allocation

(in billion pesos)

Universal

Health Care

(80%)

Enrollment coverage of the poor (supporting NHIP premium)

31.26

Health policy, regulations, general administration

7.56

Hospital operations

6.41

Health facilities enhancement including capital outlay of

DOH hospitals

5.46

Attainment of MDGs

4.24

Quick response fund

0.51

Health awareness program

0.04

0.06

Subtotal

55.48

Medical

assistance

and facility

enhancement

(20%)

Facility enhancement

7.96

Enhancement of doctors to remote areas

4.16

Medical assistance to indigent patients confined in

government hospitals

1.91

Subtotal

14.03

Total

69.51

100

Source: DOH. Sin Tax Law Incremental Revenue for Health, Annual Report CY 2015.

In December 2012, the reformed Sin Tax Law, which increased taxes on all tobacco and alcohol

products was passed. 85% of the incremental revenue from reformed Sin Tax Law was

earmarked for DOH, 80 percent of which is to be transferred to PhilHealth in order to promote

the initiative of Universal Health Care under the previous administration (promotion of NHIP,

achievement of MDG goals, increasing health awareness, etc.). The remaining 20% is to be used

to finance medical assistance and facility enhancements.

Table 3- 3 summarizes the allocation

of the Sin Tax increments in the 2016 DOH budget proposal. DOH’s budget increase

attributable to Six Tax increment revenue was first seen in 2014.

[Local government Units]

Provincial and district hospitals are funded out of the provincial government’s budget

while municipal/city hospitals are financed by the municipal/city budgets. Financial

management is determined primarily by the local chief executive and the local hospital

chief.

Local health expenditures are funded from a variety of sources, including the Internal

Revenue Allotment (IRA) from the national government, the LGU’s own budgets, user

fees, transfers from DOH, PhilHealth, congressional discretionary funds, such as Priority

Development Assistance Funds and the Philippine Charity Sweepstakes Office, and the

DOH. (2016). Sin Tax Law Incremental Revenue for Health, Annual Report CY 2015.

The Philippines Health System Review 2011.

Bottoms-up Budgeting, initiated by the Aquino administration, to provide additional

assistance to poor LGUs in class 4 to 6.

50,51

The health financing system is complex and

uncoordinated.

The LGU budget calendar is governed by a Local Budget Memorandum and typically

issued in the middle of June by DBM. Following the process prescribed by DBM, each

local health office and facility prepares a medium-term strategic plan and an annual health

plan to be submitted for review.

These plans are meant to be consistent with the LIPH.

DBM issues the budget notification stating the Internal Revenue Allotment (IRA), which is

part of the tax revenue automatically released by the national government to LGUs on a

quarterly basis. The IRA is first subdivided among the different levels of LGUs using the

following distribution: provinces 23 percent, cities 23 percent, municipalities 34 percent,

and barangays 20 percent. The shares for each level of LGU are then allocated horizontally

for provinces, cities and municipalities based on the following formula: population 50

percent, land area 25 percent and equal sharing 25 percent. For barangays, the horizontal

sharing is based on population for 60 percent and equal sharing for 40 percent. However,

past studies have suggested that the formula for distributing the IRA across the different

levels of LGUs has been inconsistent with the distribution of expenditure responsibilities

among the different levels (see Figure 3- 4).

Table 3- 4 IRA Distribution vs. Estimated Share of Devolved Functions

Source: World Bank. (2011). Philippines: Study on Local Service Delivery.

DOH transfers have come through direct subsidies, in-kind transfers, that is public health

commodities such as vaccines, and grants for national programs, such as maternal and

LGUs are divided into income classes according to their average annual income during the previous

four calendar years.

Interview with the Department of Interior and Local Government (August 1, 2016).

World Bank. (2011). Philippines: Study on Local Service Delivery.

Bureau of Local Health Systems Development (BLHSD) DOH & UNICEF. (2015). Local Investment

Planning for Health Handbook on Principles, Guidelines, Procedures, and Processes.

World Bank. (2011). Philippines: Study on Local Service Delivery.

% IRA Share % Share of Devolved Functions

Provinces 23% 46%

Cities 23% 7%

Municipalities 34% 46%

Barangays 20% Undefined

child health. For PhilHealth, transfer comes to health facilities to reimburse the medical

costs of the members

55,56

Table 3- 5 Local Taxes

Source: World Bank. (2011). Philippines: Study on Local Service Delivery.

X Types of local tax assigned to LGUs

* Local tax allocated from a higher LGU to a lower LGU

Table 3- 5 summarizes the various taxes that are assigned to LGUs by Local Government

Code 1991 (LGC). Cities are assigned with the widest range of taxes available, while

provinces and municipalities have either no access to certain tax measures or are required

to share the proceeds with sub-levels of LGUs. Cities are generally allowed higher tax rate

ceilings compared to provinces and municipalities, and their urbanized economies serve as

larger and more dynamic tax bases. As a result, on average, cities rely much less on the

IRA and other transfers compared to municipalities and provinces (see Table 3- 6).

Table 3- 6 2003-2007 Case Studies of Visaya and Luzon:

LGU Annual Income Breakdowns

Source: World Bank. (2011). Philippines: Study on Local Service Delivery.

PhilHealth reimburses health facilities in two checks: 1) addressed to the facility as payment for

procedures and supplies (drugs, medical supplies, laboratory, room and board), and 2) addressed to the

facility chief as payment for professional fees.

World Bank. (2011). Philippines: Study on Local Service Delivery.

ibid

Local Tax Cities Provinces Municipalities Barangays

On Real Property Transfers X X

On Business of Printing and Publication X X

On Franchises X X

On Sand, Gravel, and other Quarry Resources X X

* *

On Amusement Places X X

On Professionals X X

On Delivery Vans Trucks X X

On Real Property X X

* *

On Idle Lands X X

On Businesses X X X

On Community Tax X X *

Provinces Cities Municipalities

IRA & Other Transfers 83.0 43.8 78.7

Own-source Revenues 15.1 53.7 19.6

-Tax revenues 8.8 43.0 12.1

-Non-tax revenues 6.3 10.7 7.6

Loans 1.9 2.5 1.6

While the national average of health expenditures out of total budget of LGU is 18.6

percent, the World Bank’s case study of LGU health care expenditures

has shown that

there is a considerable divergence in spending levels among the different levels of LGUs

from 6.3 percent in a city to 39.4 percent in a province in Luzon; as well as different

provinces: from 20.1 percent in a Visaya province to 39.4 percent in a Luzon province.

The difference derives from the presence/absence of a tertiary provincial hospital with its

higher cost implications. It was reported by DOH that health expenditures per capita were

8.5 percent greater for provinces that operated a tertiary hospital compared to those where

DOH continued to operate the tertiary hospitals.

Despite the fact that LGUs allocate the majority of the health sector budget to payment for

personnel salaries, wages and benefits, LGUs often have difficulty maintaining the level of

staff minimally accepted by DOH. In order to mitigate the problem of under-funding and

under-staffing, the LGU health facilities could charge user fees. However, in practice, the

local chief executives and Local Council are reluctant to raise rates.

Devolution has created a fragmented health system. The typical planning and budgeting

process has become compliance-oriented rather than needs-oriented. Budgetary decisions

are in the hands of the local chief executives and the LGU accounting officers, and

participation of the local health officials is minimal. Consequently, it is questionable

whether the resource allocations for health are reflective of actual health needs of the

LGUs.

③ Health Financing Flow

Figure 3-11 shows revenue sources and flows within the public health system in the

Philippines. DBM transfers the general tax revenues collected by the DOF to DOH,

PhilHealth, as well as LGU. DOH further distributes the budget to the DOH-retained

hospitals and LGUs that operate hospitals and other health facilities. PhilHealth, Health

Maintenance Organizations (HMOs) and other private insurance companies reimburse the

accredited health facilities for healthcare costs of the members, and households are

responsible to pay for health expenses not covered by health insurance.

World Bank. (2011). Philippines: Study on Local Service Delivery & Bureau of Local Government

Finance. (2007).

World Bank. (2011). Philippines: Study on Local Service Delivery.

Figure 3- 11 Revenue sources and flows within the public health system

in the Philippines

Source: The Philippines Health System Review (2011) & Philippines: Study on Local Service Delivery (2011)

(4) Health Facilities and MCH Service Delivery

Table 3- 7 shows the public health facilities under DOH, province and municipality/city.

The private sector plays an important role for the provision of health services in the

Philippines. While it is reported that the number of beds is almost equal for private and

public facilities, 763 out of 1,971 hospitals (38.7 percent) are public and 1,208 hospitals

(61.3 percent) are owned by the private sector.

Table 3- 7 Public health facilities

Responsible entity

Health facility

DOH

National, specialized and regional hospitals

Provincial government

Provincial and district hospitals, and other health facilities, e. g. infirmary

Municipal/City government

Municipal/City hospitals, RHU, BHS and other health facilities, e. g. infirmary

Source: JICA Survey Team

The Philippine health facilities are classified as hospitals and non-hospitals on a basis of the

functions. Moreover, hospitals are classified into Level 1 to Level 3 hopitals. Non-hospitals

include infirmaries and birthing homes. The basic functions of each health facility determined

by DOH is shown in Table 3-8.

The Philippines Health System Review 2011.

Infirmary is the facility not certified as DOH level 1-3 hospitals but with beds.

DOH

DBM

DOF

PhilHealth

Firm

Household

LGU

Healthcare

Providers

Donors

HMOs &

Privare

Insurance

Legend

Budget

Tax

Premiums

Reimbursement

User fees

Table 3- 8 Basis Functions of Health Facilities

Health facility

Functions

Non-hospitals

Ambulatory care and basic health care including normal spontaneous delivery

is provided. The average period of hospitalization is 1 to 3 days.

Level 1 Hospitals

Health care in the areas of internal medicine, pediatrics, obstetrics and

gynecology, (including cesarean section), ssurgery, dentistry and emergency

medical care are provided. Pharmacy, secondary clinical laboratory (DOH

standard), primary image analysis laboratory and/or blood station

are often

attached.

Level 2 Hospitals

In addition to the health care provided by the Level 1 Hospitals, specialists

are assigned to each diagnosis and treatment department. ICU, pediatric ICU,

respiratory therapy, tertiary clinical laboratory, and secondary image analysis

laboratory are attached.

Level 3 Hospitals

In addition to the health care provided by the Level 2 Hospitals, dialysis

clinic, rehabilitation center, blood bank, tertiary clinical laboratory and

tertiary image analysis laboratory are attached. It is also functioned as a

training institution.

Source: JICA Survey Team

Table 3- 9 Major MCH services by various health facilities

Facility

MCH services

Human resource

BHS

ANC, immunization, health education,

consultation, referral

Nurse, midwife (RHU personnel make

regular visit where there are no personnel

stationed at BHS), Barangay Health

Worker (BHW), Barangay Nutrition

Scholar

RHU

In addition to BHS services, laboratory

test (no ultrasound), normal delivery

(at selected RHUs), PNC

Doctor (mainly internal medicine), nurse,

midwife, lab technician, etc.

Municipal/

District/Provin

cial Hospital,

Infirmary

ANC, normal delivery, PNC,

laboratory test and others as delivered

at BHS/RHU.

Accredited with BEmONC and

HIP-MCP. Caesarean Section can be

conducted where/when the obstetrician

and anesthetist are available.

Doctor, nurse, midwife, lab technician etc.

Regional

Hospital

All services are provided at two

regional hospitals as CEmONC.

Obstetrician, anesthetist, pediatrician,

nurse, midwife, paramedical etc.

Source: JICA Survey Team

Table 3-9 shows MCH services provided at each level of facility and the personnel serving

the services. In the Philippines, one can seek health care at any level of facility without a

medical referral letter. Generally, an expectant mother is to receive ANC at the nearest

At a bank station, whole blood and concentrated red blood cells are stored and provided, and red blood

cells fit inspection is performed. Whereas at a blood bank, all blood components are stored and provided,

and red blood cells fit inspection, red blood cells antibody screening, transfusion reaction test and

transfusion safety monitoring test are performed. (Administrative Order No. 2001-0008, Rules and

Regulations Governing the Regulation of Blood Service Facilities)

BHS, RHU or private clinic, and deliver a child at a RHU with a lying-in facility, a

municipal hospital or a district hospital for normal spontaneous delivery. A high-risk

expectant mother delivers at a Comprehensive Emergency Obstetric and Newborn Care

(CEmONC) facility, such as a provincial hospital or a regional hospital. However, it is not

uncommon, especially in urban areas, that an expectant mother receives ANC and performs

normal spontaneous delivery at a tertiary health facility.

Barangay Health Workers (BHWs) are trained health volunteers to provide basic health

care in a community. They receive fixed amount of rewards from barangay. They visit

households on a regular basis and record the information of the household members, check

with expectant mothers, mothers and infants, follow them up after they receive health care,

provide them with health information and advice, and refer them to health facilities when

necessary. Meanwhile, some women still deliver a child at home attended by a traditional

birth attendant (TBA).

(5) Health-related Information

There exist a variety of information systems dedicated to the Philippine health sector. The

basic health data on health service delivery and selected program accomplishment at the

barangay, municipality/city, provincial and regional levels are collected through the Field

Health Service Information System (FHSIS) developed by DOH. The fundamental building

block of the FHSIS is the Recording Forms and Reporting Forms for the DOH and LGU

staff with managerial or supervisory functions in facilities and program areas. The second

building block of the FHSIS is the Target Client Lists (TCL) for nurses/midwives with

planning and operation of patient care, monitoring and supervision of service delivery

activities, reporting of delivered services, and clinic-level data provided for further studies.

There are various kinds of TCLs including those in areas of Prenatal Care, Post-Partum Care,

Under 1-Year-Old Children, Family Planning, Sick Children, National TB Program Register,

and the National Leprosy Control Program. Midwives in BHS collect this data on a monthly

basis and consolidate it in the Summary Table composed of (1) Health Program

Accomplishment and (2) Morbidity Disease.

Institutional delivery is usually recorded on a basis of where a woman delivers a child in

FHSIS. However, the JICA project in CAR encouraged the health workers to record

institutional delivery on a basis of where a woman lives. Likewise, the project team also

Scribd. The field health service information system (FHSIS)

https://ja.scribd.com/doc/27872414/The-field-health-service-information-system-FHSIS

instructed them not to use an estimated number of expectant and nursing mothers, but use a

real number as a denominator of a consultation rate of ANC and PNC. These efforts

enabled them to understand the real situation of maternal and child health. Today, DOH is

introducing the above efforts to other areas of the country.

A census is conducted every ten years by Philippine Statistics Authority (PSA).

Although the first Census was conducted in 1878 by the colonial Spanish government, the

regular practice was adopted in 1960, and an inter-censal survey was added in 1995. The

last Census was conducted in 2010 and the inter-censal survey measured the size of the

population in 2015. The public-school teachers are assigned to collect data in the Census

and the PSA staff train and supervise them at the Regional, Provincial, and Municipal/City

levels. The households are enumerated based on the information obtained through Local

Chief Executives and Barangay Captains. PSA establishes the Census Board some time

before the data collecting period and tasks the Barangay Captains to confirm households in

their barangays. For migrants and people living on the streets, data collectors visit them on

an ad hoc basis. For overseas migrant workers, the data collectors ask each household

whether there is any household member working overseas and count the person if he/she

stays overseas shorter than five years.

The Vital Statistics Division of PSA provides DOH with the data of births and deaths. A

Birth Certificate has to be submitted to the Local Civil Registry Office in the

municipal/city office within 30 days and registered within six weeks after the birth.

Likewise, a Death Certificate has to be submitted to the Local Civil Registry Office in the

municipal/city office within 48 hours and registered within 30 days after the death. PSA

only provides supervision to the Local Civil Registry Office, and the registration is

managed by LGUs. For indigenous people, the Local Civil Registry Office goes to their

residential area and resisters them. For people living on the streets, the Department of

Social Welfare and Development (DSWD) does the registration. According to the Census

2010, 93.5 percent of births and 66.0 percent of deaths had been registered. Vital statistics

were initiated in 1939 and became computerized in 2000 in the Philippines.

The National Demographic and Health Survey (NDHS), globally known as the

Demographic and Health Survey (DHS), also provides DOH with health information with

On the basis of the Philippine Statistical Act of 2013 (Republic Act No. 10625), National Statistics

Office, National Statistical Coordination Board, Bureau of Agricultural Statistics and Bureau of Labor

and Employment Statistics were merged to be National Statistics Authority.

Interview with the Population and Housing Census Division, PSA (October 7, 2016).

Interview with the Vital Statistics Division, PSA. (August 1, 2016).

a specific focus on reproductive health. The enumeration is conducted based on the Census

data. The latest NDHS 2013 used the Census 2000. The data collectors are called for each

survey and trained by ICF International, supervised by the PSA staff. The contents of the

questionnaires are modified on the basis of requests by the United States Agency for

International Development (USAID), the sponsor of NDHS, and the Philippine

government. The survey is usually conducted every five years, but the next NDHS survey

will be conducted in 2017, one year earlier than originally scheduled, as the government

wishes to collect the SDG baseline data through the NDHS results.

Other health-related information sources include the Family Income and Expenditure

Survey (FIES) and Small Area Estimates (SAEs) conducted by PSA. There is also the

community-based household information system called the Household Profile, primarily

developed for the community-based monitoring system in which community health teams

(CHTs) are engaged. The Household Profile will be collected by Barangay Health Workers

(BHWs) in the future.

3-2 Maternal and Child Health Conditions

(1) Maternal conditions

Although a decline of the Maternal Mortality Ratio (MMR) has been observed in the

Philippines since 1990, it has slowed done in recent years. The MMR was estimated at 112

per 100,000 live births in 2015,

which was higher than the MDG target of 52 per

100,000 live births.

There are regional disparities exist according to the available

information from the DOH at the regional level.

With regard to antenatal care (ANC), nationally 95 percent of pregnant women received at

least one ANC from skilled providers in 2013, which is an increase from 2008 at 91

percent. Facility-based delivery (FBD) at the national level also improved from 44 percent

in 2008 to 61 percent in 2013 and 72 percent of mothers received post-natal care (PNC)

during the first two days after birth.

Interview with the Demographic and Health Statistics Division, PSA. (October 5, 2016).

Interviews with LGUs in Eastern Visayas and Corderilla Administration Regions.

WHO, UNICEF, UNFPA, World Bank Group and United Nations Population Division Maternal

Mortality Estimation Inter-Agency Group. (2015). Maternal Mortality in 1995-2015 – Philippines.

The Philippines Fifth Progress Report MDGs, NEDA, 2014.

Based on some of the available websites by regional health offices, CAR and Central Visayas

recorded MMR lower than the MDG target while higher in Caraga (at 120-150 per 100,000 live

births) between 2013-2015.

Regionally, Autonomous Region in Muslim Mindanao (ARMM) had a much lower ANC

rate at 53 percent compared to other regions. About 12 percent of women deliver a child

with assistance by a TBA and the most common skilled birth attendant is a midwife in

ARMM. Regarding FBD rates, it is the highest in the National Capital Region, lower in

Mindanao (except for Davao), Cagayan Valley, Mimaropa and Bicol and the lowest at 12

percent in ARMM. The factors associated with the low FBD include low educational

attainment of mother, low income, having more than six children, resided in remote area,

and not receiving ANC. It was reported that the major reason for not having FBD is the

financial burden, followed by not found necessary, distance to a health facility, and

non-availability of transportation.

(2) Child mortality

The National Infant Mortality Rate (IMR) and the under-five mortality rate have both

declined steadily (IMR: 23/1000, U5MR: 31/1000) and are predicted to achieve the

respective MDG targets (IMR: 19/1000, U5MR: 27/1000). However, regional

discrepancies also exist with Mindanao and Mimaropa having higher rates than the

national average, although discrepancy is not as large as that seen for maternal mortality in

ARMM. National average of early neonatal death and still birth rates remains high at

22/1000. In general, mortality rates are higher in remote areas than urban areas. Like FBD,

mothers’ lower educational attainment and income level are associated with higher child

mortality rates. As compared with the first child, the seventh and later children is five

times more likely to die before his/her first birthday.

(3) Teenage Pregnancy

Teenage pregnancy and motherhood is becoming a social and health concern in the

Philippines. It was found that teenage women are at higher risk of having anemia,

premature birth, and low-birth-weight baby. It is also reported that the risk of still birth or

child death within a week after birth is 50 percent higher for a child born to a teenage

mother than a child born to a mother in twentieth. While the total fertility rare decreased

from 6.0 in 1973 to 3.0 in 2013, the age-specific fertility rate of women ages 15-19 has

remained somewhat constant during the same period (see Figure 3- 12).

Philippine National Demographic and Health Survey 2013.

ibid

Socioeconomic concern includes the fact that many of teenage mothers drop out of school

and therefore it is not easy for them to make living by themselves. Another issue of teenage

pregnancy is that many of their children are born outside of marriage. Childbirth outside of

marriage results in social and economic disadvantages for both teenage mothers and their

children, such as ineligibility for public health insurance and social stigma.

Figure 3- 12 Trends of Total Fertility Rate and the Teenage Fertility

out of Total Fertility Rate from 1973 to 2013 in the Philippines

Source: National Demographic Survey for 1973, 1983, 1993, Republic of the Philippines Fertility Survey for 1978,

Contraceptive Prevalence Survey for 1986 and National Demographic and Health Survey for 1998 to 2013

3-3 Assistance of Development Partners

(1) Development Partners in the Philippine Health Sector

Figure 3- 13 shows the breakdown of official development assistance (ODA) by

development partners for ongoing projects as of the end of 2015.

In terms of the amount, USAID, the Global Fund and the European Union (EU) are the

three top development partners, accounting for 37%, 27% and 17%, respectively. JICA

accounts for 5% of the total ODA of development partners to the health sector.

1973 1978 1983 1986 1993 1998 2003 2008 2013

Total Fertility Rate Age Specific Fertility Rate (15-19)

Figure 3- 13 Donor Contributions in Philippine Health Sector

as of the End of December 2015

Source: Bureau of International Health Cooperation of DOH (2016). The Official Development Assistance on Health.

In terms of the areas of assistance, MDG 4 (child mortality) and MDG 5 (maternal

mortality) are by far the major areas, accounting for 43% of the total, in which

development partners are providing their assistance (See Figure 3- 14).

Figure 3- 14 Areas of Assistances by Donors as of the End of December 2015

Source: Bureau of International Health Cooperation of DOH (2016).

