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Field Trip Report 2016

　

The Philippines

School of Tropical Medicine and Glo

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School of

Tropical Medicine and Global Health

Nagasaki University

The Philippines

Field Trip Report 2016

Contents

Map of the Philippines 2

Photos 3

Forewords 8

Abbreviation List 10

Overview of the Philippines 12

Overview of the Field Trip 14

Daily Field Reports

29th FebruaryDepartment of Health (DOH), Health Human Resource Development Bureau

18

1st March (AM)World Health Organization Regional Office for the Western Pacific (WHO / WPRO)

22

1st March (PM)Japan International Cooperation Agency (JICA) Philippines Office

24

2nd MarchSan Lazaro Hospital (SLH)

26

3rd March (AM)A.A. Zapa Health Center in Caloocan City, Manila

28

3rd March (PM)Research Institute of Tuberculosis / Japan Anti-Tuberculosis Association (RIT/JATA) Philippines, Inc.

30

4th March (AM)Research Institute for Tropical Medicine (RITM)

32

4th March (PM)Philippine Red Cross (PRC) Headquarters

34

7th MarchPhilippine Red Cross (PRC) Leyte Chapter

36

8th MarchInstitutions related to Project for Strengthening Maternal and Child Health Services in Eastern Visayas, Philippines (SMACHS-EV Project)

38

11th MarchWorld Health Organization Regional Office for the Western Pacific (WHO / WPRO)

40

Report of the Final Presentation

Report 44

Presentation Slides 49

Afterword 52

Editor’s Note 53

1

Map of the Philippines

*This map does not represent the view of Nagasaki University concerning the legal status of any country.

2

29th Feb, Department of Health, Lecture

Daily Activities (1)

1st Mar, WPRO, Group photo

2nd Mar, San Lazaro Hospital, Lecture

1st Mar, WPRO, Briefing

1st Mar, JICA, Lecture

2nd Mar, San Lazaro Hospital, Tour (TB ward)

3

3rd Mar, Caloocan City, Tour with barangay health workers

Daily Activities (2)

4th Mar, RITM, Laboratory tour

4th Mar, Red Cross Headquarters, Information and Technology Operation Center

3rd Mar, RIT / JATA Philippines, Inc., Lecture

4th Mar, Red Cross Headquarters, Lecture

4th Mar, Recap meeting

4

7th Mar, Red Cross in Leyte, Lecture

Daily Activities (3)

7th Mar, Red Cross in Leyte, Visiting WASH project site

8th Mar, JICA SMACHS-EV Project in Tolosa, Reception

7th Mar, Red Cross in Leyte, Lunch time

8th Mar, JICA SMACHS-EV Project in Tolosa, Visiting barangay health station

8th Mar, JICA SMACHS-EV Project in Dulag, Courtesy visit to the Mayor

5

8th Mar, Provincial health office, Leyte, Group photo

Daily Activities (4)

9th Mar, Preparation for final presentation

11th Mar, Final presentation, Reception

9th Mar, Preparation for final presentation

11th Mar, Final presentation at San Lazaro Hospital

11th Mar, Final presentation, Group photo after the presentation

6

Manila Intramuros

Casual Photos

Leyte Island

Food stand

On the way

Sightseeing in Leyte

Philippine cuisine

7

For everyone around the world “health” is irreplaceable. It is the same for our planet. How do we grasp

“health” as a “science” and respect “life” for the sustainable development of humans? In the 21st century,

globalization progresses rapidly in all fields and a variety of factors are mutually related creating complex

issues. To solve these global problems, it is essential to understand the current situation fully while continuing

to follow a specific direction with quick efficiency.

The School of Tropical Medicine and Global Health (TMGH) is intended to contribute to the fostering of

professionals in order to find solutions to global health problems alongside those from low-income countries

who must balance development with health issues. Though such talented people were lacking around the

world, particularly in Japan, large-scale graduate schools focused on public health and the institution of tropical

medicine were few in Japan.

In order to solve this problem, the Graduate School of International Health Development (Master course)

was established in 2008 at Nagasaki University. Here, in addition to classes that dealt with hygiene and public

health, comprehensive education regarding the natural environment, local situations, political circumstances,

economics, societies, and cultures was offered. Many of the young graduates from this School left for the field

and international organizations to work worldwide while others have been active in academia and research

institutes such as universities.

Changes in the world, however, occur more and more rapidly, especially in reference to “global health”.

When looking at the Ebola hemorrhagic fever in West Africa in 2014, then the example of the Middle East

Respiratory Syndrome (MERS) in South Korea that has finally subsided recently, one can’t help but think that

“the Earth is really connected”. Clearly, there is a need for a high degree of education and research in this field.

Therefore, in April 2015, TMGH was established as a new graduate school in Nagasaki University. TMGH aims

to further the development of high-level professionals in the field of global health. Our three courses, Tropical

Medicine (MTM), International Health Development (MPH), and Health Innovation (MSc) provide a variety of

learning experiences for each graduate student, motivating them to meet the requirements of research and

practice. In addition, in cooperation with the London School of Hygiene & Tropical Medicine which is leading

the world in global health studies, our School carries out education at a global level for students who are

internationally-oriented by using progressive instructions and integrating classroom education with in-field

practice.

The short-term field training in abroad during the first year of study for our MPH students is one of the key

subjects in our curriculum. Although my scientific background is biochemistry, I know field training is essential

for students in our School because I had a very valuable experience in Paraguay as a team leader for a JICA

project where I met many patients suffering from Chagas’ diseases and Leishmaniasis. This is why I have spent

much time studying parasites while attempting to discover and develop new drugs in order to help those in

need.

I hope that from this report you will have a better understanding of the activities and goals of TMGH.

Foreword

Kiyoshi KitaDean, School of Tropical Medicine and Global Health, Nagasaki University

8

The School of Tropical Medicine and Global Health (TMGH) at Nagasaki University was newly opened in October 2015. As a Master of Public Health (MPH) course at the School, International Health Development course welcomed 16 new students in its debut year, aiming to train them and their successors into health professionals who can contribute to solving global health problems. Through the very name of “International Health Development” we hope to convey our strong commitment to developing health-related status worldwide.

Entering into the 21st century, it has been made apparent that fundamental global health problems cannot be solved by relying on medicine and conventional public health alone. The promotion of problem-oriented education, research and practice, the integration of knowledge from development studies, international relations, development economics, area studies, social anthropology, pedagogy, environmental science, ecology, and many more aspects of our world are required. International Health Development, as an independent master program, is seeking to foster field-minded but sophisticated practitioners in global health.

The course’s two-year curriculum is characterized by the ‘short-term field training’ in developing countries during the first year and the ‘long-term field training’ conducted in the second year (5 month internship plus 3 month research). This report is a summary of the short-term field training which took place in the Republic of the Philippines from February 28th to March 12th, 2016. During these two weeks, students visited and observed field activities and sat in on lectures given by health professionals. Class discussions were held and a final presentation was also conducted. This experience was valuable for the students to prepare them for the long-term field training of their second year.

This year, the students were accompanied by Prof. Miho Sato (assistant professor) who was in charge of coordinating the entire trip, as well as Prof. Hisakazu Hiraoka (associate professor), Prof. Kota Yoshioka (assistant professor), and Mr. Masashi Teshima (second year student). They visited Manila and Leyte, observing and learning from various activities and organizations. This report has been compiled using the contents of the lectures held by the visited organizations, the students’ daily records, the summary presentation, and other materials gathered from the trip.

It is my hope that this report will be read by those who are actively working in, or are interested in, the area of international health. The commitment of the students to solving international health problems can be assessed through these reports and I would be greatly pleased if readers would be willing to share their feedback towards educational improvements of our School.

Finally, I would like to extend my profound thanks to all who provided valuable training opportunities to our students, including WHO/WPRO, JICA Philippines, San Lazaro Hospital, the Philippine Department of Health, RIT/JATA Philippines, Inc., Research Institute for Tropical Medicine, Philippine Red Cross, and more.

As a final note, please understand that the contents and data in this report were collected and described as a part of the students’ training and learning process. I would like to ask for your kind consideration if any of the information contained is inadequate or incomplete, and to please refrain from citing this report in any situation.

Foreword

Kazuhiko MojiDirector of International Health Development Course, School of Tropical Medicine and Global Health, Nagasaki University

9

AIDS acquired immunodeficiency syndromeANC antenatal careBEmONC basic emergency obstetric and newborn careBHS barangay health stationBHW barangay health workerCHV community health volunteerDOH Department of HealthDOTS directly observed treatment, short-courseEPI Expanded Programme on ImmunizationHIV human immunodeficiency virusJ-GRID Japan Initiative for Global Research Network on Infectious DiseasesJICA Japan International Cooperation AgencyLGU local government unitMDG (s) Millennium Development Goal (s)MDR-TB multidrug-resistant tuberculosisMPH Master of Public HealthNCD noncommunicable diseaseNGO non-governmental organizationNHIP National Health Insurance ProgramNTP National Tuberculosis Control ProgrammeNU Nagasaki UniversityODA official development assistanceOOP out-of-pocketPhilHealth Philippine Health Insurance CorporationPhilPACT Philippine Plan of Action to Control TuberculosisPRC Philippine Red CrossRHU rural health unitRIT/JATA Research Institute of Tuberculosis / Japan Anti-Tuberculosis AssociationRITM Research Institute for Tropical MedicineSATREPS Science and Technology Research Partnership for Sustainable DevelopmentSDG (s) Sustainable Development Goal (s)SLH San Lazaro HospitalSMACHS-EV Project for Strengthening Maternal and Child Health Services in Eastern Visayas, Philippines

/ Government of the Philippines-JICA ProjectSTI sexually transmitted infectionTB tuberculosisTMGH School of Tropical Medicine and Global Health (at Nagasaki University)UHC universal health careUN United NationsWASH water, sanitation and hygieneWHO World Health OrganizationWPRO WHO Regional Office for the Western Pacific

Abbreviation List

10

Name of country Republic of the Philippines (in English)Republika ng Pilipinas (in Tagalog)

Land area 299,404km2

Climate Tropical monsoonPopulation 99.14 million (2014)1

Annual population growth rate: 1.6% (2014)2

Geography The Philippines is divided into three main island groups:Luzon, Visayas, and Mindanao.Luzon is the largest island and Mindanao is the second largest island.

Languages Filipino (official; based on Tagalog) and English (official); eight major dialects - Tagalog, Cebuano, Ilocano, Hiligaynon or Ilonggo, Bicol, Waray, Pampango, and Pangasinan2

Adult literacy rate Definition: age 15 and over can read and writeMale: 95.8% Female: 96.8% (2015 est.)2

Both sexes: 96.3%Ethnic groups Tagalog (28.1%), Cebuano (13.1%), Ilocano (9%), Bisaya/Binisaya (7.6%),

Hiligaynon Ilonggo (7.5%), Bikol (6%), Waray (3.4%), other (25.3%) (2000 census)2

Religions Catholic (82.9%), Muslim (5%), Evangelical (2.8%), Iglesia ni Kristo (2.3%), other Christian (4.5%), other (1.8%), unspecified (0.6%), none (0.1%) (2000 census)2

Currency Philippines Peso (₱)₱ = USD10.022 = JPY2.44 (March 2016)

Natural hazards Typhoons, cyclones, landslides, active volcanoes, destructive earthquakes, tsunamis2

President Benigno Simeon Cojuangco Aquino III (as of March 2016)Economy Gross domestic product (GDP): $284.8 billion (2014)1

GDP per capita (current US$): $2,872.5(2014)1

GDP growth: 6.1% (2014)1

Poverty headcount ratio at national poverty line (% of population): 25.2% (2012)1

Education Enrollment rate Primary education: 96.8%Secondary education: 67.4% (2013)1

System In 2011, the Department of Education started to implement the new “K to 12” educational system, prolonging the compulsory education period. The K to 12 Program covers 13 years of basic education with the following key stages:- Kindergarten to Grade 3- Grades 4 to 6- Grades 7 to 10 (Junior High School)- Grades 11 and 12 (Senior High School)3

Health Life expectancy at birth, total (years): 68.3 (2014)1

Maternal mortality ratio (modeled estimate, per 100,000 live births): 114 (2015)4

Under five mortality rate (per 1,000 live births): 28 (2015)4

Overview of the Philippines

12

Philippines’ progress based on the MDG (Millennium Development Goal) Indicators (Excerpt)2,5

(September 2015)

Goals/Targets/Indicators Target(2015)

Baseline(1990)

Latest

GOAL 1. ERADICATE EXTREME POVERTY AND HUNGERTarget 1.A Halve, between 1990 and 2015, the proportion of people whose income is less than one

dollar a dayIndicator 1.1a Proportion of population below national poverty

threshold17.2 34.4

(1991)25.2

(2012)GOAL 4. REDUCE CHILD MORTALITY

Target 4.A Reduce by two-thirds, between 1990 and 2015, the under-five mortality rateIndicator 4.1 Under-five mortality rate 27.0 80.0 31.0

(2013)Indicator 4.2 Infant mortality rate 19.0 57.0 23.0

(2013)GOAL 5. IMPROVE MATERNAL HEALTH

Target 5.A Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratioIndicator 5.1 Maternal mortality ratio 52 209 221

[182-260](2011)

Indicator 5.2 Proportion of births attended by skilled health personnel

100.0 58.8 87.0(2013)

GOAL 6. COMBAT HIV/AIDS*, MALARIA AND OTHER DISEASESTarget 6.C Have halted by 2015 and begun to reverse the incidence of malaria and other major diseasesIndicator 6.8a Prevalence associated with tuberculosis 0.0 246 461

(2013)Indicator 6.8b Death rate associated with tuberculosis 0.0 39.1 24.0

(2013)Indicator 6.9a Proportion of tuberculosis cases detected under

directly observed treatment, short-course70.0 53.0

(2001)83.0

(2014)*Human immunodeficiency virus / acquired immunodeficiency syndrome

References1 The World Bank. Data, Philippines [Internet]. Washington, D.C.: The World Bank; [updated 3 March 2016;

cited 31 March 2016]. Available from: http://data.worldbank.org/country/philippines2 Central Intelligence Agency. The World Factbook [Internet]. Washington, D.C.: Central Intelligence Agency;

[updated 3 March 2016; cited 29 March 2016]. Available from: https://www.cia.gov/library/publications/the-

world-factbook/geos/rp.html3 Republic of the Philippines Department of Education. K to 12 General Information. [Internet]. Manila: Republic

of the Philippines Department of Education; [cited 29 March 2016]. Available from: http://www.deped.gov.

ph/k-to-12/faq4 The World Bank. Data, Indicators [Internet]. Washington, D.C.: The World Bank; [updated 3 March 2016; cited

3 March 2016]. Available from: http://data.worldbank.org/Indicator5 Philippine Statistics Authority. MDG Watch, Philippines’ Progress based on the MDG Indicator [Internet].