The Official Development Assistance on Health.

(2) Trends of the Assistance by Development Partners in the Philippine Health Sector

Figure 3- 15 compares DOH budgets and the amount of ODA by development partners in

the past 18 years, subtotaling every 6 years. While the DOH budget has increased

significantly especially since 2011, the increase in the amount of assistance by

development partners has not kept up.

USAID

37%

Global Fund

27%

17%

JICA

Germany

KOICA

UNFPA

UNICEF

WHO

ADB

World Bank

MDG4 (Child Mortality)・MDG5

(Maternal Mortality), 43%

MDG 6 (HIV/AIDS, Malaria, TB

and Other Infectious Diseases),

27%

Health Systems and

Crosscutting Issues,

12%

Disaster Management

and Strengthening

Disease Survellance, …

Noncommunicable

Diseases, Environmental

Health and Mental …

Health Facility

Enhancement, 3%

Knowledge Management and Information

System, 1%

Figure 3- 15 DOH Budgets and Amount of Donor Assistances (1998-2016)

Source: Bureau of International Health Cooperation of DOH (2016).

The Official Development Assistance on Health.

(3) Details of Assistance by Development Partners

Major development partners assisting the Philippine health sectors, other than JICA,

include the World Bank, USAID, EU, WHO, Asian Development Bank (ADB), United

Nations Children’s Fund (UNICEF) and United Nations Population Fund (UNFPA).

Below describes the content of the assistance from each development partner.

① World Bank

The World Bank provides assistance in maternal and child health (MCH), health finance

and health policy and systems.

[Maternal and Child Health]

BlueStar Output Based Project

From April 2012 to December 2015, the World Bank piloted the output-based project

(Global Partnership on Output-based Aid) to improve the poor population’s health,

particularly in the area of maternal and reproductive health, in the provinces of Leyte,

Southern Leyte, Samar, Northern Samar and Eastern Samar in the Eastern Visayas

Region.

Interview with World Bank

World Bank. Global Partnership on Output-based Aid, Grant Reporting and Monitoring Report: Ref.

TF0101757.

28.0

24.0

12.0

417.7

97.8

75.3

0.0 100.0 200.0 300.0 400.0 500.0

2011-2016

2005-2010

1998-2004

DOH Budget (billion

pesos)

ODA (Loans and Grants,

billion pesos)

The project was implemented by BlueStar, a franchise developed and owned by Marie

Stopes International, the United Kingdom-based non-profit organization. The project

intends to promote enhancement and accreditation of maternal health facilities by

PhilHealth, especially in hard-to-reach areas. Population Services Philipinas, Inc. (PSPI) is

the national franchisor of BlueStar. The World Bank gave grants to PSPI when third-party

organizations

had verified the following three outputs:

1. Private birthing facility becomes accredited by PhilHealth.

2. Private birthing facility completes refurbishment of facility as agreed.

3. Private birthing facility completes staff training as agreed.

By the end of the project, refurbishments of 27 birthing facilities as well as construction of

seven Barangay Health Stations (BHSs) were completed, and US$ 3 million was paid out in

total.

According to the World Bank, this mechanism could be employed in other areas of the

country if a private institution is willing to take on the financial risk until the required

output targets are achieved.

Voucher Project

In conjunction with the BlueStar Output-Based Project described above, the World Bank

carried out the subsidized voucher project.

Under this project, a voucher is sold for 50 pesos at a franchised birthing facility in

Northern Samar and Eastern Samar, relatively poor provinces. The voucher allows a

woman to receive maternal health services, such as ante-natal and post-natal care, free of

charge, and she redeems the voucher for a total of 1,500 pesos at the bank designated by

the project when she completes necessary care at the birthing facility. A redemption

method can be either a single redemption or a redemption on the milestone basis at a time

of receiving a maternal health service.

The project sold a total of 10,000 vouchers in one year, 60 percent of which were

redeemed. Concurrently, World Bank placed two series of 30-second advertisements with

AM and FM radio to educate the target group of people with PhilHealth benefits.

However, the World Bank learned that radio was not effective media as residents do not

listen to the radio today: they watch television instead.

PRIMEX, local consulting firm, served as the third-party inspector

[Health Finance]

Healthcare Finance Strategy

In 2010, DOH published the Health Care Financing Strategy of the Philippines 2010-2020

– Toward Financial Risk Protection that provides a roadmap towards attaining the strategic

goals of increasing the overall level of health spending, promoting universal coverage,

improving allocative efficiency, and promoting technical efficiency. The World Bank,

DOH and PhilHealth are currently reviewing the Strategy.

Japan Policy and Human Resources Development: PHRD UHC Window

World Bank and the Japanese government have formulated a proposal of a technical

assistance project on Health Financing Review and Systems Strengthening by utilizing the

Japan Policy and Human Resources Development Fund (PHRD) established under the

partnership between World Bank and the Japanese government to achieve the goals of the

Aquino Administration's Kalusugan Pangkalahatan - Universal Health Care (KP) program

in the Philippines. The project is to start in 2016.

[Health Policy and System]

Primary Care Package

To study the best implementation mechanism for the primary care benefit package of

NHIP (Primary Care Benefit 1, or PCB1), the World Bank, in conjunction with PhilHealth

and the Korea Development Institute – School of Public Policy and Management, is

carrying out the study, the Impact of Incentives and Information on Quality and Utilization

in Primary Care (I3QUIP).

The I3QUIP studies the impact of different implementation mechanisms to boost

effectiveness of the PhilHealth’s performance-based payment for PCB1. The World Bank

is currently working on the baseline report that describes the current status of primary care

package implementation and compliance by LGUs and primary health providers.

② USAID

USAID is assisting the Philippine health sector with the following three pillars:

1. Improving the supply of integrated family health services

World Bank. (February 2016). Philippines Impact of Incentives and Information on Quality and

Utilization in Primary Care: Baseline Survey Report.

Interview with USAID

USAID website

2. Developing healthy behaviors and practices

3. Improving health policies and systems

Within the assistance framework of the three pillars, USAID is currently providing the

Philippine government with assistance in the following areas:

 Maternal and Child Health (MCH)

 Service Delivery Network (SDN)

 Health finance

 Health policy and system

[Maternal and Child Health (MCH)]

To improve the quality of Maternal, Neonatal, Child Health and Nutrition/Family Planning

(MNCHN/FP) services, USAID is carrying out the following three regional projects:

1. VisayasHealth Project

2. MindanaoHealth Project

3. LuzonHealth Project

The project period for all three is from 2013 to 2018. Table 3- 10 summarizes the target

regions and provinces for each project.

Table 3- 10 Target Regions and Provinces for the USAID Assisted MNCHN/FP Programs

Project

Regions

Province

VisayasHealth

Western Visayas

Iloilo, Negros Occidental

Central Visayas

Bohol, Cebu

Eastern Visayas

Leyte, Southern Leyte, Samar, Northern Samar

MindanaoHealth

Zamboanga Peninsula

Zamboanga del Sur, Zamboanga del Norte, Zamboanga

Sibugay

Northern Mindanao

Misamis Oriental, Bukidnon, Lanao del Norte

Davao

Davao del Sur, Compostela Valley, Davao Oriental

Soccsksargen

Cotabato Province, South Cotabato, Sultan Kudarat

Caraga

Agusan del Sur, Agusan del Norte

Autonomous Region

in Muslim Mindanao

Lanao del Sur, Basilan, Maguindanao, Sulu, Tawi-Tawi

LuzonHealth

CAR

Benguet

Ilocos

Pangasinan

Cagayan Valley

Cagayan, Isabela

Central Luzon

Neva Ecija, Balacan, Tarlac

Calabarzon

Quezon, Batangas, Laguna, Cavite, Rizal

Mimaropa

Oriental Mindoro

National Capital

Region

(City of) Caloocan, Malabon, Marikina, Pasig, Quezon,

Taguig, Valenzuela

Bocol

Albay

Source: USAID website

USAID website and Interview with USAID

USAID is planning on post-2018 MNCHN/FP projects. Regions for assistance are

expected to be selected from a list of the 20 poorest provinces, for which DOH is calling

for donor assistance. Given the direction of the current administration, USAID will place

emphasis in assisting the poorest families with difficulties in accessing health facilities.

[Service Delivery Network (SDN)]

The Private Sector Mobilization for Family Health Project – Phase 2 (PRISM2) was

implemented from 2009 to 2014 with the goal to strengthen SDN and to assist the DOH

and the LGUs in engaging and mobilizing private sector resources in delivering family

planning and MCH services and products. Involvement of the private sector in the network

has been successful in some areas. It was reported that there was one province in which the

number of SDNs increased from just a few to more than 100.

USAID has tested and fine-tuned various models in the PRISM2 project. Illoillo and

Cavite provinces were cited as examples in which more advanced and mature SDN

networks exist.

[Health Financing]

Since 2014, USAID has assisted Tacloban City in their efforts to re-establish the functional

health system and maximize the income of health facilities facing devastations from

Typhoon Yolanda.

USAID studied the status of service delivery in the area and recommended the following to

maximize the income of health facilities.

∙ USAID advised Tacloban City to open a bank account, called the Trust Fund, to

exclusively receive PhilHealth reimbursements.

By securing the health budget through

this arrangement, it was expected to motivate the City to provide better health services.

∙ USAID advised Tacloban City to use some of the PhilHealth reimbursements to

incentivize the volunteers and barangay health workers (BHWs) who had taken

Interview with USAID

UPecon-Health Policy Development Program. (2015). Concept Note on the Establishment of a

Service Delivery Network for Tacloban City

PhilHealth reimbursements are to be redistributed to health facilities and professional, and LGUs are to

open a Trust Fund bank account for PhilHealth related transactions. However, it is reported that some

LGUs have not opened the bank account and the said LGUs may not be making appropriate

redistributions, as PhilHealth reimbursements are accounted for as part of the general budget. According

to PhilHealth, health LGU-owned institutions are not able to open a bank account as they are not legal

entities.

expectant mothers to health facilities. Through this arrangement, it was expected that

the number of facility-based deliveries (FBD) would increase and subsequently

reimbursement for the Maternity and Child Package (MCP) would also increase in

Tacloban City.

Both of these measures became city ordinances in 2015, and Tacloban City saw significant

increase in PhilHealth reimbursement. For instance, the Tacloban City Hospital received

4.2 million pesos for PhilHealth reimbursement in 2014, but the amount increased up to

22.8 million pesos by October 2015. Moreover, in the first quarter of 2016, 9.4 million

pesos, equivalent to 6.3 times as much as that in 2014 and 2.8 times as much as that in

2015, was paid to Tacloban City by PhilHealth.

[Health Policy and System]

Health Policy

Health Policy Development Program – Phase 2 is a five-year (2012-2017) health policy

project in partnership with the UPecon Foundation, Inc. It supports the DOH-led policy

formulation process by scaling up the Government of the Philippines’ Universal Health

Care initiative.

So far, USAID has supported DOH with the following initiatives:

∙ Development of guidelines for implementing the Responsible Parenthood and

Reproductive Health Law

∙ Design of the 2015 National TB Prevalence Survey

∙ Implementation of monitoring operations for Universal Health Care

∙ Assessment of family planning logistics and promotion of new logistics for provider

participation

∙ Training on planning and contracts management for the staff of DOH Regional Offices

Health Governance Related

In October 2013, USAID and DOH entered into a three-year Global Development Alliance

with the Zuellig Family Foundation (ZFF).

ZFF has implemented leadership and

governance capacity building programs for health in various rural municipalities in the

Philippines since 2008.

USAID website

ibid

The goal of the capability-building programs is to improve health outcomes in the areas of

maternal and child health, family planning and tuberculosis by enhancing the leadership

and governance capabilities of local chief executives and local health officers of the 121

LGUs.

Health Information Improvement

As statistical data collected in the Philippines is not highly reliable, USAID verifies the

accuracy of data, such as the Family Income and Expenditure Survey (FIES), before it

utilizes it. On the basis of this experience, USAID has recently developed a data

standardization tool, which is now recommended by DOH and adopted by some

development partners, including UNICEF.

③ EU

The EU provides budget support to DOH. The current budget support is for the period of

2015-2017 and this is the third offer by the EU, followed by 2007-2010 and 2011-2013

support. Funds are paid out to DOH through the Department of Finance (DOF) upon

meeting targets, many of which are based on the FIES.

Current assistance by the EU for the Philippine health sector is provided in the following

areas.

 Service Delivery Network (SDN)

 Health financing

 Health policy and system

[Service Delivery Network (SDN)]

The EU launched the SDN project in August 2016. As there are similar SDN projects

carried out by other development partners, the EU hopes to differentiate this project by

uncovering valuable information, such as why public hospitals with no PhilHealth

accreditation still exist today.

[Health Finance]

In December 2015, the EU proposed a technical assistance program to update PhilHealth

case rates. The EU believes that the new administration is positively considering the

proposal.

Interview with EU

Most targets are based on the indicators in FIES

[Health Policy and System]

The EU has provided following the Information and Technology (IT) -related assistance

projects:

∙ Project to link provincial-level electronic medical records to PhilHealth

The EU normally provides technical assistance and DOH prepares the necessary

hardware; however, there are some cases in which development partners provide the

hardware, such as in Calabarzon Region by the Korea International Cooperation

Agency (KOICA).

∙ Project to ensure privacy and security of data

DOH has been working on this subject since 2014 to manage electronic data records

at the LGU level.

∙ Project to improve the monitoring capacity of health enterprise architecture

The project aims at data transfer and connection through digitization of the health data.

∙ Project to build up the health information system in which DOH, PhilHealth and

hospitals play clearly defined roles

Health information systems have been adopted by merely 10 to 15 percent of

hospitals, and even when adopted, quality of data is low, both in medicine and

finance.

As IT is a broad arena in which assistance by only the EU and KOICA is not

sufficient, the EU has recommended to JICA to join them and start providing similar

assistance.

④ WHO

Current assistance by WHO for the Philippine health sector is in the following areas:

 Service Delivery Network (SDN)

 Health policy and system

Interview with WHO

[Service Delivery Network (SDN)]

WHO considers SDN as important as healthcare finance for better health in the

Philippines, and it is currently carrying out the SDN project in Davao City, Mindanao.

WHO is carrying out this initiative with KOICA, and would welcome JICA to join the

initiative in this or another region.

On the basis of the belief that motivation and morals of local government officials, especially

barangay chiefs, are keys to success in building an effective SDN, WHO recently expressed

interest in assisting LGUs to strengthen their governance structure.

In addition to the Davao project, WHO, together with UNFPA, UNICEF and DOH, is

currently carrying out a project to formulate the guidelines for MCH-related SDNs in

Cotabato City, Soccskasargen Region of Mindanao.

[Health Policy and System]

WHO is currently assisting the Asian Pacific Observatory to update the Philippine Health

System Review – Health in Transition.

⑤ ADB

Asian Development Bank (ADB) currently provides assistance to the Philippine health

sector in the areas of health policy and systems.

In early 2016, the National Economic and Development Authority (NEDA) drafted a

25-year strategic master plan, Philippines Strategy 2040. ADB provided comments and

suggestions with respect to the said draft from the viewpoint of universal health coverage.

This draft is the product of the former administration, and if the current administration

were to pursue the same strategic master plan, ADB would assist NEDA and DOH. Aside

from the above, ADB provides US$ 300 million budget support for the Conditional Cash

Transfer (CCT) program.

⑥ UNICEF

UNICEF currently assists the Philippine health sector in the following areas:

 Maternal and Child Health (MCH)

Interview with ADB

Refer to 2-12 (4) “Supporting Indigents of Section 2 for details of CCT,

Interview with UNICEF

 Service Delivery Network (SDN)

 Health financing

[Maternal and Child Health (MCH)]

The Maternity Care Package (MCP) of NHIP has not substantially changed in the last ten

years and there is no benefit package for premature care. UNICEF is working towards

improvement of the situation.

∙ MCP: MCP data of ten million cases are now available. On the basis of this large

data analysis, UNICEF plans to make recommendations for improvement of the

MCP.

∙ Package for Premature Baby: UNICEF is working with PhilHealth on the creation

of a pre-mature benefit package, as the premature death rate remains high, while the

neonatal death rate has been stabilized in the Philippines.

[Service Delivery Network (SDN)]

As previously mentioned, UNICEF, together with WHO, UNFPA, UNICEF and DOH, is

working to formulate guidelines for MCH-related SDN in Cotabato City, Soccsksargen

Region of Mindanao.

[Health Finance]

Primary Care Package

As the primary care package, named Tamag Serbisyo para sa Kalusugan ng Pamilya

(TSeKaP Program), does not cover sufficient drugs for asthma and tuberculosis, UNICEF,

together with WHO and UNFPA, has been working towards improvement of the program

since 2014.

The original proposal was submitted to DOH at the time of Secretary Ona, but no progress

was seen after his resignation. The new DOH Secretary Ubial is keen on taking this

initiative further.

Rational Prioritization of Benefit Packages

Prioritization of benefit packages of NHIP tends to reflect the preference of those with

power. However, UNICEF is advising PhilHealth to rationally prioritize benefit packages.

⑦ UNFPA

Assistance by UNFPA for the Philippine health sector is provided in the following areas:

 Maternal and Child Health (MCH)

 Service Delivery Network (SDN)

[Maternal and Child Health (MCH)]

UNFPA is assisting the Philippine MCH service delivery in the following three areas:

1. Facility Based Deliveries (FBD): UNFPA sees the following issues in deliveries in

the Philippines.

 There are facilities that are not meeting minimum requirements for Basic

Emergency Maternal Obstetrics and Newborn Care (BEmONC).

 Many facilities have a shortage of drugs.

 There are areas where accessible birthing facilities do not exist for expectant

mothers.

2. Skilled Birth Attendant (SBA): A higher proportion of births attended by a SBA

was one of the targets of MDG5. Although the Philippines was closer to the target,

it has room for improvement.

3. Family Planning: The Philippines is not likely to achieve the MDG 5 targets in

respect to contraceptive prevalence and unmet needs for family planning.

While

neo-natal deaths are a large proportion of all child mortality cases in the Philippines,

the study conducted by UNFPA in 2013 revealed that 50 percent of the deaths could

have been prevented if proper family planning was practiced.

[Service Deliver Network (SDN)]

UNFPA is currently involved with the following two SDN related projects.

Interview with UNFPA

Indicators of MDG 5 Target 5.A: reduce the maternal mortality ratio by three quarters between 1990

and 2015 include 5.1 - maternal mortality ratio and 5.2 - proportion of deliveries attended by skilled

health personnel.

Indicators of MDG 5 TARGET 5.B: achieve, by 2015, universal access to reproductive health include

5.3 contraceptive prevalence rate, 5.4 adolescent birth rate, 5.5 antenatal care coverage, and 5.6 unmet

need for family planning.

∙ A project targeting indigenous people in Soccskasargen, Mindanao

As their residential areas extend to more than two administrative divisions, special

consideration needs to be given in building SDNs in those areas.

∙ A project to formulate guidelines, together with other development partners, for

MCH-related SDNs in Cotabato City, Soccskasargen of Mindanao.

As previously mentioned, UNFPA is carrying out this project with WHO, UNICEF

and DOH.

Chapter 4 National Health Insurance Program (NHIP) – Overview

and Utilization

4-1 Current Framework of NHIP

The National Health Insurance Act of 1995 (RA No. 7875) institutionalized social health

insurance in the country through the National Health Insurance Program (NHIP), in order to

provide health insurance coverage and ensure affordable, acceptable and necessary health care

services for all citizens of the Philippines. Also in the same year, the Philippine Health

Insurance Corporation (PhilHealth) was established as the implementing agency of NHIP by

integrating the health insurance sections of the Government Service Insurance System (GSIS),

the insurance system for government employees, and the Social Security System (SSS) for

private sector employees. Although the operation became unified, there exist several

membership categories as described in 4-3, and premium collections are carried out based on

the methodology designed for each membership category. The goal of the Philippine

government is to cover all citizens under the NHIP.

4-2 PhilHealth

PhilHealth is the part of the Department of Health (DOH), and is governed by a board of

directors composed of seventeen members, chaired by the secretary of DOH. Figure 4- 1 is the

simplified organizational chart of PhilHealth.

Figure 4- 1 Organizational Chart of PhilHealth

Source: PhilHealth website.

PhilHealth website

Board of

Directors

Internal Audit

Group

President and

CEO

Actuarial Sys

and Risk

Management

Information

Management

Executive Vice

President and

COO

Management

Services

Fund

Management

Regional Office

North & Central

Luzon

NCR & South

Luzon

Visayas Mindanao

4 other offices

(8 in total)

Health Finance

Policy

Legal

Member

Management

Organization

and Systems

Development

Corporate

Planning

Corporate

Affairs

Corporate

Secretary

Approximately 6,400 employees work for PhilHealth and 800 of them work at the headquarters

in Quezon City.

At the local level, more than 100 branch offices (PhilHealth Local Health Insurance Office and

PhilHealth Business Center) are administered by the eight Regional Offices. Moreover,

approximately 70 express offices (PhilHealth Express) are situated at convenient locations, such as

shopping malls.

The following authorities and responsibilities are allocated to PhilHeath.

∙ To administer the NHIP

∙ To formulate and promulgate policies for the NHIP administration

∙ To formulate and implement guidelines on the above, namely premium collection, claim

procedure, cost containment, quality assurance of health care, and health care provider

accreditation, payment, and referral systems

4-3 Goals for the Philippine Health Agenda

As mentioned earlier, under the new Duterte administration, DOH has launched the Philippine

Health Agenda 2016-2022 and one of the three Guarantees is Universal Health Insurance. With

respect to Universal Health Insurance, PhilHealth has set the following goals:

∙ National Health Insurance Program (NHIP) enrolls 100% of Filipinos where formal sector

premiums are paid through payroll and non-formal sector premiums are paid by tax subsidies.

∙ NHIP’s support value is 100% (or zero-copayment) for the poor and those admitted in

basic accommodation, and predictable (ﬁxed co-payment) for those admitted in non-basic,

private accommodation.

∙ NHIP covers a comprehensive range of services and becomes the main revenue source of

public health care providers.

4-4 Membership Category

Today, the PhilHealth memberships are classified into six categories as shown below. Table 4-

1 summarizes qualifications for each category.