Manila: Philippine Statistics Authority; [updated 1 September 2015; cited 2 April 2016]. Available from: http://

nap.psa.gov.ph/stats/mdg/mdg_watch.asp

13

1. Objectives

· To deepen students’ insight and to enhance their understanding on the importance of the practical

utilization of basic knowledge

· To motivate students to pursue global health practices through exposure to model health improvement

activities and research fields

2. Method

· From 28th February to 12th March, 2016, students visited several organizations:

❖ World Health Organization Regional Office for the Western Pacific (WHO/WPRO)

❖ Japan International Cooperation Agency (JICA) Philippines

❖ San Lazaro Hospital (SLH)

❖ Department of Health (DOH)

❖ Research Institute of Tuberculosis/ Japan Anti-Tuberculosis Association (RIT/JATA) Philippines,

Inc.

❖ Research Institute for Tropical Medicine (RITM)

❖ Philippines Red Cross (PRC)

❖ Others

· Students had an opportunity to sit in on lectures at each place, to attend a conference, and to discuss

health issues in the Philippines.

· Students gained experience regarding logistic management and developed necessary skills for activities

related to global health.

· Students acquired group discussion and facilitation skills by participating in daily recap meetings as well

as by making a final presentation.

· Students discussed their ideas regarding each facility they visited and wrote a report on what they

learned through this field trip.

3. Supporting Organization and People

Supervising Professors

Prof. Miho Sato Assistant Professor, Nagasaki University School of Tropical Medicine and Global Health

Prof. Kota Yoshioka Assistant Professor, Nagasaki University School of Tropical Medicine and Global Health

Prof. Hisakazu Hiraoka(Feb 28th to Mar 5th)

Associate Professor, Nagasaki University School of Tropical Medicine and Global Health

AccompanyingStudent

Mr. Masashi Teshima MPH course student (7th batch), Graduate School of International Health Development, Nagasaki University

Overview of the Field Trip

14

Supporting Organizations

Asian Health Institute (for preparatory lecture)JICA/ Japan International Cooperation Center (JICE) for the international students supported by the Japanese Grant Aid for Human Resource Development Scholarship (JDS)Japan Student Services Organization (JASSO)Student Support Department, Nagasaki University

4. Participating Students

▷ Nobuya Goto

▷ Satomi Ichino

▷ Aiko Inoue

▷ Khin Zar Wai

▷ Ryo Kobayashi

▷ Asuka Miyazaki

▷ Shoko Ogino

▷ Masanobu Ono

▷ Takuya Shizume

▷ Kumiko Takai

▷ Noriko Tamari

▷ Reiri Tsumura

▷ Meguru Yamamoto

▷ Erika Yoshimoto

▷ Yasue Yoshino

▷ Zar Lwin Hnin

5. Schedule of Trip

Date AM/PM Schedule28/Feb. SUN Flight from Fukuoka to Manila29/Feb. MON AM Cultural/historical program: Manila Intramuros

PM Department of Health1/Mar. TUE AM WHO/WPRO

The Tenth National TB Programme Managers Meeting in the Western Pacific Region

PM JICA Philippines Office2/Mar. WED AM/PM San Lazaro Hospital3/Mar. THU AM A.A. Zapa Health Center in Caloocan City

PM RIT/JATA Philippines, Inc.4/Mar. FRI AM Research Institute for Tropical Medicine

PM Philippine Red Cross Headquarters5/Mar. SAT Flight from Manila to Tacloban6/Mar. SUN AM/PM Cultural/historical program in Leyte7/Mar. MON AM/PM Philippine Red Cross Leyte Chapter8/Mar. TUE AM/PM JICA Project for Strengthening Maternal and Child Health Services in

Eastern Visayas (SMACHS-EV Project)DOH Regional Office 8Field sites (Dulag, Tolosa)Leyte Provincial Health OfficeLeyte Provincial Hospital

9/Mar. WED AM/PM Preparation for the final presentation10/Mar. THU Flight from Tacloban to Manila

PM Internal meeting/discussions11/Mar. FRI AM WHO/WPRO

PM Final presentation12/Mar. SAT Flight from Manila to Fukuoka

15

6. Persons met at visiting sites

Visiting sites Lecturers and CoordinatorsDOH ❖ Dr. Gloria Nenita Velasco, Medical Officer IV

❖ Dr. Juanita H. Fandiño, Human Resource Management Officer❖ Ms. Jocelyn T. Sosito, Senior Health Program Officer❖ Mr. Shogo Kanamori, JICA Health Advisor

WHO/WPRO ❖ Dr. Tomohiko Makino, Medical Officer❖ Dr. Nobuyuki Nishikiori, Coordinator❖ Ms. Mina Kashiwabara, Technical Officer❖ Dr. Aya Yajima, Technical Officer

JICA Philippines Office ❖ Ms. Eri Asada-Solleza, NGO Coordinator❖ Mr. Patrick Adams G.San Juan, Program Officer❖ Ms. Teresa Mendoza, Program Officer

SLH ❖ Dr. Carina H. Frayco❖ Dr. Rhona Fulgar❖ Dr. Lynsil Roy❖ Dr. Flora P. Marin❖ Dr. Marietta Solomte❖ Mr. Paul Solano

NU-SLH Collaborative Office

❖ Dr. Nobuo Saito

A. A. Zapa Health Center ❖ Dr. Panfilo B. Solano Jr., Medical OfficerRIT/JATA Philippines, Inc. ❖ Ms. Aurora G. Querri, Deputy Executive DirectorRITM ❖ Mr. Rex J. Centeno, Senior Science Research Specialist

❖ Mr. Neil Tristan M. Yabut, Science Research SpecialistRITM (Tohoku Team) ❖ Dr. Hitoshi Oshitani, SATREPS Chief Advisor, Professor, Tohoku University

Graduate School of Medicine❖ Dr. Raita Tamaki, SATREPS Expert, Assistant Professor❖ Mr. Ryosuke Kojima, SATREPS Coordinator, JICA❖ Dr. Mariko Saito, J-GRID Expert, Assistant Professor❖ Dr. Emiko Nakagawa, J-GRID Coordinator, Research Associate