1. Formal Economy

2. Informal Economy

3. Lifetime Members

4. Senior Citizens

5. Indigent Members

6. Sponsored Members

Table 4- 1 PhilHealth Membership Category

Membership Category

Qualification

Formal Economy

 Workers in the government and private sectors who have established

employee-employer relations (includes housewife and driver

employed by an individual)

 Business entrepreneur

Informal Economy

 Migrant Workers: Filipinos who are engaged in a remunerated

activity in another country of which they are not citizens

 Informal Sector: includes among others, street hawkers, market

vendors, taxi drivers, small construction workers, and home-based

industries and services

 Self-Earning Individuals: individuals who render services or sell

goods as a means of livelihood outside of an employer-employee

relationship or as a career. These include professional practitioners

including but not limited to doctors, lawyers, engineers, artists,

architects and the like, businessmen, entrepreneurs, actors, actresses

and other performers, news correspondents, professional athletes,

coaches, trainers, and such other individuals

Lifetime Members

 Individuals aged 60 years and above and have paid at least 120

monthly contributions to PhilHealth and the former Medicare

Programs – i.e., Social Security System (SSS) and Government

Service Insurance System (GSIS)

 Uniformed personnel aged 56 years and above and have paid at least

120 monthly contributions to PhilHealth and the former Medicare

Programs of SSS and GSIS

 SSS underground miner-retirees aged 55 years above and have paid

at least 120 monthly contributions to PhilHealth and the former

Medicare Programs of SSS and GSIS

 SSS and GSIS pensioners prior to March 4, 1995

Senior Citizens

 Filipino citizens who are residents of the Philippines, aged sixty (60)

years or above and are not currently covered by any membership

category of PhilHealth

Indigent Members

 Persons who have no visible means of income, or whose income is

insufficient for family subsistence, as identified by the Department

of Social Welfare and Development based on specific criteria.

Indigent Members are identified under the National Household

Targeting System for Poverty Reduction (the “NHTS-PR”), will

automatically be enrolled and covered as PhilHealth Members.

Sponsored Members

 Individual whose premium is paid for by a sponsor such as an

institution or another individual

 Orphans, abandoned and abused minors, out-of-school youths, street

children, persons with disability (PWD), senior citizens

and

battered women under the care of the Department of Social Welfare

and Development, or any of its accredited institutions run by NGOs

or any non-profit private organizations

 Barangay health workers, nutrition scholars, barangay police officer,

and other barangay workers and volunteers

 Those enrolled through the Point of Care program of PhilHealth

Source: PhilHealth website and Title III Section 5 of the Implementing Rules and Regulations (IRR) of RA 7875

as amended otherwise known as the National Health Insurance Act of 2013

Formerly there was a category for “Overseas Filipinos”, which is now merged into Informal Economy.

Interview with PhilHealth (October 26)

A citizen is classified under the Senior Citizen category if a citizen is 60 years old or above and is not

under the care of the DSDW or NGO

Qualified dependents of the members are entitled to PhilHealth benefits without additional

premiums. Following are qualified dependents:

∙ Legitimate spouse who is not a member

∙ Unmarried and unemployed legitimate, legitimated, acknowledged, illegitimate children,

legally adopted or step children below 21 years of age

∙ Children who are twenty-one (21) years old or above but suffering from a disability that

renders them totally dependent on the member for support, as determined by PhilHealth

∙ Foster child as defined in Republic Act 10165 otherwise known as the Foster Care Act of 2012

A qualified dependent is claimed by a member and enlisted in the member’s Member Data

Record (MDR). MDR proves that the individuals enlisted are the PhilHealth Members.

4-5 Enrollment Procedures

Enrollment procedures to PhilHealth slightly differ depending on the membership category.

Table 4- 2 summarizes enrollment procedures to PhilHealth.

100

Table 4- 2 Enrollment Procedures by Membership Category

Membership Category

Enrollment Procedure

Formal Economy

 Submission of PhilHealth Member Registration Form (PMRF”) or

other personal identification number in the PhilHealth ID card to

employer (employer will proceed to enroll the employee to

PhilHealth)

Informal Economy

 Submission of PMRF to PhilHealth Local Health Insurance Offices

or PhilHealth Express outlets nationwide

 For Migrant Worker, if in the Philippines, submission of PMRF to

either PhilHealth Regional Office, PhilHealth Local Health

Insurance Office, PhilHealth Business Center or PhilHealth Express

outlet. If overseas, electronically submitting PMRF from any branch

of accredited collecting partners of PhilHealth – i.e., iRimit, Inc. and

Ventaja Corporation

Lifetime Members

 Submission of PMRF and other necessary documents to PhilHealth

Local Health Insurance Office

Senior Citizens

 Submission of PMRF and other necessary documents to either

Office for the Senior Citizen Affairs or PhilHealth Local Health

Insurance Office

Indigent Members

 Indigents are automatically enrolled to PhilHealth

Sponsored Members

 Submission of PMRF and other necessary documents to sponsors or

at PhilHealth offices

Source: PhilHealth Website

PhilHealth website

100

ibid

4-6 Premium Contributions

Premium payment procedure varies depending on the Membership category, as summarized in

Table 4- 3.

101

Table 4- 3 Premium Payment Procedures

Membership Category

Premium Payment Procedure

Formal Economy

 Members in the formal economy shall pay the monthly contributions

to be shared equally by the employer and employee at a prescribed

rate set by PhilHealth not exceeding 5 percent of their respective

basic monthly salaries. Below is the excerpt from the Formal

Economy contribution table for 2016 (in pesos).

Salary

Bracket

Salary Range

Base

Salary

Total

Monthly

Premium

Employee

Employer

~8,999.99

8,000

200.00

100.00

9,000~9,999.99

9,000

225.00

112.50

10,000~10,999.99

10,000

250.00

125.00

…

34,000 ~ 34,999.99

34,000

850.00

425.00

35,000~

35,000

875.00

437.50

***

Informal Economy

 Annual premium of 2,400 pesos are paid monthly or yearly for those

earning P25,000 or less per month.

 Annual premium of 3,600 pesos are paid monthly or yearly for those

earning more than 25,000 pesos per month.

Lifetime Members

 Annual premium of 2,400 pesos for each member is shouldered by

the National Government based on the General Appropriations Act.

Senior Citizens

Indigent Members

Sponsored Members

・Annual premium of 2,400 pesos for each member is shouldered by

LGU, Department of Social Welfare and Development (DSWD),

healthcare institutions, national government, private individuals,

private corporations, etc.

102

Source: PhilHealth website & Interviews with PhilHealth

101

PhilHealth website and Title III Section 5 of the Implementing Rules and Regulations (IRR) of RA

7875 as amended otherwise known as the National Health Insurance Act of 2013, annual audit report

for the year ended December 31, 2015

102

Healthcare institutions tend to pay the premium and become sponsors of the uncovered indigents upon

admission of the indigents under Point-of-Care enrollment program that enrolls them into PhilHealth

on site, offered by public healthcare institutions. As public healthcare institutions (DOH retained

hospitals and LGU owned hospitals) are subsidized by the national government and/or LGUs, they are

effectively supporting the Sponsored Members. Based on an interview with PhilHealth (October 26)

4-7 Payment Mechanisms

Previously, PhilHealth had employed the payment mechanism called Fee-for-Service, which

determines the fee based on the health services provided, the type of health facility and the

severity of illness. In 2011, aiming to reduce payment cost and claim document processing,

PhilHealth introduced the Case Rate Payment method for the following 11 medical cases and 12

surgical cases shown in the Table 4- 4. Case Rate Payment is a payment method that reimburses

health facilities a predetermined fixed rate for each treated case. PhilHealth had selectively used

the Case Rate Payment method for such conditions as outpatient malaria treatment, HIV/AIDS,

tuberculosis treatment and cataract surgery. However, with this introduction, approximately 50

percent of all claims filed to PhilHealth came to be reimbursed through the Case Rate Payment

method.

Table 4- 4 Case Rate Payment Introduced in 2011 – Cases and Rates (in pesos)

Medical Case

Surgical Case

Case

Rate

Case

Rate

Dengue I (Dengue Fever and DHF Grades I & II)

8,000

Radiotherapy

3,000

Dengue II (DHF Grades III & IV)

16,000

Hemodialysis

4,000

Pneumonia I (Moderate Risk)

15,000

Maternity Care Package

8,000

Pneumonia II (High Risk)

32,000

Cesarean Section

8,000

Essential Hypertension

9,000

Appendectomy

6,500

Cerebral Infarction (CVA I)

28,000

Cholecystectomy

19,000

Cerebro-Vasluar Accident (hemorrhage) (CVA II)

38,000

Dilatation & Curettage

24,000

Acute Gastroenteritis (AGE)

6,000

Thyroidectomy

31,000

Asthma

9,000

Herniorrhaphy

21,000

Typhoid Fever

14,000

Mastectomy

22,000

Newborn Care Package in Hospitals and Lying-in

Clinics

1,750

Hysterectomy

30,000

Cataract Surgery

16,000

Source: Dr. Francisco Z. Soria, Jr. (2016). PhilHealth Benefits.

In 2014, PhilHealth introduced the All Case Rate payment mechanism when reimbursing health

care providers and professionals. Through this introduction, members came to know how much

PhilHealth is paying for their illness or injury at the PhilHealth website by searching for

illness/injury, operation, ICD 10

103

or RVS codes.

104,105,106

103

International Statistical Classification of Diseases and Related Health Problems Tenth Revision (ICD

10)

104

PhilHealth. (2014). Annual Report 2014

105

PhilHealth. (January 30, 2015). Get to know your PhilHealth benefit in just one click.

106

International Statistical Classification of Diseases and Related Health Problems Tenth Revision (ICD

10) and Relative Value Scale (RVS) are codes used by PhilHealth in identifying specific rates for

every reimbursable medical condition and procedure.

Moreover, introduction of the Case Rate Payment curtails prolonged hospital stay,

over-utilization of diagnostic tools, and provision of un-necessary healthcare services. In some

areas of the country, turnaround time taken from claim receipt to payment was shortened from

70 days under the Fee-for-Service method to 17 days with the introduction of Case Rate

Payment method.

107

Generally speaking, for medical cases, healthcare professionals are allocated 30 percent of

PhilHealth reimbursements, with 40 percent allocation for surgical cases.

108

Figure 4- 2 is the

sample of Case Rate Payment for Pneumonia II (High Risk). A Case Rate of 32,000 pesos is

first reimbursed to a healthcare facility or the LGU that operates the healthcare facility. Then 30

percent of the reimbursement is redistributed to healthcare professionals and the remaining 70

percent goes to the healthcare facility.

Figure 4- 2 Reimbursement Flows under Case Rate for Pneumonia II (High Risk)

Source: Dr. Francisco Z. Soria, Jr. PhilHealth benefits

4-8 Benefit Packages

Broadly speaking, the following four types of benefit packages are offered by PhilHealth.

109

Benefit

packages include room and board, and doctors’, lab, procedure, and medicine fees.

1. Inpatient Benefit Packages

2. Outpatient Benefit Packages

3. Z Benefit Packages

4. MDG-related Benefit Packages

The following sub-sections describe each of the benefits.

(1) Inpatient Benefit Package

Inpatient benefits are available to all PhilHealth members.

107

Leopoldo J. Vega, Southern Philippines Medical Center. Shifting to Case Rates: Efficiency Gains.

108

There are exceptions – e.g., P500 fixed payment to healthcare professional for dialysis treatment. (Dr.

Francisco Z. Soria, Jr., PhilHealth. PhilHealth Benefits.)

109

PhilHealth website

Case Rate

Reimbursement Cap

P32,000

Healthcare Provider

Component (70%)

P22,400

Professional Fee

Component (30%)

P,9,600

(2) Outpatient Benefit Package

PhilHealth offers outpatient benefit packages targeting primarily indigents.

110

In 2012,

PhilHealth amended its primary benefit package and introduced the Primary Care Benefit 1

(PCB1) package in order to promote the utilization of the service. In 2014, PhilHealth

re-branded PCB1 Package into TSeKaP (see Table 4- 5). TSeKaP consists of essential

services aimed at prevention and early detection of diseases, as well as interventions for

healthy living.

111

Sponsored Members, Indigent Members and Senior Citizens can access the TSeKaP

benefit free of charge.

112

The maximum benefit is 1,800 pesos per year per family, 800

pesos of which is reimbursed to health facilities for their services, and 1,000 pesos are paid

to accredited drug stores.

113

Benefits are basically available through public health service

providers though limited privately owned facilities.

Table 4- 5 Primary Care Service Offered under TSeKaP Program

i. Preventive Services

ii. Diagnostic

Examinations

iii. Drugs and Medicines

Consultation

Complete

blood count

Asthma including nebulization services

Visual inspection with acetic acid

Urinalysis

Acute Gastroenteritis (AGE) with no or

mild dehydration

Regular BP measurements

Fecalysis

Upper Respiratory Tract Infection

(URTI)/Pneumonia (minimal and low risk)

Breastfeeding program education

Sputum

microscopy

Urinary Tract Infection (UTI)

Periodic clinical breast

examinations

Fasting blood

sugar

Counseling for lifestyle

modification

Lipid Profile

Counseling for smoking cessation

Chest x-ray

Body measurements

Digital rectal examination

Source: PhilHealth website

Aside from TSeKaP, outpatient benefits in Table 4- 6 are currently available for

non-Indigent Members free of charge.

110

PhilHealth. (2014). Annual Report 2014.

111

PhilHealth website

112

This program also covers Household Help, such as drivers and housekeepers, as defined in the

Republic Act 10361 or “Kasambahay Law.”

113

Dr. Francisco Z. Soria, Jr, PhilHealth. PhilHealth Benefit Packages: Understanding the Role of

Quality Medicines and Quality Pharmaceutical Care.

Table 4- 6 Outpatient Benefit Packages Offered by PhilHealth (other than TSeKaP)

Service

Case Rates (in pesos)

Day Surgeries (ambulatory or outpatient surgeries)

All Case Rate applies

Radiotherapy

Using Cobalt

Using linear accelerator

2,000/session

3,000/session

Hemodialysis

2,600/session

Outpatient Blood Transfusion

3,640 (including drugs & medicines,

X-ray, lab, operating room)

Source: PhilHealth website

(3) Z Benefit Package

114

In 2012, PhilHealth launched the new Z Benefit Package (Z Benefit) that gives substantial

financial risk protection for the treatment of catastrophic illnesses. Since its introduction,

the coverages have expanded annually.

Table 4- 7 Z Benefit Package: Year of Introduction and Case Rates (in pesos)

2012 (Initial implementation)

Acute Lymphoblastic Leukemia in Children (standard risk)

210,000

Breast Cancer (early stage)

100,000

Prostate Cancer (low to intermediate risk)

100,000

Low Risk Kidney Transplantation

100,000

2013 (Z benefit expansion)

Elective Surgery for Coronary Artery Bypass Graph

550,000

Tetralogy of Fallout or “Blue Baby Syndrome”

320,000

Ventricular Septal Defect (VSD)

250,000

Cervical Cancer (stage IIIB)

Low dose

High dose

120,000

175,000

Prosthetic limb

15,000

2014 (Z benefit expansion)

Selected Orthopedic Implants

9 types of implant including Total Hip Prosthesis

48,740~103,400

Peritoneal Dialysis

270,000/year

10,384.60/tranche

2015 (Z benefit expansion)

Colon Cancer

Stage I-II (Low Risk)

Stage II (High Risk) - III

150,000

300,000

Rectum Cancer

Stage I (Clinical and Pathologic)

Stage II-III (Clinical and Pathologic)

Use of linear accelerator as mode of radiotherapy

Use of cobalt as mode of radiotherapy

150,000

400,000

320,000

Source: PhilHealth. Annual Report 2014 and PhilHealth website

114

“Z” of Z Benefit package stands for “zero,” meaning that the program requires no co-payment.

Table 4- 7 summarizes current offerings of the Z Benefit Package.

115

Currently, 20 percent

of the Z Benefit reimbursement is allocated to healthcare professionals, with some

exceptions, such as Cervical Cancer whose professional fee is 15 percent of the case

rate.

116

Z-benefits are only offered at hospitals contracted with PhilHealth for a specific illness or

treatment in the Z Benefit Package. Table 4- 8 is the list of hospitals contracted for the

Elective Surgery for Coronary Artery Bypass Graph.

117

Table 4- 8 Contracted Hospitals for Elective Surgery for Coronary Artery Bypass Graph

Province

Contracted Hospitals for Elective Surgery

for Coronary Artery Bypass Graph

National Capital Region

Philippine Heart Center

University of Philippines - Philippine General Hospital

Central Luzon

Angeles University Foundation Medical Center

Central Visayas

Vicente Sotto Memorial Medical Center

Northern Mindanao

Northern Mindanao Medical Center

Davao

Southern Philippines Medical Center

Source: PhilHealth website

(4) MDG related package

A MDG-related package is aimed at promotion of MDG target achievements in the

Philippines, which include a maternity package such as MCP, Normal Spontaneous

Delivery Package (NSD) and Antenatal Care Package (ANC01), New Born Care Package

(NCP), and benefit packages summarized in Table 4- 9. PhilHealth Circular No. 026

requires that no fees be charged in excess of the relevant benefit package provided that the

patient pays for the full amount of the required annual premium.

[Maternity Care Package

118

]

The MCP provides for comprehensive coverage from pre-natal to post-natal care, and NSD

encourages normal low risk deliveries in birthing homes and maternity clinics in a safe

environment, as opposed to deliveries at homes.

119

As Table 4- 9 shows, MCP related

benefits differ depending on the type of health care facilities. Case rates for hospitals are

different from that for other facilities, such as, infirmaries, birthing homes and maternity

clinics.

115

PhilHealth website and “Annual Report 2014”, PhilHealth

116

Dr. Francisco Z. Soria Jr., PhilHealth. (2016). PhilHealth Benefits.

117

PhilHealth website.

118

PhilHealth. Circular No. 26, 2015.

119

PhilHealth. Annual Report 2014.

Table 4- 9 Maternity Care Package (in pesos)

Source: PhilHealth. Circular No. 26, 2015.

[New Born Care Package (NCP)

120

]

The NCP covers health services that newborns must receive within the first hours of life

regardless of the method of their delivery and presence of co-morbidities. Table 4- 10

summarizes the benefits and case rates.

120

PhilHealth. Circular No. 26, 2015.

Hospital

Non-

hospital

facility

Services, Conditions, etc. Allocation

MCP 6,500 8,000

Covers the essential health services during

antenatal period, normal delivery and immediate

post-partum period including follow-up visits

within the first 72 hours and 1 week after

delivery. Minimum stay of mother in the facility

shall be 24 hours. Avaliment of this package shall

be charged to the annual 45-day benefit limit.

NSD 5,000 6,500

Covers the essential health services during

normal delivery and immediate post-partum

period including follow-up visits within the first

72 hours and 1 week after delivery. Minimum

stay of mother in the facility shall be 24 hours.

Avaliment of this package shall be charged to the

annual 45-day benefit limit.

ANC01 1,500 1,500

At least 4 doctor check-ups are required with that

last check-up being in the last part of pregnancy -

i.e., last 3 months before delivery

Non-hospital facility→

eventual referral to hospital

650

Cesarean Section 19,000

Complicated Vaginal

Delivery

9,700

Breech Extraction 12,120

Vaginal Delivery after

Cesarean Section

12,120

40% to

professional

60% to

facility

Table 4- 10 Newborn Care Package (in pesos)

Source: PhilHealth. Circular No. 26, 2015.

[Others]

Other MDG-related benefit packages are summarized in Table 4- 11.

Table 4- 11 Other MDG Related Packages (in pesos)

Benefit Packages

Case Rates

Outpatient Malaria (MDG6)

Diagnostic malaria smears and other laboratory procedures; drugs and

medicines & consultation service

600

Outpatient HIV-AIDS (MDG6)

Drugs, medicines and laboratory examinations

30,000/Year

(7.500/Quarter)

Outpatient Anti-Tuberculosis Treatment (MDG6)

 Diagnostic exams, consultation services, drugs, health education and

counseling during treatment

4,000

Voluntary Surgical Contraception (MDG5)

 Health facility charges such as room and board, drugs and medicines

 Physician fee

 Post-operative consultation within 90 days from day of surgery

4,000

Animal Bite Package (MDG4)

 Rabies vaccine

 Rabies immune globulin

 Local wound care

 Tetanus toxoid and anti-tetanus serum

 Antibiotics

 Supplies such as syringes

3,000

Source: PhilHealth website

4-9 Claim Procedures

In order for members to claim PhilHealth benefits, members are to submit the following

documents to health service providers.

 PhilHealth ID and/or MDR

PhilHealth provides ID cards to members. Membership is good for one year, after which

renewal is necessary. MDR proves that individuals are enlisted as PhilHealth Members and

dependents must be enlisted in the MDR.

Services Offered under NCB Package

Reimbursement Allocation

Essential Newborn Care (including vitamin K

administration, first dose of hepatitis B and

BCG vaccine)

1,000

40% to

professional

60% to facility

Newborn Screening Test 550

Newborn Hearing Test 200

Total 1,750

100% to facility

 Document evidencing premium payments

Members must have made a payment of at least the 3-month premium for the last 6

months. In some cases, including MCP and NCP Packages, one-year premium payment is

required at the time of facility visit.

 Claim Form 1, 2 and 3

If necessary documents are properly submitted, the value of PhilHealth case rate is

deducted from the total medical bill upon discharge. PhilHealth will later send a benefit

payment notice to the PhilHealth members.

4-10 Accreditation Processes

121

Accreditation is a process whereby the qualifications and capabilities of health care providers

are verified in accordance with the guidelines, standards and procedures set by PhilHealth.

Health facilities and health care professionals need PhilHealth accreditation in order to receive

reimbursements to PhilHealth.

(1) Health Facilities

The conditions that a health facility must satisfy before applying for PhilHealth

accreditations are (1) no record of a medical accident for at least 3 years (with some

exceptions) following the approval of its practice by DOH, (2) provision of an official

quality standard program, and (3) accountability for its own medical practice. The

following facilities may apply for accreditation.

∙ Hospitals

∙ Dialysis clinics

∙ Outpatient clinics (Rural Health Unites/ Health Centers, Dispensaries, Birthing Homes, etc.)

∙ Ambulatory surgical clinics

∙ Birthing Homes (Normal Spontaneous Delivery)

∙ TB Clinics

Table 4- 12 is the number of the accredited facilities as of the end of December 2015.

121

PhilHealth website

Table 4- 12 Institutional Providers with PhilHealth Accreditations

Category of the Institutional Providers

Private

Public

Total

Level 1: Offers primary care services

444

310

754

Level 2: Institution situating between Level1 and Level3,

equipped with general ICU and ICU for newborns

254

303

Level 3: Highest level institution offering education,

emergency care, and etc.