PRC Headquarters ❖ Dr. Gwendolyn Pang, Secretary General❖ Ms. Norwina D. Eclarinal, Officer in Charge❖ Mr. Briccio L. Echo Jr., Emergency Field Hospital Officer❖ Mr. Alv Jordan V. Manansala, International Relations Officer❖ Ms. MayCarol Z. Layugan, Operations Center Manager

PRC Leyte Chapter ❖ Mr. Leo Haniff C. Ko, Field Operations Head❖ Ms. Ma Jessilou Marigo❖ Ms. Ethel Villodres❖ Mr. Hebert M Quijano

DOH Regional Office 8 ❖ Dr. Minerva P. Molon, Director IV, Regional Health Office8Leyte Provincial Health Office and Leyte Provincial Hospital

❖ Dr. Ofelia C. Absin, Officer in Charge, Chief of Leyte Provincial Hospital

JICA SMACHS - EV Project Office

❖ Ms. Chisaki Sato, Training/Project Coordinator❖ Ms. Lucila C. Loterte, Local Senior Project Coordinator❖ Ms. Esther Ruth Amable, Local Project Coordinator

Dulag MunicipalityRural Health Unit,Barangay Health Station

❖ Mr. Manuel Siaque, Mayor❖ Dr. Allan B. Alvarez, Municipal Health Officer

Tolosa MunicipalityRural Health Unit,Barangay Health Station

❖ Mr. Erwin C. Ocaña, Mayor❖ Dr. Ma. Aurora Lyn R. Benitez, Municipal Health Officer

16

Department of Health (DOH), Health Human Resource Development Bureau

Site Overview and Background

The DOH is the executive health department of

the Philippines government. It is responsible for

ensuring access to fundamental public health services

for all Filipinos through the provision of quality

healthcare, and the regulation of health providers,

services and products.1 The Philippines’ health care

service is decentralized; the country has 17 DOH

Regional Offices, 82 Provincial Health Offices, 38 City

Health Offices, and 865 Municipal Health Offices.2

Agenda

1. Philippines Health System

1-1. Health status and population transition

Health in the Philippines has improved dramatically

over the last two decades. According to data from

the MDGs, life expectancy at birth increased from

68.1 in 1999 to 71.8 in 2014 for women and 62.6 in

1990 to 64.9 in 2014 for men.3,4 During the MDG era,

under-five mortality rate and malaria infection

decreased significantly for past two decades,

however, tuberculosis (TB) is still a major burden in

the Philippines. Although maternal mortality ratio

has also been decreasing, it could not reach the MDG

targets.5

The Philippines total population boomed from

66.9 million in 1990 to 99.1 million in 2014.6 In recent

years, a demographic transition has also occurred in

that the proportion of children in the population has

gradually decreased when compared to those of

working-age and the elderly.7

1-2. Causes of death

According to the data on causes of death in 2010,

the most common causation was heart disease

(102,936 cases, 109.5 per 100,000 populations),

while TB (24,714 cases, 26.3 per 100,000 populations)

ranked sixth.8 The proportion of deaths caused by

noncommunicable diseases (NCDs) has increased

while that of infectious diseases has decreased.7

1-3. Overview of the health system

The health system of the Philippines consists of a

public sector and a private sector. The public sector’s

financing is based on taxes. In 1991, the health

service was delegated to the local governments.

Under the leadership of the DOH, local government

units (LGUs) became responsible as direct service

providers. As a result, this system led to the

fragmentation of health services in the Philippines.

For the private sector, a lot of actors including “for-

profit and non-profit” health providers such as clinics,

hospitals, health insurance service providers, health

products providers, and research and academic

institutions are taking part in the health system.

According to data in 2013, the number of private

hospitals accounted for 63% of the total number of

hospitals in the Philippines. Thus, in addition to

public hospitals, private hospitals also play an

important role in the country.9

1-4. PhilHealth and healthcare financing in the

Philippines

The proportion of out-of-pocket (OOP) health

expenditures in the Philippines has been relatively

high. This means that indigent people can easily fall

into financial difficulties just by paying for health

services. To improve this situation, the Philippine

Health Insurance Corporation (PhilHealth) was

established in 1995. The PhilHealth is a government-

owned and controlled corporation that deals with

29th February

18

healthcare financing.9 It aims to implement the

National Health Insurance Program (NHIP) for all

Filipinos. The NHIP includes formal, informal, and

sponsored sectors as well as non-paying members. It

has expanded its coverage up to 91% as of November

2015.7

1-5. Universal Health Care

To strengthen the NHIP, Universal Health Care

(UHC), Kalusugan Pangkalahatan (in Tagalog), was

implemented in 2010. It was a government mandate

aimed at ensuring every Filipino could receive

affordable and quality health benefits. There were

three strategic thrusts of the UHC:

1) Financial risk protection through expansion in

enrollment and benefit delivery of the NHIP

2) Improved access to quality hospitals and

health care facilities

3) Attainment of health-related MDGs7

Mainly to pursue the third branch, a strategy

called “High Impact Five” (UHC-Hi-5) was launched.

It aimed to achieve the greatest improvements in

health with the highest impact on the most

vulnerable portion of the population, which focused

on five critical UHC interventions within 15 months,

starting from 2015. The Hi-5 activities were:

1) Maternal care

2) Infant care

3) Under five care

4) Preventing HIV/AIDS

5) Building the Service Delivery Networks7

1-6. Human resources for the health system

There are two main concerns regarding medical

professionals needed for the health system; uneven

resource distribution across the country and brain

drain to other countries. For the first concern, the

DOH is taking measures such as the deployment

program in an attempt to ameliorate the issue. For

example, medical professionals such as doctors and

nurses are assigned to rural areas for a certain period

of time with the hope that they will realize the

importance of ensuring efficient health service

provision in the rural areas.7 As for brain drain, it is

one of the sources of remittance supporting Filipino

finance which the country depends on. Since it is

benefitting the country, the government faces the

challenges of how to tackle and balance the

professional brain drain with national need.

2. JICA Expert’s Work in the DOH

2-1. Technical advisory to the DOH

The health technical advisory in the Philippines

includes two main functions; one is making

recommendations to the ongoing policies while the

other is enhancing the Service Delivery Networks.2

2-2. Policy recommendations to improve maternal

care SDNs based on field studies

Interview survey was conducted by JICA expert

with health professionals and administrators, DOH

officers, and other international cooperation partners.

This short study aimed to recognize the challenges

and to identify good practices. Key findings are:

❖ Poor referral system

❖ Limited availability of essential maternal care

services at rural health units (RHUs) / barangay

health stations (BHSs)

❖ High burden of OOP health expenditure

❖ No balance billing practice at private hospitals2

Reflection

In the early 1990s, the major causes of death

started to shift from infectious diseases to NCDs.

Therefore, it is necessary to consider the impact of

westernized dietary habits, environmental degradation

19

due to industrialization, and the widening economic

disparity. On the other hand, the number of patients

suffering from communicable diseases such as TB is

still high, which requires continuous efforts on a

public health approach, health promotion, and

health education.

The challenges relating to health professionals

such as uneven distribution of medical professionals

in the country and brain drain of medical professionals

to overseas are difficult to tackle, however, the

country’s deployment system has the potential to

make the situation better. Not only increasing the

number of medical students, but considering the

quality of education to retain students could be

another solution to these challenges.