115

Other than above

370

345

715

Total

1,135

752

1,887

% Total

60%

40%

100%

Source: PhilHealth (2016). 2015 Stats & Charts.

Table 4- 13 summarizes the number of accredited outpatient clinics, the number of cities

and municipalities with accredited outpatient clinics and the proportion of cities and

municipalities with accredited clinics for Primary Care Package (PCB1), Maternity Care

Package (MCP) and TB/DOTS Package (DOTS Package.). PCB1 is available in nearly all

cities and municipalities with more than 80 percent available for MCP and DOTS Package.

Table 4- 13 Number of Accredited Outpatient Clinics, Number and Percentage

of Cities and Municipalities with Accredited Outpatient Clinics

PCB1

MCP

DOTS Package

Number of accredited outpatient clinics

2,553

2,981

1,739

Number of cities and municipalities with

accredited outpatient clinics

1,567

1,268

1,286

Percentage of cities and municipalities with

accredited outpatient clinics

99%

80%

81%

Source: PhilHealth (2016). 2015 Stats & Charts.

(2) Professionals

Physicians, dentists and midwives need to be accredited in order to receive PhilHealth

reimbursements. To ensure continuous accreditation from NHIP, renewal must be

completed annually by no later than 45 days prior to their birthday.

4-11 Funding for PhilHealth

Figure 4- 3 shows the premium contributions to PhilHealth for the years between 2008 and

2015. Significant increase in the government subsidy for the year 2014 is attributed to Republic

Act (RA) 10351, or the Sin Tax Reform Act of 2012.

122

15 percent of the incremental revenue collected from the excise tax on tobacco and alcohol products

shall be allocated for programs to promote economically viable alternatives for tobacco farmers and

workers. Out of the remaining 85 percent of the incremental tax revenue, 80 percent is allocated for

Government/Sponsored includes Indigent Members, Sponsored Members,

Senior Citizens and contributions from Special Government Programs

Figure 4- 3 Premium Contribution to PhilHealth by Membership Categories (in pesos)

Source: PhilHealth. (2010-2015). Annual Report 2009-2014 and PhilHealth. (2015). Annual Audit Report on

PhilHealth for the Year Ended December 31,2015.

4-12 Cross Subsidy among PhilHealth members

NHIP consists of Members with different professions and income levels. Consequently, some

Members pay higher contributions and claim less benefits than others.

Table 4- 14 Premium Contributions and Benefit Claims for 2015 by NHIP Members

Source: Annual audit report for the year ended December 31, 2015

universal health care under the NHIP for the attainment of MDGs and health awareness programs, and

20% for medical assistance and health enhancement facility programs.

20,000

40,000

60,000

80,000

100,000

120,000

2008 2009 2010 2011 2012 2013 2014 2015

Formal Economy Informal Economy

Government/Sponsored* Total

Premium Contributions for 2015

(million P)

Membership Type Amount %

Formal Economy 40,544 40.7%

Informal Economy

6,803 6.8%

Indigent-NHTS 36,258 36.4%

Senior Citizens 13,045 13.1%

Sponsored Members

22.10 38.44 36.68 31.39 2.12 2.41 1.59

NHTS-PR

- 18.90 20.43 21.01 - - -

LGU/Regular

- 19.55 16.25 10.37 - - -

Covered Members

67.26 78.39 80.92 76.90 86.22 93.44 92.61

Projeted Population

90.89 95.60 95.88 97.70 99.56 101.45 102.90

Coverage Ratio(%)

74 82 84 79 87 92 90

(2) NHIP Utilization

Table 4- 16 summarizes the NHIP utilization rate, unique member claims reimbursed out

of the total eligible beneficiaries, from 2012 to June 2016. The rate has gradually

increased.

Table 4- 16 NHIP Utilization from 2012 to 2015NHIP

Year

Ratio of the Unique Member Claims

Reimbursed to the Total NHIP Members

2012

2013

2014

11%

2015

12%

6/2016

8% (January-June)

Source: “2012-2015 Stats & Charts”, PhilHealth

4-14 Supporting Indigents

(1) Facilitating Enrollments for Indigent Members

In 2011, PhilHealth adopted the National Household Targeting System for Poverty

Reduction (NHTS-PR) of the Department of Social Welfare and Development (DSWD) as

a means to identify indigent families. This has proved to be successful in increasing the

number of the Indigent Members in NHIP.

126

Families identified as indigent under the

NHTS-PR automatically become PhilHealth Members without any premium payment.

NHTS-PR is the system to determine whether a household is indigent through a proxy

means test

127

(PMT) that estimates the level of economic welfare of a household based on

its socioeconomic and demographic characteristics. DSWD, in collaboration with the

National Statistics Office (currently Philippines Statistics Authority), conducted a pilot

survey in 2007, thereafter conducting the first nationwide assessment in 2011.

NHTS-PR identifies indigents from the selected groups of population in order to make the

process efficient. On the basis of the Family Income and Expenditure Survey (FIES) and

Small Area Estimates (SMEs) results, all municipalities nationwide are classified as a

“very poor municipality,” which has more than 50 percent of Poverty Incidence (PI), and

the “moderate poor municipality,” which has less than 50 percent of PI. In the very poor

126

PhilHealth.

2011 Annual Report.

127

Income estimate survey based on the analyses of FIES and LFS, covering such items as household

members, their educations and professions, conditions of their house, access to basic services.

Face-to-face interviews are conducted based on the Household Assessment Form that consists of 34

questions on one double-sided sheet (Second survey is based on the Household Assessment consisting

of 52 questions.) There are two PMT Models – one for urban areas and one for rural areas

municipalities, all households are assessed. For the moderate poor municipalities, full

assessment is conducted only in pockets of poverty and for the rest of the moderate poor

municipalities, on-demand application was applied in which households are actively

encouraged to submit applications for assessment. In the first NHTS-PR assessment,

10,909,456 households in 489 very poor municipalities and 1,045 moderately poor

municipalities/cities were covered.

128

Interviews were conducted based on the Household

Assessment Form that consists of 34 questions. For the second NHTS-PR assessment, it

was converted into a Family Assessment Form as family is a more common unit to receive

social services (see Attachment 6). Reportedly about 55 million individuals, equivalent to

57 percent of the nationwide population, were covered in the first NHTS-PR assessment.

Thereafter, based on the latest Per Capita Poverty Threshold (PCPT) of each province, as

determined by the Philippine Statistics Authority (PSA), indigent households are identified

and listed in the Listahanan.

129

After posting the Listahanan in each community for some

period of time for the community members to request reinvestigation,

130

the Listahanan is

finalized and used for various social services.

Listahanan is mandated for renewal every four years, and the second assessment was

conducted from April to September in 2015. The data are currently analyzed. While the

first assessment was conducted on a household basis, the second assessment was

performed on the basis of the “family” unit, as are many social services, including NHIP,

are provided for a “family” (parents and children under 21),

131

instead of a household.

(2) No Balance Billing Policy

132

In addition to the NHTS-PR, PhilHealth adopted the No Balance Billing (NBB) policy for

the most common medical and surgical conditions in the country in 2011, to provide

optimal financial risk protection for the most vulnerable group, through PhilHealth Board

Resolution No. 1441, 2010. The NBB policy provides that no other fees or expenses shall

be charged or be paid for by the indigent patients above and beyond the packaged rates.

133

128

The National Household Targeting Office of the Department of Social Welfare and Development.

(2015). Listahanan.

129

Means list of household in Tagalog

130

On-site visits confirmed the postings of Listahanan at a community level. However, few residents

were aware of their rights for petitions.

131

Interview with DSWD (October 6

, 2016)

132

PhilHealth Circular No. 011-2011, New PhilHealth Case Rates for Selected Medical Cases and

Surgical Procedures and the No Balance Billing Policy

133

PhilHealth Circular No. 0003, s. 2014

The characteristics of NBB policy are as follows:

134

∙ The NBB policy is always applied when members are admitted to government health

facilities, while some private hospitals have adopted the NBB policy.

∙ The NBB policy is also applicable to non-indigent members for specific benefit

packages, such as the Maternity Care Package (MCP) and New-born Care Package

(NCP) in all accredited facilities.

In 2014, the NBB policy was expanded to cover Household Help, such as a household

driver and a housekeeper, as defined in the Republic Act 10361 or “Kasambahay Law.”

135

(3) Point-of-Care Enrollment Program

136

As mentioned earlier, the NHTS-PR is not able to reach all indigents in the Philippines.

Therefore, PhilHealth introduced another measure called the Point-of-Care (POC)

enrollment program in 2013 in order to cover non-NHTS-PR indigents. At health facilities

with POC accreditation, a Medical Social Worker (MSW) checks to see if the patient is

included in the list of PhilHealth Members, and if not, he/she conducts an interview. If the

patient is deemed indigent, the healthcare facility pays the annual premium of 2,400 pesos

and enrolls him/her into NHIP. POC is valid for a year and the patient is obligated to pay a

premium the following year to renew the membership. POC does not necessarily mean a

net cash outflow for a health facility because PhilHealth’s reimbursement usually makes

up for the premium payment of 2,400 pesos upon POC enrollment.

137

Adoption of POC is

mandated at all DOH-retained hospitals. LGUs and other health facilities need to obtain

approval by PhilHealth.

In enrolling patients through POC, an MSW estimates the patient’s monthly income based

on the interview compared with the PSPT

138

of the Region where the health facility exists,

and classifies the patient from A to D as stipulated in the DOH Administrative Order No.

51-A s. 2001, Implementing Guidelines on Classification of Patients and on Availment of

Medical Social Services in Government Hospitals (see Table 4- 17). The patient becomes

eligible for POC if she/he is categorized as C-3 or D. It should be noted that POC is the

PhilHealth program; however, the poverty threshold is set by PSA, while the patient

categorization into A to D is set by DOH.

134

PhilHealth Circular No. 011-2011

135

PhilHealth Circular No. 0003, s. 2014

136

PhilHealth Circular No. 0032. s.2013, October 14, 2013.

137

Interview with Jose Fabella Hospital

138

Refers to the PCPT for the region where a healthcare facility is located.

Table 4- 17 Patient Categories Based on the Ability to Pay

and Respective Payment Amounts

Patient

Category

Conditions for Qualification

Payment by Patient

Class A

Patient whose monthly per capita income is over 220% of

the latest PCPT for the region in which the hospital is

located, using a private room

Patient pays 100% of the

medical fee not covered by

PhilHealth

Class B

Patient whose monthly per capita income is over 220% of

the latest PCPT for the region in which the hospital is

located, using a shared room for 3 or more patients

Patient pays 100% of the

medical fee not covered by

PhilHealth

Class C-1

Patient whose monthly per capita income is between 180%

and 220% of the latest PCPT for the region where the

hospital is located

Patient pays 75% of the

medical fee not covered by

PhilHealth

Class C-2

Patient whose monthly per capita income is between 140%

and 180% of the latest PCPT for the region where the

hospital is located

Patient pays 50% of the

medical fee not covered by

PhilHealth

Class C-3

Patient whose monthly per capita income is equal to but

not more than the 140% of the latest PCPT for the region

where the hospital is located

The patient shall share any

affordable amount for

medicines provided and

ancillary services

rendered.

Class D

Patient whose monthly per capita income is less than

140% of the latest PCPT for the region where the hospital

is located

The patient shall not pay

for incurred hospital

charges.

Source: Administrative Order No. 51-A s. 2001, “Implementing Guidelines on Classification of Patients and on

Availment of Medical Social Services in Government Hospitals”

Despite the stipulation that POC can be utilized only once per Member, in reality, annual

membership renewal is not observed in many cases and some members wait until they are

hospitalized again and repeat POC.

139

Also there are some cases that A to C2 patients

insist that they cannot pay premiums and the health facilities have the MSW look for a

sponsor or become a sponsor himself/herself. When the MSW is unable to find a sponsor,

the MSW intentionally categorizes such patients as C3 or D. The patients classified as C1

and C2 are required to pay 25 percent and 50 percent of the medical bills respectively, and

encouraged to pay for the annual premium.

140

(4) Conditional Cash Transfer

The Conditional Cash Transfer (CCT) program in the Philippines, known as Pantawid

Pamilyang Pilipino Program (4Ps), is the social welfare program offered by DSWD. It was

introduced in 2008 with the objectives of providing monetary as well as social assistances

139

Interview with Dr. Jose Fabella Memorial Hospital

140

Interview with DOH Health Facility Development Bureau (October 4, 2016)

for poor families with children 0-18 years old.

141

Although CCT is outside the framework

of NHIP, this subject is briefly touched herein as both CCT and NHIP support indigents.

[Eligibility]

Poor households are identified by the NHTS-PR that employs a statistical model to

estimate income, as explained earlier. The following criteria must be satisfied to become

eligible for the CCT program.

142

∙ Residents of the poorest municipalities, based on the 2003 Small Area Estimates of

the National Statistical Coordination Board (incorporated into the Philippine Statistics

Authority today)

∙ Households are deemed to be “indigent” whose economic conditions are equal to or

below the provincial poverty threshold

143

∙ Households that have children 0-18 years old and/or have a pregnant woman at the

time of assessment

∙ Households that agree to meet conditions specified in the CCT program

As of August 26, 2015, there were 4,353,597 active household beneficiaries, 570,056 of

whom are indigenous households. The program also covers 10,235,657 schoolchildren

aged 0 to 18.

144

Eligible members are provided with ID cards and assigned to a health facility.

[Cash Grants and Conditions for Payment]

Two types of cash grants are provided to the household-beneficiaries:

∙ Health Grant: 500 pesos/ household every month totaling 6,000 pesos per year

∙ Education Grant: 300 pesos/ child every month for 10 months, totaling 3,000 pesos

per year

Cash grants are distributed to the household through the Land Bank of the Philippines or

any other alternate payment scheme, such as rural bank transactions.

141

Official gazette of the government of the Philippines. Pantawid Pamilyang Pilipino Program.

142

ibid

143

Poor Household, is identified through a “Household Assessment” survey conducted by DSWD,

recorded onto NHTS-PR by the same. First Household Assessment was conducted in 2009 and 2010

covering 17 million households, with the latest conducted in 2015 covering 20 million households.

Results of the 2015 survey are being complied as of the date of this writing.

144

Official gazette of the government of the Philippines. Pantawid Pamilyang Pilipino Program.

To receive the cash grants, all of the following conditions must be met by the household

beneficiaries.

145

1. Pregnant women use pre- and post-natal care, and be attended during childbirth by a

trained professional

2. Parents or guardians attend family development session with topics, such as

responsible parenting, and health and nutrition

3. Children aged 0-5 receive regular preventive health check-ups and vaccines

4. Children aged 6-14 receive deworming pills twice a year

5. Children-beneficiaries aged 3-18 enroll in school, and maintain an attendance of at

least 85 percent of class days every month

Compliance rates are generally high. In March and April 2015, for instance, the lowest

compliance rate was 94.84 percent for the condition 2 above.

146

[Promotions of NHIP Benefits to CCT Beneficiaries]

Although the CCT beneficiaries are automatically enrolled with NHIP, 5-6 percent of the

CCT beneficiaries are not aware of this fact.

147

Also, their NHIP utilization rate is low. In

order to promote NHIP utilization by CCT beneficiaries, DSWD is engaged in the

following promotional activities:

∙ PhilHealth representatives conduct seminars to explain PhilHealth benefits to CCT

beneficiaries.

∙ DSWD recommends health facilities place signboards indicating that the CCT

beneficiaries will not need to shoulder medical bills as they are automatically covered

under the NBB policy of NHIP, as there are many cases wherein patients are hesitant

to go to health facilities for fear of having to pay medical bills.

145

Official gazette of the government of the Philippines. Pantawid Pamilyang Pilipino Program.

146

ibid

147

Interview with DSWD

Chapter 5 Maternal and Child Health Services in Bicol and

Eastern Visayas Regions

5-1 Bicol Region (Region V)

(1) Regional Profile

① Socioeconomic Profile

Bicol region is comprised of the southern part of Luzon with six provinces. Legaspi city

and Naga city are the center of commerce, finance and transportation, while the main

industries of the region are agriculture and fishing. The economic growth rate in 2015 was

the highest in the country at 8.4 percent, however, the GDP per capita was the second

lowest with 25,648 pesos after ARMM.

148

Provincial populations in Bicol region is

shown in Table 5- 1.

Table 5- 1 Provincial populations in Bicol Region (in thousand)

Population

Population Growth Rates

2000

2010

2015

2010-2015

Albay

1,091

1,233

1,315

1.22

Camarines Norte

471

543

583

1.38

Camarines Sur

1,552

1,822

1,953

1.32

Catanduanes

215

246

261

1.11

Masbate

708

835

892

1.28

Sorsogon

651

741

793

1.30

Region

4,688

5,420

5,797

1.29

Source: Philippine Statistics Authority

② Maternal and Child Health (MCH) Status

Figure 5- 1 shows the trend of maternal mortality rate (MMR) in Bicol based on FHSIS

data, which are different from that of the Albay Provincial Health Office whose number of

matarnal death was 44 in 2014, 29 in 2015 and 6 up to July 2016. Although it is generally

believed that quality of FHSIS data is not high, the number of maternal death differs

depending on whether it is counted based on the patient residential area or the area of

occurrence. On the other hand, the DOH Regional Office reported that, since 2015, the

number of deaths has been registered based on the patient residential area and the data of

the private health institutions have been included in the Field Health Service Information

System (FHSIS) to enhance credibility. However, as a result, it has become difficult to

compare the data before and after 2015. In Bicol region, maternal and newborn death

review was introduced in 2015 as requested by the central government.

148

Philippines Statistics Authority 2016

Figure 5- 1 Trend of maternal deaths and MMR in Bicol

Source: FHSIS from DOH Bicol Regional Office

Most of maternal deaths have occurred at Level 3 hospitals or on the way to hospitals in

the Philippines. Table 5- 2 shows the number of deaths at two regional hospitals in Bicol. It

has slightly improved in 2016.

Table 5- 2 Number of maternal deaths at tertiary hospitals

2013

2014

2015

2016

Bicol Regional Training and Teaching Hospital (BRTTH)

16 (Aug)

Bicol Medical Center (BMC)

5 (June)

Source: BRTTH and BMC

Facility-based delivery (FBD) has been increasing in all areas as shown in Table 5- 3. On

the other hand, the rate of antenatal care (ANC) visits has been around 50 percent in the

region and no major change has been seen over the last few years.

Table 5- 3 Proportion of FBD (%) by province/city

Province/City

2011

2012

2013

2014

2015

Albay

67.7

76.5

90.1

87.7

Cumarines Norte

38.2

68.5

81.7

Cumarines Sur

19.9

38.7

37.2

58.6

63.7

Catanduanes

79.1

85.7

88.6

90.3

90.4

Masbate

30.5

42.6

75.4

Sorsogon

85.9

91.9

93.8

94.8

96.1

Iriga city

34.5

7.8

13.5

89.6

Legaspi city

44.9

100

33.1

95.4

98.2

Naga city

42.1

44.8

71.2

88.2

Region

46.5

57.2

61.9

78.9

86.2

Source: FHSIS from DOH Bicol Regional Office

The infant mortality rate (IMR) in Bicol is shown in Table 5- 4. While it has been static

over the last five years, it is lower than the national average.

100

120

100

120

140

2011 2012 2013 2014 2015

No of Death

No of Death MMR

Table 5- 4 IMR by province/city

Province/City

2011

2012

2013

2014

2015

Albay

8.1

8.4

5.6

4.5

4.2

Cumarines Norte

15.3

13.2

9.6

9.9

Cumarines Sur

11.8

4.9

5.3

4.4

Catanduanes

8.6

7.4

8.9

18.7

7.9

Masbate

7.3

18.1

20.5

Sorsogon

6.2

9.1

7.3

6.9

5.1

Iriga city

12.8

5.2

19.3

14.4

Legaspi city

10.6

2.4

14.2

5.6

Naga city

12.8

15.9

10.9

20.8

Region

9.7

8.8

8.5

10.5

7.1

Source: FHSIS from DOH Bicol Regional Office

③ Health Governance

The DOH Bicol Regional Office is composed of the Local Health Support Division

(LHSD), Licensing, Regulation and Procurement Division and Management Support

Division. LHSD is in charge of technical projects and the Family Health Cluster under

LHSD is responsible for MCH. The LHSD total budget in 2016 is 194 million pesos and

the budget of the Family Health Cluster in 2016 is 26 million pesos. Provinces develop a

three-year Local Investment Plan for Health (LIPH) and receive their budget from the

DOH regional office based on the approved plan.

The number of hospitals registered in the region is shown in Table 5- 5. Several hospitals

have been downgraded to infirmaries in 2015 through the new DOH hospital criteria.

While private hospitals are mainly located in the urban areas, private lying-in clinics exist

in most of the municipalities.

Table 5- 5 Registered number of public and private hospitals (2015-2016)

Type

Public

Private

Level 3 hospital

2 (DOH)

Level 2 hospital

4 (LGU)

Level 1 hospital

16 (LGU)

Source: DOH Bicol Regional Office

(2) Overview of Study Sites

The study was conducted in two provinces – Albay and Camarines Sur (CS) out of the six

provinces in Bicol.

[Albay]

Albay province is the center of Bicol region and the Provincial Health Office and the

PhilHealth Regional Office exist. The provincial health budget was 220 million pesos in

2016. In principle, 20 percent of the provincial budget should be allocated to the health

sector, however, the proportion is lower than that now. There is also the fund based on the

three-year LIPH.

Regarding public health facilities, the Bicol Regional Training and Teaching Hospital

(BRTTH), Level 3 hospital, is in Legaspi City, and there are four Level 1 hospitals as of

2015. FBD rate and the proportion of women receiving more than 4-time ANC are higher

than the national average.

[Cumarines Sur]

Cumarines Sur (CS) is located in the center of Bicol region and it has the largest land area

and population in the region. The provincial health budget was 20 million pesos in 2016.

There is also transferred budget from DOH, but it is usually insufficient. It was also

reported that size of the staff is also insuffient in order to execute all the health programs.

Another Level 3 hospital in the region, the Bicol Medical Center (BMC), is located in

Naga City and there are three Level 1 hospitals, including the Naga City Hospital, in CS.

Currently, a provincial hospital is being constructed. In Naga City, outside the provincial

governance, there is the Naga City Hospital and an infirmary. In CS, FBD rate is lower

than other provinces.