Different perspectives can help further push

improvements in healthcare in the Philippines. By

sharing experiences in other developing countries

and Japan, the JICA experts push the DOH to broaden

its scope which can help to identify unrecognized

problems and discover new approaches to the

current situation.

References1 Republic of the Philippines Department of Health.

About us [Internet]. Manila: Republic of the

Philippines Department of Health; [cited 31 May

2016]. Available from:

http://www.doh.gov.ph/about-us

2 Overview of JICA Expert’s Work at Department of

Health, Philippines [unpublished lecture notes].

Japan International Cooperation Agency; notes

provided at lecture given 29 February 2016.

3 The World Bank. World DataBank, World Development

Indicators [Internet]. Washington, D.C.: The World

Bank; [cited 30 March 2016]. Available from:

http://databank.worldbank.org/data/reports.

aspx?source=2&country=&series=SP.DYN.LE00.

FE.IN&period=

4 The World Bank. World DataBank, World Development

Indicators [Internet]. Washington, D.C.: The World

Bank; [cited 30 March 2016]. Available from:

http://databank.worldbank.org/data/reports.

aspx?source=2&country=&series=SP.DYN.LE00.

MA.IN&period=

5 Republic of the Philippines Philippine Statistics

Authority. MDG Watch, Statistics at a glance of the

Philippines’ Progress based on the MDG indicators

[Internet]. Quezon City: Republic of the Philippines

Philippine Statistics Authority [cited 12 April 2016].

Available from:

http://www.nscb.gov.ph/stats/mdg/mdg_watch. asp

6 The World Bank. World DataBank, World Development

Indicators [Internet]. Washington, D.C.: The World

Bank; [cited 30 March 2016]. Available from:

http://databank.worldbank.org/data/reports.

a s p x? s o u r c e = 2 & c o u n t r y = & s e r i e s = S P. P O P.

TOTL&period=

7 The Philippine Health System [unpublished lecture

notes]. Department of Health; notes provided at

lecture given 29 February 2016.

8 Republic of the Philippines Department of Health

National Epidemiology Center. The 2010 Philippine

Health Statistics [Internet]. Manila: Republic of the

Philippines Department of Health National

Epidemiology Center; [cited 20 March 2016].

Available from:

http:/ /www.doh.gov.ph/sites/default/f i les/

publications/PHS2010_March13.compressed.pdf

20

9 Asia Pacific Observatory on Health Systems and

Policies. The Philippines Health System Review,

Health Systems in Transition Vol. 1 No.2 2011

[Internet]. Manila: World Health Organization

Representative Office Philippines; [cited 4 April

2016]. Available from:

http://www.wpro.who.int/philippines/areas/

health_systems/financing/philippines_health_

system_review.pdf

21

World Health Organization Regional Office for the Western Pacific (WHO / WPRO)

Site Overview and Background

WHO is an organization which deals with global

health issues as an United Nations (UN) agency. With

an initial membership of 61 countries, the number of

member states has more than tripled to 194 as of

March 2016.1,2 WHO has six regional offices and 149

country offices around the world.3 Countries are not

necessarily divided into regions based on their

geographical location. For example, Pakistan belongs

to the East Mediterranean region, although the

Southeast Asia regional office, located in New Delhi,

India, is the closest to the country.4 WPRO is one of

the regional offices of the WHO. It covers 37 countries

and areas and serves approximately 1.8 billion

people.5 WPRO consists of one head office located in

Manila, and 15 country offices in the region with 640

employees as of March 2016.6,7 Since the region

contains countries which vary greatly in regards to

development, from developing countries like

Cambodia and Lao People’s Democratic Republic to

developed countries like Australia and Japan, health

situations are different from country to country.5

Agenda

1. Briefing on WHO from Dr. Makino and Dr.

Nishikiori

Japan has been contributing to UN agencies

including WHO as a member state for around 60

years. The main roles for Japan as a developed

country are financial support and human resource

contribution.7 Financial support can be divided into

two aspects; assessed contribution and voluntary

contribution.7,8 Assessed contribution is mandatory for

all member states of the organization.8 Voluntary

contribution is additional contribution given by the

member states and others.7 Japan is the fifth highest

contributor in the organization.7 Considering the

amount of the annual budget contributed to the UN

system, Japan is one of the under-represented countries

in terms of human resources allocation in the system.7

2. Observing the Tenth National TB Programme

Managers Meeting in the Western Pacific Region

During the visit to the WPRO, there was a regional

TB conference. Experts from various organizations

and representatives from member states in the region

participated in the conference with several observers

in the room. The contents of the meeting in the

opening session consisted of an overview of the

agenda and a brief discussion based on lectures and

reports from participants. It was a closed conference

focusing its discussion on the “End TB Strategy”.

Reflection

WHO sets global goals and plays a vital role for

elevating the health of people around the world. It

faces challenges, however, in translating the global

agenda to local strategies. In the conference convened

by WPRO, participants actively discussed topics based

on not only the global situation but also their own

experiences and the situations in their home countries.

1st March (AM)

22

These processes can help draft necessary plans for the

region and to help shape a common understanding of

the magnitude of the existing problems that threaten

the health of the world. WHO exercises its convening

power to share and capture a diverse set of

perspectives and knowledge to find solutions to

overcome current health issues. Putting aside the

issues of political interest and financial contribution,

Japan has tremendous experience and expertise in

the public health field which can be disseminated,

applied, and replicated across the world.

References1 World Health Organization. WHO definition of Health

[Internet]. Geneva: World Health Organization; [cited

20 March 2016]. Available from:

http://www.who.int/about/definition/en/print.html

2 World Health Organization Representative Office

Philippines. About WHO in the Philippines,

Governance [Internet]. Manila: World Health

Organization Representative Office Philippines;

[cited 20 March 2016]. Available from:

http://www.wpro.who.int/philippines/about/story_

governance_in_WHO/en/

3 World Health Organization. WHO’s work with

countries, Where WHO works [Internet]. Geneva:

World Health Organization [cited 20 March 2016].

Available from:

http://www.who.int/country-cooperation/where-

who-works/en/

4 World Health Organization. About WHO, Regional

offices for East Mediterranean [Internet]. Geneva:

World Health Organization [cited 25 March 2016].

Available from:

http://www.who.int/about/regions/emro/en/

5 World Health Organization Western Pacific Region.

Countries and areas [Internet]. Manila: World

Health Organization Western Pacific Region; [cited

20 March 2016]. Available from:

http://www.wpro.who.int/countries/en/

6 World Health Organization Western Pacific Region.

WHO in the Western Pacific, Offices [Internet].

Manila: World Health Organization Western Pacific

Region; [cited 20 March 2016]. Available from:

http://www.wpro.who.int/about/offices/en/

7 Cooperation between WHO and Japan, 1. Financial

Contribution [in Japanese] [unpublished lecture

notes]. World Health Organization Western Pacific

Regional Office; notes provided at lecture given 1

March 2016.