(3) Study Findings

[Study sites]

The study sites in Albay and CS provinces are shown in Table 5- 6. The visits/interviews

were conducted with LGU health offices, RHU, BHS, public and private health facilities,

PhilHealth offices and community members.

Table 5- 6 Study Sites and Community Interviewees

Province

City/Municipality

Barangay

Interviewees

Albay

Malinao

Balading, Burabad

Pregnant and lactating women

Camarines

Sur (CS)

Naga City

(Independence city)

Panicuason, San Isidro

Husbands

Pamplona

Batang, Poblacion

Women with grand children

Sipocot

Binahian

TBA

Source: JICA Survey Team

[Supply Side]

1) Service Delivery

While all the RHUs were supposed to be equipped with a delivery facility, the study

team observed that some of them did not have a delivery facility due to the lack of

human resources or insufficient infrastructure. It is desirable for RHUs to have a

delivery facility particularly in remote areas where no public hospitals or private

lying-ins are available. The cost of MCH services at visited RHUs is free based on

municipal policy, which could be user-friendly for community members, but it could

also burden health facilities unless enough resources are provided by the municipal

government.

Some of the district or municipal hospitals, which were downgraded to infirmaries in

2015, explained that the high-risk cases are now immediately referred to the regional

hospital as they can no longer take care of high-risk cases under the current mandate.

There are two Regional hospitals in Bicol that are located in Albay and CS provinces.

Most caesarean sections and/or high risk cases in the Region are referred to the two

hospitals. In addition, many women prefer the well-equipped Regional hospital even for

normal delivery; caesarean section accounts for approximately 30 percent of total

deliveries at the regional hospitals. Consequently, those two Regional hospitals are

always highly overcrowded and it could at times effect the implementation of

emergency operations, their original mandate. It was observed that two to three women

and their babies were sleeping in one bed. The regional hospital is considering

establishing a BEmONC for normal delivery within the compound of the hospital, so

that the Regional hospital as CEmONC could focus on high-risk cases as mandated.

2) Referral and SDN

The DOH regional office has been

strengthening/reactivating the delivery

networking system in the Region with

the assistance of LuzonHealth. In Albay,

the province was divided into three zones

and Inter-local Health Zone (ILHZ) and

Service Delivery Network (SDN) have

been established in each zone. ILHZ is

led by municipalities and its purpose is to

coordinate public health issues among

Figure 5- 2 Rural Health Unit

in Camarines Sur

concerned municipalities. In terms of SDN, the province issued the ordinance of the

MCH SDN and it included the public as well as private health facilities. Collaboration

with private facilities was obtained by providing them with free training and

information. Regular meetings are held separately for ILHZ and SDN.

In CS, there was one functioning ILHZ, called CASILI, with the three municipalities of

Cabusao, Sipocot and Libmanan. It started activities in 2005 when three municipalities

issued a joint ordinance on the MCH ILHZ. This joint ordinance enabled ILHZ to

continue functioning for the last 10 years even with a change of mayors as the joint

ordinance could not be invalidated unless all mayors agree. They hold a joint trust fund

with approximately 500,000 pesos of annual budget and developed a three-year plan for

the fund. Activities include joint procurement of drugs from the Regional stock yard,

bulk printing of reporting formats/booklets, death review, and discussions on common

issues. Private facilities were also involved in ILHZ and vaccines were provided free of

charge by the municipality health offices. ILHZ reactivation in the other areas was

planned; however, the issuance of joint ordinance with multiple municipalities appeared

to be challenging.

BOX 5- 1 Story of RHU Medical Doctor outside CASILI Zone

There is also a plan led by the DOH regional office to establish an inter-facility referral

system in CS. Based on the successful experience in Albay, a meeting is going to be

held with various stakeholders including public and private health facilities – both

hospitals and non-hospitals – to discuss the issues, such as the development of referral

policies/guidelines and the standardization of the referral format.

When an ambulance referring a pregnant woman to BMC passed by our RHU, I received

a call from them. I immediately went to the ambulance and gave the woman oxygen, but

I could not save her. There was only her husband and no medical staff attended her in the

ambulance. I wished I had received a call earlier, so that I could have collaborated with

other medical staff and provided her with better service. However, unfortunately, one can

only receive medical services from the RHU in the residential area.

3) Maternal Death Review

The majority of maternal deaths reportedly occur

at referral hospitals or on the way to the

hospitals. A death confirmed within 72 hours

from arrival is registered as non-institutional and

such cases account for around half of the deaths

at the Regional hospitals in Bicol. The two

Regional hospitals attempt to strengthen death

review activities that lead to concrete actions to

reduce the number of maternal deaths.

Bicol Regional Training and Teaching Hospital (BRTTH) receives referral cases within

and outside the province including Catanduanes and Sorsogon. It accounts for the

highest number of deaths in the region. The hospital strengthened its efforts on maternal

death review in 2015.

BOX 5- 2 BRTTH leadership (Story of DOH Regional Officer)

The maternal death review has been given strong leadership from the hospital chief. The

comprehensive and in-depth review of all deaths, namely route cause analysis,

identification of three delays, referral condition, direct death cause audit and so on was

conducted at an internal conference in 2015. Concrete recommendations and action plans

have been developed as a result. BRTTH also sought to improve collaboration with other

health facilities through participation in SDN/ILHZ meetings, provincial death review or

other opportunities and advocacy for promotion of effective referral policies/guidelines.

4) NHIP Implementation and Utilization

The number of NHIP accredited health facilities has been increasing annually in Bicol.

As of August 2016, there were 292 NHIP-accredited health facilities, 187 of which were

primary health facilities and 105 were hospitals, and 186 NHIP-MCP accredited health

facilities, 99 of which are public facilities and 87 are private facilities. The PhilHealth

office conducts regular monitoring including surprise visits to the health facilities to

ensure adherence to various policies including the No Balance Billing (NBB) Policy.

The office also visits municipalities once a year and conducts awareness-raising

campaigns for communities.

Figure 5- 3 BRTTH

Two regional hospitals follow the NBB

Policy and Point of Care (POC) program.

However, as described below, there were

some cases in which indigent people

could not utilize POC at the public

hospitals. PhilHealth-accredited private

facilities are also supposed to follow the

NBB and the POC Policies. The

adherence rate has been increasing due to

PhilHealth regular monitoring. Full

implementation by private facilities is PhilHealth’s current challenge.

The online system has been gradually operationalized in Bicol. The

improvement/correction of the database is required for smooth and full scale operation.

Also, it is ideal to make online payment claims possible as it is currently only accepted

in the PhilHealth provincial office. The disbursement of NHIP benefits for LGU-owned

hospitals is made to LGU bank accounts and some LGUs do not allocate facility fees

properly to the appropriate health facilities.

According to the PhilHealth Bicol Regional office, currently there are more benefit

claims than collected premiums in Bicol. Loss has been offset by other regions;

however, there was a concern that the premium amount would have to be reviewed soon

if utilization keeps increasing. The current challenges include full implementation of

NBB Policy for both public and private facilities, behavioral changes of the community

in remote areas and an increase in the number of PhilHealth officers in provincial and

regional offices.

Overall, NHIP introduction is seen to have contributed to the improvement of public

health services in the Region (see BOX 5- 3).

BOX 5- 3 Story of Provincial Health Officer

Public hospitals used to lack medical specialists, such as obstetricians or anesthetists, due

to a deficiency in the market. Now that the NHIP professional fees are available, specialists

go under contract with multiple public hospitals and receive payment per service. The

experienced doctors have improved the quantity and quality of services at the public

hospitals in Bicol. The regional hospitals are also making efforts to provide incentives for

the retention of experienced doctors, by providing them with private rooms where patients

receive exclusive care with extra professional fees.

Figure 5- 4 PhilHealth Bicol

regional office

5) NHIP Awareness

Awareness of NBB Policy and the POC program varies from facility to facility. In

general, the knowledge level of NHIP is found to be sufficient among LGU and regional

hospital personnel and adherence to NHIP policies was established in the regional

hospitals.

On the other hand, the knowledge level among barangay personnel, including BHWs,

seems to be limited. The NHIP Indigent Member list was produced by the DSWD and

PhilHealth distributed Member Data Record (MDR) based on the list to the members via

RHUs. The personnel at visited barangays mentioned that while they were aware of the

NHTS-PR assessment mission to have visited their community for the purpose of

producing the NHIP Indigent Member list, they did not receive feedback from the

assessment team and did not know how the list was produced.

Figure 5- 5 Barangay Health Station in Camarines Sur

For the community members, information on NHIP was usually provided through the

PhilHealth advocacy campaign held annually at all municipalities, monthly education

sessions for 4P beneficiaries and household visits and health education by BHWs. Some

of the BHWs, who were members of Community Health Team (CHT) or focal persons

for NHIP, have opportunities to receive information from LGUs or PhilHealth.

However, in general, there is limited opportunity for the BHWs. Therefore, community

members, except for 4P beneficiaries, tend to have limited knowledge about NHIP.

6) LGU Financial Assistance

Most of LGUs, barangays, and RHUs own ambulances or public transportation, such as

police or security vehicles, that can be used free of charge or with a nominal fuel fee for

emergency cases, including delivery. Some barangays established emergency

transportation funds to hire registered private vehicles to be used for delivery for free.

At the same time, interviews with pregnant and lactating women reveal that many are in

fact paying for transportation to go to a health facility. Details will be described below.

Provision of NHIP sponsorship by LGUs varies depending on the LGU’s priority issues

and budgetary situation.

LGUs informed TBAs of the prohibition on home delivery, and some of them are

proactively involved in safe-motherhood efforts by providing incentives for bringing

pregnant women to health facilities.

7) Effects of Devolution

The level of health service delivery depends on the capacity and leadership of the LGU.

The LGU leader is elected every three years and this can make it challenging to

maintain a high level of commitment and resources. The collaboration among health

facilities managed by different LGUs is also not easy. Under these circumstances, the

DOH Bicol Regional Office showed strong leadership to strengthen the Service

Delivery Networking and coordination mechanism among concerned facilities and

LGUs, and expanded good practices in different provinces. The DOH Reginal Office

would play an important role under the devolution in improving the collaboration among

various stakeholders and assisting resource-limited LGUs.

[Demand Side]

1) Health Service Utilization

There are still 15 percent home deliveries occurring in Bicol and it appears to be more

prevalent in the remote areas. However, it has been decreasing rapidly mainly due to the

issuance of the LGU ordinance on home delivery prohibition. Midwives/health care

providers at BHSs/RHUs constantly advise pregnant women to deliver at a health

facility. Family members also tend to

suggest the same for the sake of safe

delivery.

The majority of women responded that

they respected health care providers at

BHS/RHU or hospitals and followed

their advice for safe motherhood. Most

of those who were diagnosed high risk

Figure 5- 6 Group discussion

with pregnant and lactating women

had additional laboratory tests at a private facility or were referred to the regional

hospital.

On the other hand, several negative opinions were stated that the public health facilities

were overcrowded, required long wait times, provided insufficient treatment/services, and

the health care providers had disrespectful attitudes. Particularly the over-crowdedness of

the regional hospitals was emphasized by women and BHS/RHU health workers.

However, many of them took it for granted and they said that they do not have high

expectations for the public health facilities. There were a few cases of home delivery that

could have been avoided if addressed in better ways at the facility or health care providers,

as described in BOX 5- 4.

BOX 5- 4 Home delivery cases

One case involved a woman who went to the hospital with her husband for delivery, but the

midwife told them it was not time and sent them back home. As soon as they reached

home, the woman’s water broke and she went into labor. They immediately called a TBA

and the woman delivered at home.

Another case was a teenage mother who went to a private lying-in facility but was advised

to go to the hospital as a maternal age below 19 years old could not be accepted at a

non-hospital to receive the NHIP benefits. She did not consult with anyone and did not go

to the hospital, then ended up with a stillbirth delivery at home.

Better off families tend to pay extra fees, around 20,000 pesos, and use a paid room in

the public hospital where they can have an exclusive doctor and nurse with better

facility conditions. Private facilities are also cleaner and the health care providers have a

better attitude compared to the public facilities. Therefore, many women prefer the

private facilities despite additional fees for drugs or bed linens.

2) NHIP Enrollment and Utilization

NHIP Enrollment rate in the Bicol region is 89 percent as of June 2016. The detail is

summarized in Table 5- 7. Utilization rate of MCP has been rapidly increasing in recent

years (see Figure 5- 7).

Table 5- 7 NHIP coverage by sector and by province in Bicol as of June 2016

Source: PhilHealth regional office V

Figure 5- 7 MCP utilization amount in Bicol (up to June in 2016)

Source: PhilHealth regional office V

Among the interviewed women, all of them were NHIP members and had utilized MCP

benefits. They unanimously stated that this was extremely helpful. It was reported that

around 75 to 90 percent of households were indigents in the visited barangays. In the

ANC session, they were advised to save money as part of a birthing plan, but most of

them did not have enough income for saving. Many of them previously used to borrow

money from relatives or friends for delivery costs. However, thanks to NHIP benefits,

they said that they do not have to borrow

money or reduce expenses on food or

other essential items anymore.

However, not all indigents are covered by

the NHIP and availability of LGU

sponsorship varies as stated earlier. The

coverage of indigents by NHIP was

reportedly around 30-50 percent in the

visited barangays.

Formal

economy

Informal

sector

Indigent Sponsored

Migrant

w orker

Lifetime

Senior

citizen

Coverage

rate

Albay 273,987 42,941 671,515 28,795 13,438 26,110 96,068 87%

Camarines

Norte

88,589 38,390 329,253 9,573 7,037 10,844 43,136 89%

Camarines

Sur

329,270 73,356 1,087,065 15,161 21,081 28,805 83,202 83%

Catanduanes 44,502 6,939 176,247 1,620 2,070 6,524 13,831 95%

Masbate 91,445 10,327 707,892 15,552 1,920 7,660 23,333 95%

Sorsogon 125,518 24,711 619,876 2,439 5,822 11,065 34,748 113%

Region 953,311 196,664 3,591,848 73,140 51,368 91,008 294,318 89%

100

200

300

400

500

600

2011 2012 2013 2014 2015 2016

Million pesos

Figure 5- 8 Barangay houses

in Camarines Sur

In terms of the knowledge among communities, the majority of women knew about free

MCH services by NHIP benefits at PhilHealth accredited facilities. However, the

information, requirements and conditions for the NBB and POC Policies were unknown

to most of them. Regional hospitals reported that many referred women who were

indigents could not receive POC as they could not submit the required documents of

birth and marriage certificate on time. Community members, except for 4P beneficiaries,

did not seem to have enough opportunities to receive NHIP-related information.

3) Barriers to health services

Meanwhile, there were many women among the interviewees who would still prefer

home delivery if there were no ordinance. Barriers or challenges inhibiting their access

to health facility services mentioned during the interviews are described below.

 Medical Fee: In principle, the MCH-related medical fees are covered by NHIP for

its members at the PhilHealth accredited facilities. However, there were many

cases that out-of-pocket payment was required for some purposes, such as (1)

drugs as the facilities often run out of stock and patients need to purchase outside

the facility, (2) gloves or baby’s diapers, and (3) new-born screening. The amount

of payment ranges from 200 to 3,000 pesos at public and private facilities. The

laboratory test, such as ultrasound for high-risk cases, is usually not available at

BHSs/RHUs and it costs a woman 750-1,000 pesos at a private health center.

For those without NHIP, the public hospitals usually charge 2,000 to 5,000 pesos

for a normal delivery. Even without NHIP, indigents are supposed to be covered by

POC. However, in fact, some of the indigents report that they had made payments

at a public hospital. There are also cases, as described earlier, that POC cannot be

utilized due to the failure of document submission within the defined period.

 Transportation: As previously mentioned, most hospitals or LGU health offices

provided public transportation for free or with nominal fees for delivery. The

transportation fees were claimed to be big burden. However, interviews revealed

that more than half of the women had paid for transportation. Those who lived in

the center of a city or municipality 10-20 minutes from a health facility paid 200 –

300 pesos round trip, and those who lived in remote areas 1 – 1.5 hours from a

health facility required 1,000 pesos to reach a district hospital by boat and vehicle,

and 1,500 pesos to reach a regional hospital. It would take much more time and

cost for people living in very remote areas or outside two provinces, to reach a

referral hospital.

 Others: In addition to the cost for accompanying family members for

accommodation, food and transportation, some indigent women buy new clothes as

they feel embarrassed to wear old clothes in front of other people. Additionally,

payment is required for caretakers for their children or other family members while

they are away from home.

The majority of women answered that they could make the decision on where to deliver

on their own. Many pregnant women, who had previously delivered at home, stated that

they were planning to give birth at a facility this time as home delivery had been

prohibited. Their mothers, who predominantly delivered at home, also suggested to have

a facility-based delivery for their safety.

On the other hand, a few women answered that they had followed the advice of their

mother, husband or TBA for the first delivery. There was a case of a husband who

decided on home delivery due to financial constraints and his wife had no say. The TBA

charges 1,500 – 2,500 pesos, but payment on credit or installments is usually accepted.

However, health facilities do not discharge the patient unless payment is complete.

Women who have experienced home delivery frequently mention that they never

experienced complications or problems at home and never heard of maternal death in

their communities.

149

Therefore, it seemed that they do not feel they face risk in

delivery. They said that the home delivery was more convenient as they could do

housework until the last minute and almost right after the delivery. Facility-based

delivery requires time, money and preparation work. It was also mentioned that finding

a caretaker for children is not easy. Several of them had home deliveries due to

unavailability of caretakers.

BHSs/RHUs and hospitals regularly conduct pregnancy educational sessions and

encourage women to come with their partners. However, it was reported that not many

men actually participated in the session. In terms of family planning, the majority of

interviewed women were using or had used some kind of contraceptive devices, despite

149

Doctors, midwifes or nurses at BHSs/RGUs reported a few cases of maternal and neonatal deaths and

still births in the community and inappropriate practices of TBA or birth attendants in the home

deliveries.

the fact that all of them were Catholic. Some mentioned that they had received

information on family planning at the church. Thus, it was inferred that the access to

family planning was not a big challenge for most of women. However, it was still not

rare to have a big family with more than 10 children.

150

5-2 Eastern Visayas (Region VIII)

(1) Regional Profile

① Socioeconomic Profile

Eastern Visayas Region is located in the eastern part of the Visayan islands in central

Philippines, composed of Samar, Leyte and Biliran islands. It has six provinces, one

independent city (Ormoc city), 1 highly urbanized city (Tacloban city) and five component

cities with 4.4 million population in 2015.

151

Tacloban is considered as a regional center

for commerce, transport, culture and trade. Main industries of Eastern Visayas include

farming (such as rice and coconuts), fishing, mining and tourism. Nevertheless, the region

has the second highest poverty incidence among families in the country.

152

In November

2013, Typhoon Yolanda devastated the region. Table 5- 8 shows populations of provinces

and a highly-urbanized city. The population of Leyte province except that of Tacloban City

is the largest, followed by Samar province.

153

Table 5- 8 Provincial populations in Eastern Visayas Region (in thousand)

Population

Population Growth Rates

2000

2010

2015

2010-2015

Biliran

140

162

172

1.13

Eastern Samar

376

429

467

1.64

Leyte

1,414

1,568

1,725

1.83

Northern Samar

501

589

632

1.36

Samar

641

733

780

1.19

Northern Leyte

360

399

422

1.05

Tacloban City

179

221

242

1.73

Region

3,611

4,101

4,440

1.52

Source: Philippine Statistics Authority

150

The total fertility rate in Bicol Region was 4.6 on the basis of the NDHS 2013. cf. The national total

fertility rate was 3.0 and that in Eastern Visayas was 4.0.

151

Philippines Statistics Authority, 2016.

152

The poverty incidence among families in Eastern Visayas is 37.4% in 2012 according to the

Philippines Statistics Authority.

153

Samar province is also called Western Samar province.

② Maternal and Child Health (MCH) Status

Figure 5- 9 MMR and IMR of Eastern Visayas

Source: DOH Eastern Visayas

Although MMR and IMR of Eastern Visayas Region declined after 2013, not much

improvement has been observed in the past five years (see Figure 5- 9). With regard to

FBD rates, all provinces have experienced significant improvements (see Table 5- 9).

Table 5- 9 Provincial FBD Rates in Eastern Visayas

Source: DOH Eastern Visayas

On the other hand, the FHSIS data for maternal deaths and infant deaths collected by the

DOH are calculated based on the location of the occurrence of death instead of the

residential location of the deceased. For instance, MMR in Tacloban city (359.42 per

100,000 live births) and Ormoc city (185.19 per 100,000 live births) are higher due to the

100

120

140

2011 2012 2013 2014 2015

IMR/ 1,000 live births

MMR/100,000 live births

MMR IMR

Province 2011 2012 2013 2014 2015

Biliran 95.7 95.93 99.1 97.45 97.2

Eastern Samar 64.5 74.5 82.9 88.26 91.92

Northern Leyte 7.8 80.21 87.19 90.7 92.99

Nothern Samar 29.36 41.94 52.93 64.3 77.8

Southern Leyte 78.56 64.87 74.68 97.08 98.55

Samar 34.33 30.84 57.82 72.49 81.56

Calbayog City 26.32 34.37 38.4 47.01 66.94

Massin City 84.8 90.56 96.85 99.17 98.02

Ormoc City 75.15 86.43 91.17 90.88 96.87

Tacloban City 86.72 89.6 86.62 85.51 94.64

Region-wide 62.21 66.25 75.81 83.08 89.05

presence of high level hospitals

154

while in Leyte province excluding those cities has a low

MMR (41.51 per 100,000 live births). Such calculations make it difficult to have a grasp of

the situation of maternal deaths in different areas.

155

Health facilities registered at the DOH Regional Office in Eastern Visayas are listed in

Table 5- 10. It shows that 44 percent of them are located in Leyte province where Tacloban

city is. In addition, Level 3 hospitals are limited to one government hospital (EVRMC:

Eastern Visayas Regional Medical Center) and one private hospital in the entire Region.

Table 5- 10 Registered Health Facilities in Provinces of Eastern Visayas

(As of August 2, 2016)

156

Source: DOH Eastern Visayas

In addition to the fact that there is only one government Level 3 hospital, due to the

improved referral system and resultant increased facility-based deliveries in recent years,

the numbers of deliveries and maternal deaths are increasing at the EVRMC as shown in

Table 5- 11. According to the obstetrics and gynecology (OBGYN) doctors, normal

deliveries at the EVRMC have decreased because more BEmONC facilities were

established, but the number of referred cases with complications has gone up.