8 World Health Organization. About WHO, Assessed

contribution [Internet]. Geneva: World Health

Organization; [cited 20 March 2016]. Available from:

http://www.who.int/about/finances-accountability/

funding/assessed-contributions/en/

23

Japan International Cooperation Agency (JICA) Philippines Office

Site Overview and Background

JICA conducts several projects including health

projects in the Philippines through technical

cooperation, yen loan, grant aid, and Japan Overseas

Cooperation Volunteers (JOCV). The Philippines is the

third largest recipient country of technical cooperation

by JICA.1,2 Moreover, in terms of total official

development assistance (ODA) by development

partner, Japan was the second largest donor in the

Philippines in 2014.2 The government of Japan

considers the following three points as priorities for its

ODA to the Philippines, which were formulated based

on discussions between the governments of the

Philippines and Japan:

1) Achieving sustainable economic growth through

further promotion of investment (transportation,

energy, infrastructure, governance, etc.)

2) Overcoming vulnerability and stabilizing

bases for human life and production (disaster,

environment, health, agriculture, etc.)

3) Peace and development in Mindanao2,3

Agenda

1. JICA’s Assistance to the Health Sector in the

Philippines

With a combination of hard and soft components,

the current technical cooperation mainly focuses on

maternal and child healthcare and infection control.

From 2006, the focused target areas have been the

Cordillera Administrative Region and the Eastern

Visayas Region.4 Steady progress can be seen in

these two areas.

Current ongoing JICA projects in these regions

include:

❖ JICA Expert on Health Sector (2013-2016)

❖ Project for Strengthening Maternal and Child

Health Services in Eastern Visayas (2010-2016)

❖ Grant Aid Program for Rehabilitation and

Recovery from Typhoon Yolanda* (2014-2017)

❖ Comprehensive Etiological and Epidemiological

Study on Acute Respiratory Infections in Children

(2011-2017)

❖ Project for Cordillera-wide Strengthening of

the Local Health System for Effective and

Efficient Delivery of Maternal and Child Health

Services (2012-2017)

❖ Capacity Development of Public-Private-

Partnership Project Formulation (2014-2016)4

* Typhoon Yolanda internationally known as Typhoon Haiyan.

2. JICA’s Assistance in Typhoon Haiyan Affected

Areas

Based on the Philippines’ national policies of

“Build Back Better” and “Faster and Safer”, JICA has

three objectives:

1) Re-establishment of safer communities

2) Recovery of people’s daily life

3) Restoration of local economy5

In alignment with the above objectives, one of

the interventions introduced was a tide embankment

project to protect communities from the risks of

being wiped out should there be a tidal surge.

Another innovation implemented was designing and

building schools in the Piloti style which lifts buildings

above the ground while still allowing water to flow

below them. This can not only minimize the impact

on the buildings caused by water pressure, but it can

also serve as an evacuation place and accommodate

people on the second floor in case of emergencies.

1st March (PM)

24

Reflection

As Japan is a natural disaster prone country, JICA

incorporates lessons learned from Japan’s disaster

experiences to design their projects in close

communication with the government of the Philippines.

Designing and creating a ‘Hazard Map’ is one good

example of technical support provided by JICA.

Engaging relevant stakeholders, including local

governments, the project focuses on community

capacity building by conducting emergency drills and

providing training to raise awareness of disaster

response and how to appropriately use tools such as

the Hazard Map in cases of emergency. Such efforts

were put into an effect when another typhoon hit the

Philippines the year following Typhoon Haiyan. This

time, the communities and the people were much

more prepared and were capable of protecting

themselves while minimizing damages. Through

disaster recovery, the government and local

communities have learned the importance of disaster

preparedness with proactive measures in place.

References1 Japan International Cooperation Agency. JICA

Supplement to the Annual Report 2015 [Internet].

Tokyo: Japan International Cooperation Agency;

November 2015 [cited 20 March 2016]. Available

from:

http://www.jica.go.jp/english/publications/reports/

annual/2015/c8h0vm00009q82bm-att/2015_

supplement_all.pdf

2 JICA Operations in the Philippines [unpublished

lecture notes]. Japan International Cooperation

Agency; notes provided at lecture given 1 March 2016.

3 Embassy of Japan in the Philippines. Country

Assistance Policy for the Republic of the Philippines

[Internet]. Tokyo: Ministry of Foreign Affairs of Japan;

April 2012 [cited 20 March 2016]. Available from:

http://www.ph.emb-japan.go.jp/bilateral/image/

oda%202010%20update/countryassistancepolicy.

pdf

4 JICA’s assistance to the Health Sector in the

Philippines [unpublished lecture notes]. Japan

International Cooperation Agency; notes provided

at lecture given 1 March 2016.

5 JICA’s assistance in Typhoon Yolanda affected areas

[unpublished lecture notes]. Japan International

Cooperation Agency; notes provided at lecture

given 1 March 2016.

25

San Lazaro Hospital (SLH)

Site Overview and Background

Founded in 1577, SLH is one of the special

tertiary hospitals of the DOH specializing in infectious

diseases with a 500 bed-capacity.

The purpose of the visit was to learn about the roles

and activities of SLH through briefings and a hospital

tour, with a focus on its hospital-based TB program.1

Agenda

1. General Information of SLH

1-1. Characteristics of the patients

The total number of admitted patients in 2015

was 11,087. Among inpatients, records showed that:

❖ Dengue fever/dengue hemorrhagic fever

(36%)

❖ Pulmonary TB (21%)

❖ TB meningitis (1%)

❖ Pneumonia (10%)

❖ HIV/AIDS (4%)

❖ Snake bite (3%)

❖ Tetanus (2%)

❖ Leptospirosis (1%)

❖ Rabies (1%)

❖ Measles (1%)

❖ Typhoid fever (<1%)

❖ Diphtheria (<1%)

❖ Others

Fatality rates for pulmonary TB and TB meningitis

were 34.5% and 41.5% respectively. The number of

patients, particularly those with dengue fever/dengue

hemorrhagic fever and leptospirosis, increased after

typhoons and during rainy seasons.2*

1-2. User fee

For the most part, patients are covered by the

PhilHealth. According to SLH criteria, the payments

depend on their income. As most patients at SLH are

classified to be in the low income group, they are not

required to pay.

1-3. Laboratories

SLH is a designated hospital which treats

infectious diseases such as Ebola, Middle East

Respiratory Syndrome (MERS), avian influenza, and

rabies. There are specialized rooms for treating

terminal rabies patients. It has various laboratories

to carry out diagnostic tests and research, including

the national reference laboratory for HIV/AIDS,

hepatitis, and sexually transmitted infections (STIs).2

1-4. Collaboration with Nagasaki University (NU)

SLH and NU have joint collaboration to further

2nd March

26

promote research activities and clinical training of

both institutions.

2. TB Program in SLH

2-1. Outpatients

As a general routine, SLH offers directly observed

treatment, short-course (DOTS) which begins at 6

a.m. so that patients can receive treatment before

going to work.

Upon completion of DOTS, multidrug-resistant

tuberculosis (MDR-TB) patients are entitled to

receive a “reward” of 20,000 Philippine pesos as an

incentive, which is funded by the Global Fund. In

order to ensure that patients will complete the

treatment, the “reward” is distributed weekly (150

pesos/week) as an allowance. This motivates TB

patients to continue their treatment. At the same

time, the monitoring system keeps track of the

patients to prevent them from quitting their

treatment. If a patient fails to show up to receive

their medications, a hospital staff will visit their

house for a follow-up. SLH has a relationship with

LGUs to report and share information about the

progress and activities of the ongoing TB program.

TB education is provided to not only patients but

also their family members during waiting time, using

visual aids. Peer education is also carried out by

former TB patients.

2-2. Inpatients

Since family members stay with the patients to

take care of their daily needs, they have a higher risk of

becoming infected. Therefore, SLH provides them with

a TB screening test, vaccinations, and TB education.

The TB ward has difficulties in its bed-controlling

as some patients who are not required for further

admissions refuse to leave the hospital, because the

hospital provides them with free meals and more

comfortable accommodations than their homes.

Reflection

Currently the SLH TB program is sustained by

the Global Fund. Depending on such external funding

is not self-generating, thus, it is not promising in the

long-term run. A new framework or strategy that

engages the patients to be actively involved with

their treatment is necessary since the TB treatment

should be patient-oriented. This can be achieved by

fostering an enabling environment and ensuring

financial support for the patients.

References1 Department of Health, San Lazaro Hospital. San

Lazaro Hospital Today [Internet]. Manilla: Republic

of the Philippines Department of Health; [cited 28

May 2016]. Available from:

http://slh.doh.gov.ph/index.php/2-uncategorised/8-

san-lazaro-hospital-today

2 Nagasaki University SLH Project [unpublished

lecture notes]. SLH-Nagasaki Collaborative

research laboratory and office; notes provided at

lecture given 2 March 2016.* Data provided by Dr. Eumelia P. Salva, Department

of Epidemiology, San Lazaro Hospital

27

A.A. Zapa Health Center in Caloocan City, Manila

Site Overview and Background

The Caloocan area is a densely-populated area in

Manila. The A.A. Zapa Health Center is one of the

community clinics based in this area which provides

free healthcare.

The objective of this site visit was to understand

the role of barangay health worker (BHW) and how

the medical professionals at the health center handle

the challenges of a highly-populated community.

Agenda

1. The Role of the Community Health Center

Medical professionals stationed at the health

center include a doctor, nurses, midwives, and a

dentist. The BHWs are assigned to the health center.

As the objectives of the community health center are

to oversee and maintain the health of community

people, they provide clinical consultations, antenatal

care (ANC), and the measures to prevent and control

communicable diseases such as DOTS and

vaccinations. They also convene workshops on

family planning, nutrition, and hygiene promotion.

Aside from the services provided at the health center,

they also conduct home visits. In cases of emergency,

transportation to a referral hospital can be arranged

even during the night.

2. The Role of BHWs

According to the DOH, a BHW is a person who

has undergone training programs under any

accredited government and/or non-governmental

organization (NGO), and who voluntarily gives

primary healthcare services in a community after

having been accredited to function as such by the

local health board in accordance with the guidelines

promulgated by the DOH.1

Students were given a guided tour of the area

where the BHWs demonstrated and explained their

activities. Since the students were divided into four

groups guided by different BHWs, the information

obtained varied from group to group. Overall, the

basic role of the BHWs included community outreach

to encourage people to seek out services such as the

Expanded Programme on Immunization (EPI), child

growth monitoring, antenatal and postnatal care, and

deworming. In addition, there were some specialized

BHWs who worked as the TB task forces. They

supported patients undergoing DOTS. By spending

time with the BHWs, it became apparent that they

were very proud of their work and one of the common

reasons for becoming a BHW was to contribute to

3rd March (AM)

28

their respective communities. According to them, the

availability of financial incentives does not affect

significantly in their motivation to dedicate themselves

to their communities.

3. Condition Observed in Caloocan Area

People in the area lived in densely-populated

buildings where animals and people were in close

proximity. Garbage could be seen scattered along

the sidewalks and floating in stagnant water.

Reflection

Given the insufficiency of health professionals in

the Philippines, efficient resource mobilization is

crucial in the local context. Thus, BHWs play

important roles in community health outside the

realm of health facilities. Under the resource-limited

circumstances, it is essential to foster BHWs who are

highly motivated and to ensure their level of

motivation is maintained. Based on the conversations

with the BHWs, it would appear that, financial

incentives are not crucial and may not be the main

factor for their motivation. Other reasons such as

religious belief, surrounding environment, identity

as Filipinos, etc. contribute more to their enthusiasm

for their work. However, in order to better understand

the driving forces of the BHWs, further investigations

and observations are required.

From the observations of the living conditions, it

would seem that sanitation and hygiene management

is needed urgently. To improve the living environment

of the community using people-centered approach,

not only the health sector but also other sectors

should be involved. In order to maximize the effect,

the main actors should be the residents themselves

who would be required to exhibit strong leadership to

implement changes.

Reference1 The Republic of the Philippines Department of

Health. What is Barangay Health Worker? [Internet].

Manila: The Republic of the Philippines Department

of Health; [cited 27 May 2016]. Available from:

http://www.doh.gov.ph/node/837

29

Research Institute of Tuberculosis / Japan Anti-Tuberculosis Association (RIT/JATA) Philippines, Inc.

Site Overview and Background

RIT/JATA Philippines, Inc. (hereafter RIT/JATA) is a

locally-based NGO established in 2008. Its headquarters

is located in Japan while the Philippine office is located

in Manila. Currently there are seven staff members

working there.1

The purpose of the visit was to learn about the

NGO’s activities supporting TB patients at the

community level and to learn about how the NGO

collaborates with the government, national

hospitals, and health centers to tackle TB issues in

the Philippines.

Agenda

In 2009, the National Center for Disease

Prevention and the Control of the DOH led to the

formulation of the 2010-2016 Philippine Plan of

Action to Control Tuberculosis (PhilPACT), which

aimed to achieve the related MDGs.1 According to

RIT/JATA’s presentation, its activities focus on four

strategies out of eight of the PhilPACT strategies:

1) To engage both public and private TB care

providers

2) To promote and strengthen positive behavior

of communities

3) To address MDR-TB, TB/HIV and the needs of

vulnerable populations

4) To certify and accredit TB care providers2

As for the specific activities, it offers multiple

trainings for medical officers to build up their abilities

such as basic TB DOTS training, infection control

training, basic direct sputum smear microscopy

training for medical technologist, appreciation

course for chest radiography, and interpersonal

communication counseling. Trainings on the

National Tuberculosis Control Programme (NTP) and

basic STI, HIV/AIDS education for community health

volunteers (CHVs) are also conducted. In order to

motivate CHVs, RIT/JATA continues to provide them

with training sessions as well as opportunities to

recognize their own contributions at CHV assemblies.