154

Other data are as follows: Eastern Samar 103.26, Northern Samar 99.29, Biliran 98.72, Samar 60.73,

and Southern Leyte 18.44.

155

In addition, in Leyte province, the deaths of residents were counted between 2010 and 2014 while the

location of occurrence was considered in 2015, which makes it impossible to analyze changes over

time.

156

Leyte province here includes Tacloban city and Ormoc city. The category of “other” includes clinical

labs, dental labs, drug testing labs and x-ray.

Level 1 Level 2 Level 3

Government

1 0 0 0 11 0

Private

0 0 0 0 0 6

Government

10 0 1 7 33 10

Private

3 5 1 4 16 66

Government

1 1 0 9 9 1

Private

6 0 0 0 3 12

Government

2 0 0 6 15 5

Private

1 0 0 2 1 10

Government

4 0 0 2 21 2

Private

2 1 0 1 3 12

Government

2 1 0 4 16 3

Private

4 0 0 3 0 15

Samar

Southern Leyte

Other

Biliran

Leyte

Eastern Samar

Northern Samar

Province

Government

or Private

Hospital

Infirmary

Birthing

Home

Table 5- 11 Deliveries and Maternal Deaths at EVRMC

Source: EVRMC

③ Health Governance

Under the leadership of the Regional Director, the DOH Regional Office of Eastern

Visayas is composed of the Local Health Support Division, the Health Standards

Regulation Division and the Management Support Division. Maternal and child health is

handled by the Family Health Unit under the Local Health Support Division.

157

The role of the Regional Office includes (1) implementation of policies developed by

central DOH, (2) technical assistance and monitoring and evaluation of programs and

facilities under LGUs (provincial and municipal/city levels), (3) provision of vaccinations,

contraceptives and medicines, and (4) compilation of FHSIS data. Moreover, each

province submits its three-year Local Investment Plan for Health through the Regional

Office and is given budget support of approximately 1.6 million pesos of Fixed Tranche

and 0.7 million pesos of Variable Tranche

158

each year.

159

Based on the devolution of power in the Philippines, health governance of provincial and

municipal/city levels is under the jurisdiction of the respective LGUs. Nevertheless, by

deploying several Development Management Officers (DMOs) who have coordination,

technical assistance and data collection responsibilities to each province, the Regional

Office has a direct management mechanism at the LGU level.

160

The office also deploys

157

The Local Health Support Division is composed of the Health Systems Development Section which

manages the Health Systems Development Unit, the Hospital Systems and Other Support System Unit

and the Health Facility Development Unit and the Local Health Technical Assistance and Program

Management Section which manages the Family Health Unit, the Communicable Disease Unit, the

Non-Communicable Disease and Health Promotion Unit and the Environmental and Occupational

Unit.

158

Variable Tranche is determined by the performance of the previous fiscal year according to the LGU

Scorecards.

159

Some of the support for the LIPH includes activities by ILHZ, trainings and procurement of

medicines.

160

In Northern Samar, there are 8 DMOs, 283 NDPs and 64 RHMPPs. In Eastern Samar, there are 6

DMOs, 219 NDPs and 55 RHMPPs.

2013 2014 2015

Total No of deliveries 4,498 5,152 5,426

(No of live births) 4,346 4,992 5,254

(No of stillbirths) 152 160 172

No of maternal deaths 18 20 23

No of OB referral cases 1,546 1,650 2,415

nurses and midwives to RHUs through the Nurse Deployment Program and the Rural

Health Midwives Placement Program (RHMPP) for human resource strengthening.

The DOH Regional Office of Eastern Visayas has recently set regional strategies under the

Strategic and Operational Plan (2017-2021). The Plan identifies five strategic goals: (1)

development, enhancement and maintenance of health systems and health financing, (2)

quality standardization of health facilities including PhilHealth accreditation, (3)

development and enhancement of health human resources, (4) health information

strengthening, and (5) building the Service Delivery Network.

161

(2) Field Study

Among six provinces in Eastern Visayas region, the Survey conducted field studies in

Eastern Samar and Northern Samar.

[Northern Samar]

More than half of the 24 municipalities and 569 barangays in Northern Samar province are

identified as GIDA areas. The Northern Samar Provincial Hospital in Catarman city,

registered as a Level 1 hospital, is the end referral within the province.

162

There are six

district hospitals, five private hospitals, 24 RHUs and 108 BHS. As indicated in Table 5-

12, MMR and FBD rates have improved. However, it has the second highest MMR (after

Eastern Samar)

163

and the lowest FBD in the region. Table 5- 13 shows facility based

delivery rates in each municipality. Although the issue of data quality still remains, there is

disparity between municipalities where facility-based delivery rate has been high and those

facility-based delivery rate remains low even in 2015.

Table 5- 12 Maternal and Child Health Indicators in Northern Samar

Source: Northern Samar Provincial Health Office

161

The Plan will be finalized by the end of 2016.

162

The Provincial Hospital used to be Level 2 but it was downgraded to Level 1 after the DOH’s revision

of hospital standards. It is currently under construction for expansion and plans an upgrade to Level 2

during 2016.

163

The analysis is made across provinces and excludes Calbayog City, Maasin City, Ormoc City and

Tacloban City.

2011 2012 2013 2014 2015

MMR 135 304 172 181 99

IMR 18.3 9.3 9.73 5.1 3.3

FBD (%) 31.26 41.9 52.6 65 77

ANC (%) 86 67.79 72.42 82.95 62

PNC (%) 77 58 62 71.34 65

Table 5- 13 Facility Based Delivery in Municipalities of Northern Samar Province

(2012 ‐ June 2016）

Municipality

2012

2013

2014

2015

June/2016

Allen

Biri

Bobon

Capul

100

Catarman

N/A

Catubig

Gamay

Laoang

Lapinig

Lasnavas

Lavezares

100

Lope de Vega

Mapanas

Mondragon

Palapag

Pambujan

Rosario

San Antonio

San Isidro

N/A

San Jose

San Roque

San Vicente

100

Silvino

N/A

Victoria

Province

Source: Northern Samar Health Office

[Eastern Samar]

Out of one city, 22 municipalities and 597 barangays in Eastern Samar, four municipalities

and 145 barangays are identified as GIDA areas. The Eastern Samar Provincial Hospital in

Borongan city is registered as a Level 2 hospital, which is the end referral as well as the

only CEmONC facility in the province.

164

There are nine hospitals registered as

infirmaries and 25 RHUs (out of which nine are registered as birthing homes). According

to the maternal and child health indicators in Table 5- 14, while FBD has improved in the

recent years, MMR reversed in 2015 to be the lowest in the Region.

165

164

The Felipe Abrigo Memorial Hospital in Guiuan (southern part of the province) was a CEmONC

facility until recently; however, it became a BEmONC facility after the OBGYN Specialist (who was

also the Hospital Chief) passed away in 2016.

165

The analysis is made across provinces and excludes Calbayog City, Maasin City, Ormoc City and

Tacloban City.

Table 5- 14 Maternal and Child Health Indicators in Eastern Samar

Source: Eastern Samar Provincial Health Office

Table 5- 15 shows facility based delivery rate in each municipality of Eastern Samar

province. Facility-based delivery rates are steadily increasing with exception of Jipapad

where nearly half of women deliver a child at home.

Table 5- 15 Facility Based Delivery Rate in each municipality of Eastern Samar Province

(2012 – June 2016）

Municipality

2012

2013

2014

2015

June 2016

Arteche

Balangiga

Balangkayaan

Borongan Ⅰ

Borongan Ⅱ

Can-avid

Dolores

Gen. MacArthur

Giporlos

Guiuan Ⅰ

Guiuan Ⅱ

Hernani

Jipapad

Lawaan

100

Llorente

Maslog

Maydolong

Mercedes

100

Oras

Quinapondan

Salcedo

San Julian

San Policarpo

Sulat

100

Taft

100

Province

Source: Eastern Samar Provincial Health Office

(3) Study Findings

[Study sites]

In the field study in Northern Samar and Eastern Samar provinces, interviews were

conducted with health officers, RHU and BHS staff, Barangay Captains, provincial and

2011 2012 2013 2014 2015

MMR 183 141 93 92 103

IMR 11.3 8.56 11.05 7.8 2.63

FBD (%) 66 74 85 88 91

ANC (%) 65 63 82 82 77

PNC (%) 69 67 75 75 69

municipal hospitals, a private hospital and birthing clinic, PhilHealth provincial offices and

a DSWD office as shown below.

166

In addition, individual and group interviews were

conducted with pregnant and lactating women, their family members and TBAs (see Table

5- 16).

Table 5- 16 Study Sites and Community Interviewees

Province

City and Municipality

Barangay

Interviewees

Northern

Samar

Catarman City

Barangay Polangi

Pregnant and

lactating women

San Roque Municipality

Barangay Balnasan

Eastern

Samar

Borongan City

Barangay Balacdas

Husbands

Llorente Municipality

Poblacion and

Barangay Naubay

Women with

grandchildren

Can-avid Municipality

Barangay Carolina

TBAs

Source: JICA Survey Team

[Supply Side]

1) Service Delivery

According to interviewed healthcare providers, a majority of deliveries are now taking

place in facilities and fewer people are practicing home delivery. Some of the

facilitating factors they pointed out include the improvement of facility services, referral

and the adoption of LGU ordinances prohibiting home deliveries, and providing

incentives to mothers who deliver at facilities and BHWs who facilitate the mothers.

On the other hand, the number of hospitals (excluding Infirmary level) in each province

remains low: two in Northern Samar and one in Eastern Samar.

167

Although there is

only one government-owned CEmONC facility in the province, the provincial hospital

is under-capacity to respond to increasing needs.

168

As the end referral hospital is either

Level 1 in Northern Samar or Level 2 in Eastern Samar that does not have a blood bank,

referred pregnant women died due to the absence of an immediate blood transfusion.

Furthermore, more deaths tend to occur in areas with limited access to the provincial

hospitals. In Eastern Samar, most of the maternal deaths occur in five LGUs (one city

and four municipalities) in the northern part, far from the CEmONC facility.

169

It is

166

In Leyte province, the Survey Team interviewed regional actors including the DOH Regional Office,

the PhilHealth Regional Office and the DSWD Regional Office.

167

Namely, they are the Provincial Hospital and Allen District Hospital in Northern Samar and the

Provincial Hospital in Eastern Samar.

168

Bed occupancy at the Northern Samar Provincial Hospital (including OB Department) is 140-160

percent on average and 103 percent at the Eastern Samar Provincial Hospital (as of 2015).

169

Namely, Canavid, Dolores, Borongan, Oras and Artetche are considered “hot spots” where more

maternal deaths occur according to the Provincial Health Office (it is high in Borongan city due to the

presence of the provincial hospital). On the other hand, in the southern part of the province, due to the

illustrated by the fact that many maternal and neonatal deaths occur while they are

transferred from the residential areas to the facility.

170

With regard to RHUs, most of them

function as BEmONC facilities and are

MCP-accredited by PhilHealth. Some of

the RHUs covering GIDA barangays have

maternity waiting homes. Because BHSs

are not established in each and every

barangay and the majority are not

BEmONC-capable, RHU serves as the

most accessible facility for many pregnant

women. Nevertheless, these RHUs are

faced with various human resource issues

such as the lack of doctors

171

and many midwives not equipped with BEmONC skills.

172

Furthermore, while the DOH defines the rate of ANC as more than four visits, some of the

health officers pointed to the tendency to only focus on the quantity (the number of visits)

and not the quality. In particular, without sufficient equipment (especially ultrasound) at

RHUs, appropriate laboratory tests are not conducted for pregnant women for early

detection of risks, resulting in deaths during or after delivery despite more than four ANC

visits, as revealed by Maternal and Newborn Death Review (MNDR).

Public health facilities also include district hospitals and municipal hospitals. However,

except for one hospital in Northern Samar, they are all at the Infirmary level.

173

Hence,

these hospitals provide almost the same maternal and child health services as RHUs.

Therefore, for example, they are not able to assist deliveries of women 18 years old and

presence of the government hospital in Guiuan being CEmONC until recently, there was less of an

access issue.

170

Out of the nine deaths reviewed by Maternal Death Review in 2015, four occurred at hospitals, four

while in transit and one at home.

171

Although one doctor is assigned to work in each RHU, they are often away due to conferences, etc.

172

For example, 64 percent of midwives in Northern Samar have not received BEmONC training and at

least one midwife in each RHU is trained in Eastern Samar. On the other hand, it was clarified that the

midwives who are not trained in BEmONC skills had training in Life Saving Skills, which was

implemented prior to the introduction of BEmONC. The main reason so many midwives are not

trained in BEmONC is a lack of trainers: there are only four trainers at EVRMC and they are unable

to respond to all the training needs, according to LGU health officers (they said they have sufficient

budget to organize the training).

173

The only government hospital registered as Hospital Level in the two provinces is Allen District

Hospital. Other district hospitals, municipal hospitals and community hospitals (6 hospitals in

Northern Samar and 9 hospitals in Eastern Samar) are all registered as Infirmary Level.

Figure 5- 10 RHU staff of Can-avid

municipality in Eastern Samar

below and older than 35 years old (for the first pregnancy). According to the healthcare

providers interviewed, some of the Infirmary level hospitals are better equipped with

personnel, medicines and equipment than RHUs, and therefore RHUs can refer their

cases. Nevertheless, some areas are in need of rationalization of the hospitals such as by

upgrading them to Level 1 hospitals given the overlap with nearby RHUs or converting

them to specialized facilities.

Although Supportive Supervision (SSV) is

considered key to improving the quality of

BEmONC services, it lacks systematic

implementation in the provinces.

Provincial officers conduct regular visits

to RHUs in Northern Samar but without

standardized tools, such as checklists. In

Eastern Samar, SSV is only conducted

when there are issues with particular

facilities. Moreover, follow-up

assessments of BEmONC trainings occur

only once after six months by EVRMC trainers’ visits. This suggests a lack of regular

mentoring and coaching, which is an important element to ensure the retention of

healthcare providers’ knowledge and skills as well as their motivation.

At the barangay level, midwives

mobilize BHWs and implement ANC,

PNC and health education regularly.

While most of the BHS do not handle

deliveries, based on the interviews with

pregnant and lactating women, many of

them access BHS for ANC and PNC. In

fact, since TBAs do not conduct ANC

and PNC in most cases, even those who

had home deliveries said they visited

BHS or RHU for check-ups.

Challenges faced by BHSs include midwives being overburdened with various tasks at

the community level and some of the BHSs not being rehabilitated after Typhoon Ruby

hit both provinces in 2014. On the other hand, it was pointed out that the southern part

Figure 5- 12 BHS destroyed

by Typhoon Ruby

Figure 5- 11 Interview with Mayor

of San Roque, Northern Samar

of Eastern Samar heavily hit by Typhoon Yolanda in 2013 received a large amount of

assistance from donors to rehabilitate its health facilities, which contributed to more

improvements than pre-Yolanda while unaffected areas were left under-developed.

2) Referral and SDN

In Eastern Samar and Northern Samar, many ILHZ are deemed functional by the local

health authorities,

174

and Common Health Trust Fund (CHTF) are established in some

of the zones. As part of the process to strengthen ILHZ, the awareness of health systems

increased among local chief executives, particularly Mayors,

175

and resources, such as

staff, ambulances and funds were shared in an efficient manner among LGUs. This

contributed to the strengthening of the referral system. ILHZ also implements MNDR.

176

Nevertheless, some issues were raised pertaining to management: a gap in LGU’s

contributions to CHTF depending on the commitment,

177

a change in LGU’s level of

commitment after the turnover of local chief executives, and a slow procurement

process because CHTF is managed by the provincial government.

Together with ILHZ, each province is currently in the process of establishing the

SDN.

178

While ILHZ aims to strengthen a referral system among public facilities

particularly by linking city and municipal governments, SDN is sought under the

leadership of the provincial health office with objectives to not only strengthen a referral

system, including private facilities, but also identifying and creating a manual on the

services available at each facility (including the contents of services, information about

healthcare providers and service schedules) and connecting the available services with

the health needs of poor households. The LGU health officers and healthcare providers

interviewed confirmed that some progress has been made in the mapping of health

facilities and healthcare providers and the profiling of poor households in accordance

with the DOH manual. With regard to the household profiling, CHT/BHWs collect

relevant information of pregnant women, newborns, adolescents, elderly, etc. from each

household using DSWD’s indigent household list. However, many mentioned that they

174

There are six ILHZ in Northern Samar and five in Eastern Samar.

175

In the process of strengthening ILHZ, Zuellig Family Foundation (ZFF) has assisted the Leadership

and Governance Program for policy makers and health workers at LGU level.

176

In Northern Samar, the MNDR manual developed by JICA’s maternal and child health project in

Eastern Visayas was utilized in implementing MNDR. MNDR is implemented at both ILHZ level and

provincial level.

177

There was a case where the most resource-rich LGU was not contributing to the CHTF.

178

With USAID’s assistance, the DOH Regional Office is particularly accelerating the effort to build the

SDN in Leyte province as a pilot site.

do not know how to conduct the following step, which is matching, based on the

information collected through the mapping and profiling.

3) NHIP Implementation and Utilization

In Eastern Visayas Region, the total number of NHIP-accredited health facilities was 70

in 2010, increased to 139 by 2011 and 308 by 2015.

179

As Eastern Visayas was heavily

effected by Typhoon Yolanda in 2013, the central government is implementing a special

measure called the “Avail All” policy for the region until the end of 2016. This policy

entitles all residents to NHIP benefits, including those who stopped paying premiums or

who were not enrolled due to their financial constraints. As Table 5- 17 shows, 80 to 90

percent of the population is enrolled in each province, and 92 percent are enrolled in the

entire region. More than 60 percent are Indigent Members in all provinces and more

than 70 percent in the three provinces of Samar island. The NHIP enrollment and

facility-based delivery have increased recently not only because of the special policy,

but because of the PhilHealth Regional Office’s advocacy efforts to LGUs to adopt an

ordinance to provide an incentive of 1,500 pesos to mothers who deliver at facilities and

that of 500 pesos to BHWs and TBAs who facilitate mothers to health facilities out of

the reimbursement from PhilHealth. Moreover, the MCP benefit payments have also

increased in recent years (see Figure 5-13).

Table 5- 17 Numbers of NHIP Members in Eastern Visayas (as of June 2016)

180

Source: PhilHealth Eastern Visayas

179

Interview with the DOH Eastern Visayas Regional Office

180

The numbers include both members and their dependents. The coverage rate is based on the estimated

population.

Province

Formal

Sector

Informal

Sector

Indigent Sponsored Lifetime

Senior

Citizens

Total

Coverage

Rate

Biliran 21,531 6,596 98,806 30 2,744 12,934 142,641 82%

Eastern Samar 69,020 14,735 336,650 62 9,401 22,547 452,415 96%

Leyte 377,878 90,310 1,229,798 199 35,849 144,052 1,878,086 94%

Northern Samar 78,714 9,619 443,879 203 7,365 29,734 569,514 89%

Samar 95,197 21,839 549,567 100 8,866 39,230 714,799 90%

Southern Leyte 70,555 10,941 232,269 37 10,944 37,115 361,861 85%

Region 712,895 154,040 2,890,969 631 75,169 285,612 4,119,316 92%

Figure 5- 13 MCP Benefit Payments in Eastern Samar and Northern Samar

181

Source: PhilHealth Province Offices of Eastern Samar and Northern Samar

Upon termination of the special policy at the end of 2016, LGUs are required to resume

their own sponsored programs to take over the assistance. Interviews with healthcare

providers and community members revealed the concern that some of the LGUs do not

have enough funds for the sponsored programs, which could result in increased numbers

of drop-outs and unenrolled. The Survey also confirmed the presence of an RHU that

plans to charge a delivery fee once the Avail All policy expires. Therefore, there is a risk

that many non NHTS-PR poor households will be excluded from the NHIP in Eastern

Visayas Region.

The NHIP benefit payments are deemed essential to

improve the services of health facilities. The

healthcare providers interviewed also mentioned that

the regular bonus they receive from the payments

helps motivate them. Nevertheless, an issue was

pointed out with regard to the benefit payments for

facilities. Because health facilities owned by the

provincial government receive benefit payments

from PhilHealth through the general fund, it is

unclear how the money is spent.

182

According to the

PhilHealth guidelines, LGUs are requested to

establish a trust fund to receive benefit payments

181

The data excludes the hospital level.

182

According to the city and municipal health facilities interviewed, their LGUs have trust funds for

NHIP reimbursement.

100

150

200

250

300

2010 2011 2012 2013 2014 2015

Million pesos

Eastern Samar Northern Samar

Figure 5- 14 PhilHealth

Northern Samar Office

100

specifically for the improvement of facility services.

183

However, neither province has

established a trust fund and therefore it is not known how much of the NHIP reimbursed

fund is in fact used for the relevant facilities or health purposes. At the Northern Samar

Provincial Hospital, a lack of medicine has become a major issue, leading to

out-of-pocket payments by patients. The establishment of the trust fund can help ensure

the transparency and effective use of benefit payments to respond to such needs.

In many communities, more than half of the community members are enrolled in

NHIP’s Indigent Program based on the NHTS-PR. However, the interviews at barangay

level revealed that many poor households are not included in the list and therefore they

are not NHIP members. In addition, according to the BHWs and midwives who conduct

regular household profiling based on the NHTS-PR list, the list has various issues, such

as non-poor being included as indigents, the double counting of people on the list, and

the listing of the deceased and those who have moved to other communities.

Private health facilities are also accredited by PhilHealth and many are linked with

public facilities through referral systems. The private BEmONC facility interviewed

said 99 percent of its clients are indigent and the NBB Policy is implemented. On the

other hand, the private CEmONC hospital interviewed said while it implements the

NBB Policy, it limits the coverage to 10 percent of total patients from the business

perspective. Hence, in the provinces where government-owned CEmONC facilities are

extremely few, private hospitals seem to be limited in availing services to the poor.

[Demand Side]

1) Health Service Utilization

According to the BHS and RHU staff interviewed, the facility-based delivery rates are

approximately 80 to 90 percent of the total deliveries between 2015 and 2016 in their

communities, showing much improvement in the past few years. Some of the factors

discouraging home deliveries include improved facility services, awareness raised

through community activities and the implementation of LGU ordinances prohibiting

the practice and penalizing TBAs who assisted home deliveries. Some of the TBAs are

now playing the role of a BHW to facilitate facility-based deliveries. The women who

delivered at the facilities mentioned that the choice ensured a safe delivery with the help

of professional staff.

183

In both Northern Samar and Eastern Samar, benefit payments by PhilHealth are made in the form of

check.

101

On the other hand, the Survey Team acknowledged the presence of women who had

home deliveries. Some of the GIDA barangays still have 30 to 40 percent of home

deliveries. The healthcare providers in these communities are concerned about the risk

of more dangerous home deliveries without the help of TBAs due to the strict ordinance

while the women still have limited access to health facilities.

One of the key issues regarding access to health services highlighted by many healthcare

providers is increased teenage pregnancies. Interviews also identified many teenage

couples with children. The teenage girls, being ashamed of their pregnancies, tend to

hide them as much as possible. Because BHWs have a hard time tracking them, there

are many cases of late referral. Moreover, although these couples live together and have

children, many are unmarried. As a consequence, they cannot be enrolled in the NHIP

together as a family. The Survey Team identified some teenage pregnant girls who said

their partners are enrolled in the NHIP as dependents of their parents as the parents are

the NHTS-PR members, and the girls themselves are not enrolled.

2) Enrollment and Utilization of the NHIIP

The field interviews confirmed that many pregnant women were enrolled in the NHIP as

a result of the awareness-raising efforts by BHWs and the Avail All policy and were

benefitting from the maternal and child health services. However, the Survey Team also

identified some women who did not know whether they were NHIP members or if their

memberships were updated. Their impression was that the insurance is beneficial only

when they have to be admitted to a hospital because RHUs provide free services

regardless of the enrollment status. Therefore, for the women who have only been to

RHUs, they do not feel like they have utilized the insurance program. Furthermore,

some of the women who delivered at hospitals expressed that they did not see the

benefits of the NHIP because they still had to pay for drugs out of their own pockets.

Despite the Avail All policy, there were pregnant and lactating women who were yet to

be NHIP members, including unmarried teenage girls who were due to deliver in a few

months. They are required to deliver at a hospital based on the NHIP guidelines. These

women’s vulnerability will increase particularly once the Avail All policy ends at the

end of 2016.

In addition, BHWs who play a pivotal role in awareness-raising activities seem to lack

sufficient knowledge about the NHIP. Many were specifically unaware of the NBB

Policy and POC. Because the Avail All policy which automatically provides the NHIP

102

benefit in Eastern Visayas Region, it is likely not only BHWs but also the LGU

personnel and healthcare providers who have less understanding about the NHIP

regulations.

3) Barriers to Health Services

The pregnant women interviewed by the

Study are between the ages of late teens

into their 30s, many of whom are high

school drop-outs or high school

graduates. Their husbands are farmers,

tricycle drivers or daily workers such as

construction workers. Their income is

unstable: they are paid 100 to 200 pesos a

day or 1,500 to 4,000 pesos per three

months for coconuts farming. Most of the

women identified themselves as

housewives. Some of them help their husbands’ farming, but they do not earn income.

The women who earn income are engaged in small businesses, such as selling

vegetables and rice, getting 300 to 500 pesos a week.

The interviews with women of above-mentioned socio-economic attributes revealed that

they are continuing to face various economic, geographic and socio-cultural barriers

effecting their access to health services.

 Medical Fees: In principle, PhilHealth covers most medical fees, and RHUs

essentially provide free services regardless of enrollment status in the NHIP.

Nevertheless, the field study found many cases in which the families of delivering

mothers had to go to pharmacies and pay for drugs while being admitted in health

facilities due to no stock at the facilities. These out-of-pocket payments include IV

fluids, vitamins and syringes. In particular, the payments at a CEmONC hospital

could cost them as much as 2,500 to 6,000 pesos, which is a significant amount for

poor households. Some of them said they had to get donations from relatives and

the LGU. Other out-of-pockets include newborn screening for 600 pesos and

ultrasound for 500-600 pesos that were not available at the RHUs.

Figure 5- 15 Rural household

interviewed by the Study

103

As opposed to the above-mentioned fees involved in maternal and child health

services, fees for TBAs are either free or range between 50 and 1,500 pesos.

According to the TBAs and mothers interviewed, the fee is often not fixed and the

service users can decide the amount based on their financial capabilities. Given the

financial implications, some women still choose to deliver at home. There was a

case of a mother who suffered from high blood pressure, however, decided to

deliver at home as she was afraid of medical bills at hospital, and consequently lost

her newborn (see BOX 5- 5). There was also a mother who was told that she was at

high risk at the time of ANC but did not follow the advice for financial reasons to

take an ultrasound test. These examples indicate that medical fees still burden

many poor women even if they are covered by NHIP.

BOX 5- 5 Experience of a 35-Year-old Woman

I delivered my four children at home. When I was pregnant with my fifth child in 2014, I

was advised to deliver at the hospital due to high blood pressure. But because I had no

problem with my past home deliveries and I was afraid of hospital bills, I delivered at

home and the baby died. When I was pregnant again in 2015, because home delivery was

prohibited, I was planning to deliver at a facility. When I went into labor, I went to the

RHU. However, I was referred to the Provincial Hospital due to high blood pressure. I gave

birth in transit and lost the baby. My husband is a vegetable farmer and I help him. We earn

about 200 pesos every four days and buy rice from the income. We also consume

vegetables we grow at the farm. I am now using contraceptives because we cannot afford

to have any more children.

 Transportation: Hospitals and RHUs normally own one or two ambulances, but

some of them require the users to pay for the fuel. In addition, ambulances are not

available for non-urgent cases, and therefore the women and their families have to

find a means of transport such as a motorbike, tricycle or boat and bear the cost.

The actual amount depends on the access: however, even relatively accessible areas

can cost between 20 and a few hundred pesos. The fee fluctuates depending on the

time and it tends to be more expensive during evenings. Among the communities

interviewed, one barangay owns a motorbike and the mothers can use it for free

including the fuel.

 Others: Other than the above-mentioned out-of-pocket payments, there are also

costs for transport, food and accommodations for family members who accompany

the women. Furthermore, the majority of women said their husbands accompany

104

them throughout the time at the hospital, which creates a concern for the loss of

family income during the period.

Related to transport fees, in both provinces surrounded by islands, mountains and

upstream, community members depend on the local means of transport such as

motorbikes, boats and tricycles. Nevertheless, these are not available regularly and

therefore it is difficult to transfer the pregnant women from the remote areas, especially

at night. Additionally, there are communities, even those located 30 minutes away from

the provincial capital on the main road, that do not have a network signal. Prompt

referral of pregnant women from such areas is a challenge. Furthermore, in the

typhoon-prone provinces, women are sometimes forced to deliver at home in the

aftermath of a typhoon. Many experiences in the communities revealed that these

geographical barriers delayed referral of mothers and they were forced to deliver in

transit on a tricycle or boat, causing a maternal or newborn death.

The majority of mothers interviewed said they themselves made the decision where to

deliver. In addition, their husbands accompanied them throughout the period of

admission. The husbands interviewed expressed that they prefer their wives to deliver at

facilities. As for their mothers and mothers-in-laws, they had home deliveries because

there was no accessible facility for their communities and they had no choice but to

deliver at home. However, they said they recommended to their children to deliver at

facilities for their safety.

Among the women from poor households who did not access facilities for ANC, PNC or

delivery, they mentioned gender-related reasons, such as the husband’s rejection for his

wife’s facility-based delivery, the woman’s overwhelmed reproductive and productive

responsibilities at home, and unavailability of a caretaker during the woman’s

hospitalization (see BOX 5- 6, BOX 5- 7). In addition, while contraceptive prevalence

has improved in recent years, all the interviewed women and men using contraceptives

are in fact using female contraceptives, mostly pills and injectable. There was also a

woman who said she cannot use contraceptives because her husband is against family

planning.

105

BOX 5- 6 Experience of a 35-Year-old Woman

My husband is engaged in daily labor as a coconut farmer and earns 1,000 pesos every

three months. I earn 2,000 pesos a month from my laundry business. I gave birth to my five

children at home. I delivered my sixth child at the Provincial Hospital because it was a

breech delivery. For my five-day stay at the hospital, we paid about 6,000 pesos out of our

pocket for IV fluids, syringes and food for my husband. When I was pregnant with my

seventh baby, I was doing heavy labor, doing laundry at the river and noticed my baby was

not moving in my womb. I went to the hospital and found the baby was gone. I am

currently pregnant with my eighth child. A BHW comes to my house and recommends me

to take ANC, but I am busy with preparing meals for my family, helping my children to go

to school, and doing my laundry business, and cannot find time to go to the RHU.

BOX 5- 7 Experience of a 19-Year-old Woman

My 27-year-old husband is currently unemployed and I am a housewife. Together with our

five-month-old baby, we live with his parents. We are not married. He is a member of the

Indigent Program, so our baby is listed as his dependent but I’m not. I delivered the child at

home with the help of my grandmother who is a TBA. I visited BHS once for ANC when I

was still pregnant. I wanted to go back again but my husband didn’t agree with the idea

because he was afraid that we would have to pay. My husband has control over our

household expenses. I want to use contraceptives but my husband is against it because he

wants to have more children.

Some women also prefer not to deliver at health facilities because they consider the

services unsuitable for their traditional customs. According to their customs, a mother is

allowed to drink soup and eat vegetables, dried fish and noodles for at least one month

after delivery and is prohibited to eat meat. However, according to them, hospital meals

include meat, such as chicken. There was even a case where a mother died after delivery

due to hemorrhage and her family still believes it was due to the fact that she had

buffalo meat at the hospital.

There are also negative perceptions of health facilities. Some women described a health

facility as “scary” because they had never been to a facility, “lonely” without the

company of their families, and “no privacy.” Because of these perceptions, even women

in urban communities with good access to health facilities choose to deliver at home.

For them, home delivery is preferable particularly because it allows them to have a

comfortable environment with attendance of their family members. The BHWs in

communities expressed that it was challenging to change the perceptions and behaviors

of these women despite intensified awareness-raising efforts. At the same time, among

106

the health facilities, RHUs are more preferred than hospitals because they tend to be

closer to home, provide free service, and are staffed with midwives and nurses that they

are familiar with. In this respect, there are cases of women who were advised to deliver

at a hospital due to high risks but waited until the last minute so they could deliver at

RHU.

184

In such a case, the RHU would assist the delivery but cannot get a benefit payment from PhilHealth

even if the mother is a PhilHealth member.

107

Chapter 6 Good Practices and Challenges of JICA Projects

This Survey reviewed two JICA projects on maternal and child health in the Philippines and

identified good practices and challenges that are considered relevant for its future programming.

6-1 Surveyed Projects

The followings are the summary of the JICA technical cooperation projects reviewed by the

Survey.

The Project for Cordillera-wide Strengthening of the Local Health System for Effective

and Efficient Delivery of Maternal and Child Health Services was developed based on the

outcomes of JICA’s pervious health projects in Benguet and Ifugao provinces in the Cordillera

region. Its objective is to achieve UHC through health system strengthening and building

frameworks for efficient and effective maternal and child health services. The project has been

implemented in Benguet, Abra and Apayao provinces with the Regional DOH Office from

February 2012 to March 2017. Some of the activities include facilitation of BEmONC and MCP

accreditations of target health facilities, strengthening of ILHZs, promotion of enrollment in

NHIP among pregnant women, development of a referral manual, implementation of MNDR

and Supportive Supervision (SSV), enactment of ordinances and resolutions on maternal and

child health and dissemination of the project region- and nation-wide.

The Project for Strengthening Maternal and Child Health Services in Eastern Visayas was

implemented in partnership with the Regional DOH from July 2010 to July 2016, targeting

Leyte province and Ormoc city in Eastern Visayas region. The project objectives were to

increase facility-based delivery with skilled birth attendance and strengthen community-based

activities with involvement of local decision makers so as to improve the quality of BEmONC

and services and reduce maternal deaths. The project activities included equipping target health

facilities to provide BEmONC services and facilitating them to be MCP-accredited, provision of

BEmONC training, implementation of MNDR and SSV, enactment of ordinances and

resolutions on maternal and child health and organization and facilitation of management of

CHT.

6-2 Interview Sites

The Survey team conducted phone interviews with Japanese experts for the above-mentioned

projects and subsequently conducted interviews with the DOH Regional Office, the PhilHealth

Regional Office and Provincial Health Officers of Benguet and Apayao provinces in the

Cordillera region. Healthcare providers and community members were also interviewed in

108

Apayao province. Furthermore, a few project counterparts were interviewed in Eastern Visayas.

The details of the interviewees are indicated in Table 6- 1.

Table 6- 1 List of Interviewees

JICA Project

Interviewees

Project for Cordillera-wide

Strengthening of the Local

Health System for Effective

and Efficient Delivery of

Maternal and Child Health

Services

 Benguet province: DOH Regional Office, PhilHealth Regional

Office, Benguet Provincial Health Officers

 Apayao province: Apayao Provincial Health Officer, Conner

Municipality Health Officer, Far North Luzon General Hospital,

PhilHealth Provincial Office, RHU of Pudtol Municipality, BHS of

Barangay Cabatacan and Barangay Buluan, pregnant and lactating

women (14 people)

Project for Strengthening

Maternal and Child Health

Services in Eastern Visayas

 DOH Regional Office, PhilHealth Regional Office, Leyte Provincial

Health Officers

6-3 Survey Findings

(1) Good Practices

According to the achievements of goals and

project purposes as shown in Table 6- 2 and

Table 6- 3, both projects contributed to

increasing facility-based deliveries, ANC

and PNC. This successful outcome seems to

be attributable to five facilitating factors.

First, in order to increase BEmONC

facilities, the projects invested in both

facility and human resources of target

health facilities. In particular, in the

Cordillera region where there are many

remote areas, a strategy was employed to upgrade many BHS to become

BEmONC-capable for the improvement of access to essential health services.

Additionally, by facilitating the NHIP accreditation of BEmONC facilities and promoting

the enrollment in NHIP among pregnant women, benefit payments by PhilHealth

increased, which in turn contributed to the improvement of maternal and child health

services.

185

Second, the projects mobilized CHT and BHWs effectively to conduct

grassroots-level awareness raising and tracking of pregnant women, which shifted

women’s awareness and behavior from home to facility. Third, the revitalization of ILHZ

185

As of August 2016, there were 87 BHS that are MCP-accredited in Cordillera, which is the highest in

the country.

Figure 6- 1 BHS supported by JICA

109

strengthened referral systems through increasing the commitments of local executive

chiefs and sharing necessary resources among LGUs. Fourth, as a result of advocacy to

LGUs, policies were adopted to promote service access including ordinances on

prohibition of home delivery and payment of incentives to mothers and BHWs and

Barangay Maternal, Newborn, Child Health and Nutrition (MNCHN) emergency plans for

provision of transport.

186

Fifth, the project in Cordillera addressed cultural factors

hindering access to services such as the introduction of culturally-sensitive service

protocols and working with TBAs as 70 percent of the regional population are indigenous

peoples.

187

At one BHS where the survey team visited, 64 percent of deliveries were done

at home in 2011 but it was gradually reduced and achieved zero home delivery by 2015.

Furthermore, a group interview with women who had deliveries in the past year revealed

all of them had the last delivery at facilities while previous deliveries were done at home.

Table 6- 2 Outcome of the JICA Project in Cordillera

Source: JICA

Because FHSIS data were found to have issues with counting deaths based on the location

of the occurrence (i.e. in which facility the death occurred) and applying an estimated

number of pregnant women as a denominator, the projects promoted the employment of

residence-based calculations (i.e. where the deceased resided) and an actual number of

pregnant women as a denominator. This enabled the stakeholders to understand the

situations accurately. In particular, in Cordillera, a system was established to tap into

186

By incorporating an MNCHN Emergency Plan into each Barangay Disaster Risk Reduction and

Management Plan, a system was established to provide emergency transport to pregnant women and

their newborn children.

187

For example, the protocols reflected traditional customs to have husbands attend delivery and mothers

deliver in a squatting position.

# Indicator Baseline Target Year 2015 Source

1 Regional MMR (per 100,000 live births) 62 Reduced 45

2 Regional IMR (per 1,000 live births) 11 Reduced 11

3 Regional FBD (%) 74 85 92

1 FBD in project sites (％） 79 85 93

2 ANC in project sites (%) 63 80 84

3 PNC in project sites (%) 90 90 98

4 N0 of functional ILHZ in the region 7 Increased 17

5 No of LGUs implementing MNDR in the region 0 Increased 7

Hospital 0 37 36

RHU 0 50 48

BHS 0 90 104

RHU 53 51

BHS 78 93

Goal

FHSIS

Project

Purpose

FHSIS,

residence-based,

TCL analysys,

project

monitoring

No of BEmONC dacilities in the region

No of MCP accredited facilities in the region

110

BHWs’ Client Target Lists (CTLs) to collect residence-based data through the project.

Cognizant of the advantage of the system, the DOH Regional Office has adopted this

methodology (in addition to FHSIS) for the entire region and has requested the central

DOH to review the FHSIS methodology.

Table 6- 3 Outcome of the JICA Project in Eastern Visayas

188

Source: JICA

In addition, many counterparts noted that stakeholders were involved in the project

activities. From the beginning of project design and planning, efforts were made to

coordinate and discuss with all project stakeholders (e.g. provincial and municipal health

officers, PhilHealth and local chief executives). Throughout the implementation period,

regular meetings were organized to set project targets, address challenges, establish

partnerships and document project outputs. These approaches are considered sustainable

and good practice unique to JICA.

188

The ANC and PNC rates under the project purpose are calculated based on the FHSIS data using an

estimated number of pregnant women (2.7 percent for the entire country) as a denominator, and

therefore they are underestimated. According to the JICA project, the ANC rates become 63 percent in

Leyte and 84 percent in Ormoc in 2015 and the PNC rates became 96 percent in Leyte and 99 percent

in Ormoc in 2015 by using the actual number of deliveries as a denominator.

# Indicator Baseline Target Year 2015 Source

Leyte province 74.5 Reduced 41.5

Ormoc city 64.2 Reduced 185.2

Leyte province No data Reduced 2.3

Ormoc city 6.2 Reduced 14.5

Leyte province 6 Reduced 5.9

Ormoc city 10.3 Reduced 18

Leyte province 23 Reduced 12

Ormoc city 3 Reduced 13

Leyte province No data Reduced 67

Ormoc city 29 Reduced 102

Leyte province 56 90 93

Ormoc city 65 90 97

Leyte province 56 80 93

Ormoc city 65 80 97

Leyte province 22 45 46

Ormoc city 29 45 63

Leyte province 53 80 71

Ormoc city 61 80 75

FHSIS

ANC in project sites (%)

PNC in project sites (%)

Project

Purpose

FBD in project sites

Goal

MMR (per 100,000 live births)

FHSIS

NMR (per 1,000 live births)

IMR (per 1,000 live births)

No of maternal deaths

No of neonatal deaths

FBD (%)

111

The project in the Cordillera region

increased impact by supporting the

regional DOH’s project expansion plan.

Good practices of the project such as

ILHZ, TCL, CHT and MNDR were scaled

up to non-project sites in the region with

strong ownership by the Regional Office.

In Eastern Visayas, the regional DOH is

planning to expand SSV to other provinces

in the region based on the experience with

the JICA project.

(2) Challenges

The Survey identified MCP-accredited BHS

that had not received benefit payments from

PhilHealth. Other related issues included

midwives’ lack of understanding of

distribution ratios of the payments received

by the LGUs for facility and personnel and

the lack of LGU’s resolution to enable such

payments to BHS. In the case of

LGU-owned health facilities, benefit

payments from PhilHealth are not made

directly to the respective facilities but to the

LGUs, and PhilHealth does not track if they are actually utilized for the relevant facilities.

In this respect, health facilities and LGUs should make further efforts to increase

healthcare providers’ understanding of the PhilHealth guidelines and improve the

distribution processes and management of the payments.

While more pregnant women are now enrolled in the NHIP, many of them still do not

understand the program.

189

In fact, group interviews with pregnant and lactating women

revealed that some were not yet enrolled and expressed financial concerns for facility

delivery. In this sense, there are existing issues of poor families left out from the

NHTS-PR, less frequent update of the NHTS-PR list, and LGU’s limited resources for the

Sponsored program. Furthermore, some of the LGU-owned hospitals do not have sufficient

189

Interviews with BHWs also revealed that some of them did not know the NBB Policy and POC.

Figure 6- 3 MCP-accredited BHS

Figure 6- 2 BHS staff interviewed

by the survey team

112

funds to implement the NBB Policy and POC. In this sense, more efforts are required for

the financial protection of the poor.

Despite the strengthening of the referral system through ILHS, there remain various

challenges for the poor to access health services due to financial, geographical, cultural and

social factors, and home delivery is still practiced. Especially in remote and mountainous

areas like Cordillera, pregnant women have to walk for more than half a day to reach

health facilities and pay out of pocket as much as a few thousand pesos for one-way

transport,

190

food and newborn screening. In addition, according to the group interviews

with pregnant and lactating women, one of the main reasons to deliver at the facility is that

home delivery with the help of TBA is prohibited by municipal ordinance. This may

suggest that poor women living in remote areas without appropriate transport to health

facilities have a lack of options, and in fact are forced to look for more risky alternatives.

In this regard, assistance should be accompanied with other approaches to facilitate access,

such as the provision of incentives to mothers and the establishment of maternity waiting

homes.

With the improvement of the referral system, more maternal deaths are occurring while

being transferred or at high-level facilities. Under these circumstances, comprehensive

efforts should be made to tackle the factors attributing to the “three delays”: unavailability

of transport, lack of immediate and appropriate treatments with drugs and blood shortages

at health facilities, and cultural and financial factors hindering women from seeking

services.

191

Future assistance should focus on these issues to devise solutions.

While DOH Regional Offices report project outcomes and provide feedback on policies to

the central DOH, it was indicated that these efforts had not resulted in improvement of the

policies. Some policies require fundamental improvements, such as that of the FHSIS data

and the standards of midwife placement.

192

In this respect, the future project should not

only share results with the central DOH, but also fully involve them from the stage of

project design and planning.

190

According to the BHS interviewed, when an ambulance is dispatched for referral, the patient has to

pay 1,500 pesos for fuel.

191

For example, among some of the indigenous people in Cordillera, the traditional customs require them

to conduct a ritual before going to the facility and use herbal medicines.

192

According to the DOH standards, one midwife is deployed for a population of 5,000. Some

interviewees commented that it should not only consider the size of population but also the distance as

an issue in remote communities.

113

Chapter 7 Recommendations for JICA’s Future Assistance

On the basis of the survey findings and good practices and challenges of the former JICA

projects in maternal and child health (MCH), the following recommendations are made for

JICA to take into consideration when formulating future assistance projects/programs for the

Philippines.

7-1 Points to be Considered

The following four points were especially considered when consolidating the recommendations

for JICA.

 JICA’s knowledge and experience in the Philippines, particularly MCH projects.

 Universal Health Coverage (UHC), “equitable health service delivery and financial risk

protection,” the Japanese government’s diplomatic strategy, is incorporated.

 Philippine Health Agenda: ①All Life Stages & Triple Burden of Diseases, ②Service

Delivery Network and ③Universal Health Insurance are addressed.

 Achievement of the Sustainable Development Goals (SDGs), particularly in reduction of

maternal and neonatal deaths, promotion of access to sexual and reproductive health-care

services and achievement of UHC,

193

is considered.

7-2 Recommendations for JICA’s future activities

The survey found that inequality among Filipinos has not diminished, even though the country’s

economy has been thriving over the past decade. Consequently, poor families are still suffering

financially when they receive medical services, even if they are enrolled in NHIP. The quality

of health services highly depends on capacity and leadership of the local executives. The survey

team recommends JICA to pursue the new technical assistance project, “UHC enhancement in

the MCH services,” with two approaches: improved access to quality essential health-care

services and financial risk protection. Each component of the recommended project is described

below.

(1) Access to Quality Essential Health-Care Services

① Service Delivery Network (SDN)-Building

Effective SDN is indispensable for all women to have a safe delivery. However, the policy

and guidelines of SDN are not clear in the Philippines at this moment and there is a variety

193

United Nations. (2016). Sustainable Development Goals: 17 Goals to Transform Our World.

114

in the state of progress in SDN establishment in different areas of the country. It is

recommended that JICA provide technical assistance to target provincial government

officials in re-defining the “SDN” and building the SDN in the way that necessary health

services are delivered to people in need when needed.

The Japanese secondary medical area

194

could be a model when re-defining the “SDN” in

the Philippines. The Japanese secondary medical area is the zone that is set for each

prefecture, in which hospital beds serving general inpatient care are prepared pursuant to

the provision of the Medical Care Act and connected to referral care. Ideally, the DOH

Regional Office should set the SDN zones as there is a chance that a SDN zone extend

over more than two provinces. SDN zones should be carefully set while taking

geographical relationships and traffic condition into consideration.

Additionally, actions are needed to mitigate the overconcentration of patients in tertiary

health facilities. While continuing efforts to upgrade RHUs into BEmONCs as performed

in previous JICA projects for hard-to-reach areas, the new project should consider setting a

secondary or primary health facility near a tertiary health facility. Upgrading a primary

health facility to a secondary health facility was intended to bring better health care close

to the people. However, now that many women are reaching a tertiary health facility, a

place for women having a normal delivery should be established near the tertiary health

facility, so that these women can stay close and the tertiary health facilities are available

for complicated cases. Moreover, maternal waiting homes nearby a tertiary health facility

would improve accessibility for women living in hard-to-reach areas, such as GIDAs. The

women can stay at the maternal waiting homes several days prior to delivery, so that they

can receive prompt emergency care if necessary.

② Continued Supportive Supervision for Health Care Providers

The survey found that most maternal deaths are occurring within or in transit to health

facilities in the Philippines. Inadequate referral systems, poor facilities and a lack of

medical supplies are some of reasons behind this, but inadequately trained and poorly

motivated health staff are another major factor in maternal death. Health staff need to make

194

The Japanese secondary medical area is set by the Ministry of Health, Labor and Welfare based on the

Medical Law, considering various factors, such as the geographical and traffic conditions. The medical

service system within the area is designed based on the necessary number of medical treatment beds. It

aims at providing general medical services, including surgery and emergency care within the area. The

Japanese secondary medical area consists of plural municipalities and a prefecture is divided into 3 to 20

secondary medical areas. In general, municipalities provide primary care and prefectures provide tertiary

care.

115

a correct decision in emergencies at a primary or a secondary health facility to refer a

patient to a higher-level facility, and in a higher-level facility, the staff should properly

provide emergency care. The survey found that untrained midwives, without BEmONC

training, are working in health facilities. Thus, training and supportive supervision in

ANC, referral services, delivery and PNC should be continually provided to health staff at

all levels of health facilities based on previous JICA experience, and the training and

supervisory process and tools utilized in the efforts should be properly compiled. These

efforts to strengthen the emergency obstetric care system should lead to prevention of

maternal mortality. In case the target area is facing a scarcity of the trainers, the new

project team should consider exchanging memorandums with a university or an academic

institution to have them send trainers to the project sites.

③ Technical Assistance for LGUs in Administration and Public Finance

Previous JICA projects assisted LGUs to issue ordinances banning TBA practices and

home delivery, and providing mothers and BHWs with incentives when they come to a

health facility for delivery. While it is recommended to continue these efforts, new projects

should also provide technical assistance in public financial management to LGUs.

The following are examples of the activities:

1. Support establish ordinances at barangays and municipalities to incentivize BHWs

and mothers for FBD and to give penalties for home delivery.

2. Support establish a system to regularly monitor the PhilHealth reimbursement to the

LGU or hospital trust fund and the utilization for the original purposes, such as

purchase of medicine.

3. Support conduct leadership trainings for local executives of LGUs, particularly in

local governance and public financial management. Through the trainings, the project

team should convince the local executives that they should provide enough budget to

the health sector as quality health care leads to healthy population and prosperity of

LGUs.

As these activities are similar to other development partners’, it is recommended for the

project team to plan on the activities through discussions with such stakeholders.

116

(2) Financial Risk Protection

① Financial Support System Development at the LGUs

The survey found that some LGUs are reluctant to sponsor near-poor people to be enrolled

in NHIP and many women are still financially burdened by health services even if they are

enrolled in NHIP. It is recommended that the new project assist LGUs to pilot a financial

support system to mitigate and eliminate this burden on child-bearing women.

The following are examples of the activities:

1. Support establish a common pooled fund, collected out of the PhilHealth

reimbursement and religious, community and charity events, and provide

childbearing women with lump sum fund.

2. Support establish a system to provide some monetary assistance to the poor families

identified by LGUs when they receive medical services. The LGU poor families

should be identified by barangay captains and LGU officers. The monetary

assistance is provided out of the above common pooled fund and it is used for

transportation to a health facility, medicine and laboratory tests, the health expenses

not covered by NHIP.

3. Support establish a labor exchange system without monetary exchange within a

barangay or a municipality. The system allows a childbearing woman to receive

child care and/or housekeeping while she is hospitalized and she can return the

similar support to the child care taker and a housekeeper later.

② Promotion of Awareness-Raising Activities

The survey found very few people thoroughly understood NHIP. In fact, it is not only the

beneficiaries who have insufficient knowledge, but health administrators, BHWs and

health service providers also lack knowledge of NHIP. Hence, it is recommended that the

new project select the most effective media and the most important messages for each

group of people and try to convey only the selected messages in clear and simple words.

For BHWs, who are in charge of raising the awareness of the beneficiaries, the

awareness-raising training should be standardized by the project team.

117

③ Effective utilization of the BHWs’ Household Profiling

Barangay Health Workers (BHWs) are

collecting and updating household data

monthly in an assigned area. The data are

consolidated in various forms, including

Household Profiling (see Figure 7- 1) and

the Target Client List (TCL). Previous JICA

projects mobilized the activities of the

BHWs and strengthened tracking of the

ANC, PNC and facility delivery status of

women primarily with the Target Client List

(TCL) for prenatal care. Based on the experiences, the new project team should first study

the availability and quality of the data-collecting system in the target areas, and use the

most reliable data for the extended purposes. The survey revealed that there are many

women who do not know whether they are enrolled in NHIP or if they have paid premiums

to renew their membership. It would be helpful if the BHWs can use the database not only

for checking people’s health, but the status of their NHIP enrollment and premium

payment, when they visit each household. BHWs can support the households with

procedures for NHIP enrollment or premium payment. That way, people can maintain an

active enrollment in NHIP and their health expenditures are covered by NHIP when

necessary. It would be more effective if BHWs raise the people’s awareness regarding

NHIP through the household visits.

④ Third-Country Training and Training in Japan

PhilHealth has been evolving for the past twenty years; however, it is still facing new

challenges. In fact, improvement of the NHIP system itself is necessary to eliminate

financial burdens on poor women in provinces. Through the survey, it was found that

PhilHealth is eager to learn how other countries are dealing with various challenges.

Hence, it is recommended for the new project to invite PhilHealth staff to Japan or other

countries such as Thailand where JICA is implementing the Partnership Project for Global

Health and Universal Health Coverage to promote Universal Health Coverage (UHC) in

ASEAN countries as well as other regions of the world. It would help PhilHealth to

improve NHIP policies through trainings and discussions with other participating countries

and observe universal health coverage in Japan. As the Philippine government suggests to

pay non-formal sector premiums by tax subsidies in the new Philippine Health Agenda, the

Universal Coverage Scheme in Thailand could be a model. On the other hand, Japanese

Figure 7- 1 Household Profiling

118

medical fee schedule and some management systems could assist solve the current issues

that PhilHealth is facing.

7-3 Project Sites

Eastern Samar and Northern Samar provinces in Eastern Visayas are recommended as the

next project sites. These two provinces are among the 20 High Poverty Sites. A good

relationship with the DOH Eastern Visayas Regional Office has been already established

through long-time assistance in the region. It is expected that the Leyte provincial office

where JICA assisted for the past six years could transfer the knowledge and skills gained

through the project into Eastern Samar and Northern Samar provinces.

In case Eastern Samar and Northern Samar provinces are chosen as the new project sites,

however, the project team should thoroughly uphold safety management as the Communist

Party guerrilla organization, New People’s Army, is hiding in the provinces. Also, after

Super Typhoon Yolanda hit the Eastern Visayas Region, a special measure, the Avail All,

was taken in the Region to support the enrollment of people in NHIP. As the Avail All is

going to end in 2016, new sponsors should be found for those who are currently enrolled

through the Avail All, for the next year on. It is also necessary for those people to be

re-educated about NHIP as they did not have to pay premiums for the past few years.

7-4 Enhancement of Project Up-scaling Mechanism

Although JICA has been assisting the Philippine health sector for a long time, its good

practices were not necessarily utilized to improve national policies. The primary reason

should be that the health policy makers do not fully understand importance of JICA’s

achievement. For the next project, JICA should build up a mechanism to fully up-scale the

good results of the project to the entire country (see Figure 7- 2).

The JICA health advisor or a project member assigned at the DOH headquarters should

play an important role in the mechanism. The health advisor or the project member should

involve the Family Health Office, the division in charge of MCH, the Bureau of Local

Health Systems Development, the division in charge of SDN, the DOH Regional Office in

the target region, and the PhilHealth headquarters, throughout the project planning process.

It is important that all the stakeholders recognize that JICA will pilot the project for the

entire nation from the planning phase and periodically and continually share the project

updates.

119

The counterparts of the project are primarily the DOH Regional Office and the target

LGUs. The project team works with the counterparts and periodically reports to the JICA

Health Advisor/the project member in charge, so that the Health Advisor/the project

member in charge can update the stakeholders.

Now that the Bureau of Local Health Systems Development has started reviewing the SDN

policy, it is a good time for JICA to start being involved in the area of SDN policy. When

good communication is maintained among the stakeholders in the central offices, JICA’s

good practice should be taken into account when the SDN new policy is formulated.

Likewise, other lessons learned through the new project should be utilized to improve the

policies of MCH as well as NHIP as long as the project outcomes are shared with the

stakeholders. It would take approximately five years to show exactly how LGUs can take

action towards enhancing UHC through MCH services in the project sites, and

simultaneously build the project up-scaling mechanism. Afterwards, it is expected that the

Philippine government would continue the efforts towards UHC in the entire nation based

on their own policies.

Figure 7- 2 Recommended JICA New Project and Project Upscaling Mechanism

③⑥

⑦

①②④

SDN Zone

DOH HQ

Province

JICA

Experts

JICAHealth

Advisor/ Project

expert

DOH RO

FHO

PhilHealth

LHSD

Province

Barangay

City

Municipality

Barangay

③⑥

⑤

Project Upscaling

Mechanism

Legend

Assistance

Report

Plannning/

Consultation

120

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World Bank. (2011). Philippines: Study on Local Service Delivery.

World Bank. (2016). World Bank Open Data. Retrieved September 14, 2016, from

http://data.worldbank.org/

ATTACHMENTS

Time

Venue

Agency

Contact

2016/7/24 Sun 17:30

0830-0900

JICA PP Office JICA PP office

SR Mr. Morita, Ms. Itsuki

0900-0945

JICA PP office JICA PP office

Ms. Marry Ann, Ms Mendoza Teresa

1000-1200

UNFPA, 31/F Yuchengco Tower,

RCBC Plaza, 6819, Ayala Ave

UNFPA Dr Angelito Umali

1400-1600

UNICEF UNICEF

Dr Raoul Bermejo, Health & Nutrition

United Nations Children's Fund

2016/7/26

Tue 0900-1100

JICA PP Office

@Meeting Room 2

EU Consultant Team

DR. UTE SCHUMANN

Team Leader/Health Policy Planning & Financing Expert

EU PHILIPPINES HEALTH SECTOR REFORM CONTRACT

Mrs Melahi Pons.

Interim Financing Expert

0900-1100

ADB ADB

Dr. Eduardo Banzon

Regional Adviser for Health, Economics and Financing

Asssitant: Raygie dela Cruz (Ms)

1400-1500

Richmonde Hotel Ortigas NKTI

Dr Enrique Ona

Former Secretary of Health (2010-2014)

Medical Doctor, National Kidney and Transplant Institute (NKTI)

0730-0900

DSWD

Central Office, Batasan Complex,

Quezon City, Philippines

DSWD

Mr. Leonardo C. Reynoso, CESO III, National Program Manager (Conditional

Cash Transfer Program)

Mr. Gil R. Tuparan, Senior Technical Officer

Ms. Johhanna Acebes. Technical Assistance Unit

1000-1130

Jose Fabella Hospital

Lope de Vega St., Sta Cruz

Manila, Philippines

Jose Fabella Hospital

Dr. Esmeraldo T. Ilem

Medical Center Chief II

Dr. Jose Fabella Memorial Hospital

1300-1400

WHO country office WHO

Dr. Benjamin D Lane, PhD

Coordinator Health Systems, WHO Philippines

0900-1100

World Bank

26th Floor, One Global Place 5th Ave.

corner 25th St. Bonifacio Global City

World Bank

Ms. Tomo Morimoto, Senior Operations Officer

Health, Nutrition & Population Global Practice

Dr. Roberto Antonio F. Rosadia, Health Specialist

1300-1400

DOH

San Lazaro Compound, Tayuman, Sta.

Cruz, Manila

DOH

Ms. Georgina Ramiro,

Dr. Grace Fe R. Buquiran, Medical Officer N BIHC

Project Monitoring Division, Bureau of International Health Cooperation

1400-1600

DOH

San Lazaro Compound, Tayuman, Sta.

Cruz, Manila

DOH

Ms. Zeny Dy Recidoro

Chief Health Program.Officer, Program Manager of National Safe Motherhood

Program, Family Helath Office, Disease Prevention and Control Bureau,

Department of Health

2016/7/30

Sat

2016/7/31

Sun

10:00-11:00

Department of Interior and Local

Government located at EDSA corner at

Quezon Avenue in Quezon City

DILG

Ms. Girlie Zkra, Division Chief/Local Governance Performance Management

Supervision/Bureau of Local Government Supervision

13:30-14:30

Bureau of Local Health Development DOH

Mr. Raul R. Alamis, Bureau of Local Health Systems Development, Health System

Development Division of DOH

16:15-16:45

National Statistics Authority NSA Ms. AURORA T. REOLALAS, OIC-Division Chief, Vital Statistics Division

1000-1200

DOH

San Lazaro Compound, Tayuman, Sta.

Cruz, Manila

DOH

Ms. Frances Mamaril, Division Chief Planning, Health Policy Development and

Planning Bureau

1400-1500

Makati Medical Center

Credit and Collections Department

Makati Medical Center

Dr. Flor Cruz, Patient Billing Unit、2.

Ms. Janet Medina, Billing and Collections Unit, 3.

Ms. Grace Salvador, Billing and Collection Unit, Makati Medical Center , Credit

and Collections Department

1000-1100

USAID USAID

Dr. Yolanda E. Oliveros, MD MPH, Development Assistance Specialist,

Ms. Reynalda L. Perez, Project, Management Specialist, Office of Health, USAID

1330-1500

PhiHealth PhilHealth

Ms. Evelyn C. Bangalan, Senior Manager,

Ms. Christine Frances D. Limson, Project Planning and Development Officer in

International and Local Engagement Department

Dr. Mary Antonetter Rimon

16:00-17:20

Mandaluyong City Hall Mandaluyong City Office

Dr. Recos Reyes Ibanes Camarinesm MD, MHA, Obstetrician-Gynecologist,

Mandalyuong City Health Officer

Dr. Cesar Tutaan, Mandaluyong City Health Officer

2016/8/4

Thu 14:00-15:00

Executive Office

Manila Doctors Hospital

#667 United Nations Avenue,

Ermita, Manila

Manila Doctors Hospital

Ms. Dr.Bernadette Hogar-Manlapat, Quality Management Representative

Ms. Julie S. alvamz@maniladoctors_com.joh Head, SCRO, Social Sector,

Ms. Ma Thresa A. Acosta, PhilHealth Specialist

Ms. Estrella M. Garcia, Finance Director

Mr. Noel Jonathan T. See, Officer In Charge, Business Development Division,

Manila Doctors Hospital

10:00-11:00

Bureau of Local Health Development DOH

Ms. Rosario S. Torralba, Supervising Health Program Officer, Bureau of Local

Health Systems Development, Department of Health

12:30-13:30

Health Human Resource

Development Bureau DOH

DOH

DOH OIC-Asec Kenneth G Ronquillo, Director IV Health Human Resource

Development Bureau

15:30-16:30

DOH JICA PP office

Ms. Itsuki, Mr. Kanamori

2016/8/6

Sat 14:40

Leave (PR432)

2016/8/2

Tue

2016/8/3

Wed

2016/8/5

Fri

2016/7/28

Thu

2016/7/29

Fri

2016/8/1

Mon

Arrive (PR427)

2016/7/25

Mon

2016/7/27

Wed

Attachment 1

A-1

tta

chment 2

Bicol schedule (28th August - 10th September)

Time Activity Venue Accomodation

2016/8/28 Sun Arrived in Manila (PR 427: 17:30)

10:00-12:00 Mtg with JICA

14:00-16:00 Internal meeting

7:25-8:25 Move from Manila to Legaspi, Albay (5J 319)

11:00-13:00 Mtg with DOH regional office

DOH regional office V,

Legaspi

14:00-15:00

Mtg with MHO Malinao@RHU

RHU in Malinao

Municipality

16:00-17:00 Mtg with local consultant (Meg) Villa Amanda hotel

9:00-:10:30

Mtg with Albay Provincial health officer

(MNCHN coordinator)

Albay provincial office

11:00-12:00 Mtg with PhilHealth regional director

PhilHealth Albay

regional office

13:00-15:30

Visit to Bicol regional training and teaching

hospital

BRTTH, Legaspi

18:00-19:00 Luzon Health (NGO) café

(parallel conduct by consultant: FGD at Burabad)

Burabad

Barangay/Malinao

9:00 - 12:00 FGD/interiew at Balading Barangay

13:00-13:40

DSWD officer in Municipalty, Municipal

social worker

14:00-15:00 Interview with BHWs at Burabad Barangay

6:00:-9:00 Moving to Naga city, Camarines Sur (by car)

9:00-11:00 Mtg with PHO Camarines Sur Eurotel hotel

15:00-16:00

Visit to Bombon lying in clinic (privte)

Bombon

Municipality/Naga city

17:00-18:00 Mtg with Naga City health officer Naga city office

9:00-12:00

FGD/visit to BHS at Panicuason Barangay

in Naga city

Panicuason Barangay

in Naga city

Naga

13:00-15:00 Internal meeting Hotel Naga

2016/9/4 Sun Report writing Naga

2016/9/5

Mon 9:00-12:00

FGD/visit to BHS at San Isidro Barangay in

Naga city

San Isidro iBrangay in

Naga city

Naga

9:00-10:30

Municipal health office/RHU in Pamprona

Municipality

11:00-12:30

FGD/visit to BHS at Batang Barangay in

Pamprona Municipality

15:00-16:00

FGD/visit to BHS at Poblacion Barangay in

Pamprona Municipality

18:00-19:00

Interview with MHO of Sipocot

Municipality

Hotel

Naga

10:00-15:00

FGD/visit to BHS at Binahian Barangay in

Sipocot Municipality

Binahian Barangay in

Sipocot Municipality

17:00-18:00 Visit to Sipocot District hospital

Sipocot District

hospital

9:30-12:00 Visit to Bicol Medical Center BMC

14:00-16:00

PhilHealth Cum Sur provincial office in

Naga

PhilHealth Cum Sur

provincial office

10:00-10:30 Internal meeting Hotel

12:30-13:20

2016/9/10 Sat

Leave for Japan (PR 432: 14:40)

2016/9/9 Fri

Legasipi

Legaspi

Remington Hotel, Manila

Move from Naga to Manila (PR 2262)

2016/9/8

Tur

Naga

Naga2016/9/7 Wed

2016/9/2

Fri

2016/9/3

Sat

Pamprona Municipality

Date

2016/8/30 Tue

2016/8/31

Wed

2016/9/6 Tue

Legasipi

Manila

2016/8/29 Mon

Tur2016/9/1

Balading & Burabad

Barangay/Malinao

A-2

CAR and Eastern Visayas schedule (28th August - 21st September)

Time Activity

Venue

Accomodation

2016/8/28 Sun

17:30

2016/8/29 Mon

10:00

eeting with JICA

Starbucks at Greenbelt 1

Travel from Manila to Baguio (road)

13:30 Benguet PHO

OH-Benguet Office

15:00 CAR Regional DOH

DOH-CAR RO

16:00

PhilHealth Regional Office

hilHealth Regional Office

2016/8/31 Wed

All day

Luna

8:00 Farnorth Hospital

Farnorth Hospital