Aside from conducting trainings, RIT/JATA visits

target facilities regularly to monitor and evaluate the

actual implementation of the NTP. Peer education

organized by RIT/JATA also enhances former TB

patients to take an active role in supporting the

current TB patients.2

Its latest project is to build the capacity of

community based organizations to increase TB

reference cases to RHUs as well as to follow up with

patients currently undergoing treatment.2

Reflection

There are two important factors to sustaining an

NGO activities within a community. One is recognition

by the government. Being recognized by the

government allows NGOs to obtain funding to

continue their projects. In order to promote their

contributions to the society, monitoring and

evaluating their own projects is necessary. Meanwhile,

a lack of communication with the government may

result in the undervaluation of NGOs. Since RIT/JATA

has an opportunity to discuss on their activities with

the government only once a year, it seems that there

is room for more constructive dialogue between the

two parties. Recognition by the society as well as the

government generates satisfaction and confidence in

NGOs, which could be fundamental to their ownership.

Such ownership is essential to sustaining their

3rd March (PM)

30

activities.

The second factor is community involvement.

Through annual meetings, CHVs who are engaged in

NGO activities can be recognized and appreciated by

the society for their efforts, which then would

enforce their motivation and dedication. As for peer

education, recognized and highly motivated peer

educators may contribute to sustaining the activities

in their own communities. Peer educators strengthen

the treatment adherence of the current TB patients.

If these people in the community can take over the

activities even after the completion of a project, it

will be an ideal form of sustainability.

References1 Republic of the Philippines Department of Health.

Tuberculosis Control Program [Internet]. Manila:

Republic of the Philippines Department of Health;

[cited 25 April 2016]. Available from: http://www.

doh.gov.ph/national-tuberculosis-control-program

2 RIT/JATA Philippines, Inc.. Activities and

Accomplishments [unpublished lecture notes].

Research Institute of Tuberculosis / Japan Anti-

Tuberculosis Association Philippines; notes

provided at lecture given 3 March 2016.

31

Research Institute for Tropical Medicine (RITM)

Site Overview and Background

RITM was established in 1981 as a research

facility under the Philippines’ DOH. It was partially

funded by a grant aid from the government of Japan

for the establishment of the main building. Its

principle task is planning and implementing research

programs for infectious and/or tropical diseases. As

the principle research arm of the DOH, RITM

conducts multidisciplinary research and contributes

to the prevention and control of infectious and

tropical diseases with a special focus on public

health.1

The purpose of the visit was to understand the

RITM’s general tasks as well as its collaborative

project that has been implemented in cooperation

with Tohoku University.

Agenda

During the visit, two researchers explained their

ongoing research projects to the students. The

researches were under the Science and Technology

Research Partnership for Sustainable Development

(SATREPS)* program and the Japan Initiative for

Global Research Network on Infectious Diseases

(J-GRID)**. These are Japanese governmental

programs aimed to promote international joint

research in which both the recipient countries and the

Japanese research institutions work together based

on the social needs of the recipient countries.2 Their

research focused on infectious diseases in children

such as childhood pneumonia, acute gastroenteritis,

mosquito-borne infections, antimicrobial resistant

bacteria, etc. According to WHO, the Philippines is one

of the 15 countries that together account for 75% of

childhood pneumonia cases worldwide.3 Their research

is rooted in major health issues of the Philippines, and

the collaboration between the Philippines and the

Japanese researchers are realized at RITM.

A short laboratory tour was organized. Some

labs visited were a real-time PCR lab, a serology test

room, a vaccine-production room, etc. Hospital

service for communicable disease patients was on

the same premises.

* SATREPS is funded by AMED (Japan Agency for Medical Research and

Development) and JICA.

** J-GRID is funded by AMED.

Reflection

The main takeaway from the lecture was how

academia, government, and the health sector

actively collaborate with one another in the form of

joint research to find solutions for life-threatening

diseases in the Philippines and around the world. By

leveraging their core strengths, each sector works

toward the same goal of producing new interventions

while aiming to generate and scale up their

effectiveness. Since the research was result-driven in

nature, once a positive result has been produced and

presented, it could bring a multiplying effect to

further scale up research opportunities that would

be beneficial to the community and its people.

Putting a new intervention into practical use is the

main and foremost objective of conducting research,

however, in the current Sustainable Development

Goal (SDG) era, the prospective researches are

expected to expand their objectives to further

advance global health such as:

1) To use the research findings to influence the

policy-making process

4th March (AM)

32

2) To render the findings to the community for

the benefit of local people who were involved

in the research in some way

This was hinted at by the researchers during the

visit. In order to achieve the two objectives, creating

and adopting a two-way feedback framework across

various layers is important to further advance the

quality of future research conducted in the

Philippines.

References1 Research Institute for Tropical Medicine. About Us

[Internet]. Manila: Research Institute for Tropical

Medicine; [cited 26 May 2016]. Available from:

http://ritm.gov.ph/about-us/history-vision-mission/

2 Japan Science and Technology Agency. About

SATREPS [Internet]. Tokyo: Japan Science and

Technology Agency; [cited 24 April 2016]. Available

from:

http://www.jst.go.jp/global/english/about.html

3 World Health Organization Representative Office

Philippines. EWARN weekly summary, Focus on

Pneumonia [Internet]. Manila: World Health

Organization Representative Office Philippines;

February 2014 [cited 24 April 2016]. Available from:

http://www.wpro.who.int/philippines/typhoon_

haiyan/media/Pneumonia.pdf?ua=1

33

Philippine Red Cross (PRC) Headquarters

Site Overview and Background

The PRC, a member of the International Red

Cross and Red Crescent Movement, was officially

established in 1947. It is committed to providing

quality life-saving services to protect the lives and

dignities of people with a focus on indigent Filipinos

in vulnerable situations.1 The PRC is composed of

individuals who devote their time and resources to

help others. Currently, they provide blood and

disaster-related activities, first aid, and health

promotion to uplift the conditions of the most

vulnerable groups in the country.

The main purpose of the visit was to learn about

the overall functions of the organization and their

health services in the Philippines.

Agenda

1. Orientation of PRC

The PRC is governed by 30 board members and

has 102 chapters nationwide. 80% of its manpower

comes from volunteers and more than 1,000 regular

staff across the country. It is funded by public

donations.2 The services offered by the PRC1 are:

1) Disaster management services

(including emergency response, early recovery,

and disaster risk management)

2) National blood services

3) Social services

4) Community health and nursing services

5) Safety services

6) Red Cross Youth

7) Red Cross 143

Other programs offered by the PRC include the

dissemination of the basics of International

Humanitarian Law, membership and fund drives,

and volunteer recruitment.2 The PRC follows the

slogan “A Red Cross that is always first, always ready,

always there” 3 for its activities and programs which

are supported by the Red Cross 143, formed to

strengthen the PRC activities at the community

level. It is composed of one leader and 43 members

who work to plan, prepare, practice, report, and

respond in communities.4

2. Health Service Orientation

The PRC implements their health services with

four key programs:

1) Community-based health program

2) Health response program

3) Training program

4) Organ donation program

The PRC performs these services across the

country and along with other branches of the

International Red Cross including the Japanese Red

Cross Society. The community-based health program

aims to give primary health care and teach about

water, sanitation and hygiene (WASH). The health

response program targets health and WASH during

disasters and emergencies. Training programs

include disaster nursing and home nursing. The PRC

coordinates the organ donation program with the

DOH to recruit donors and establish a donor registry

database in the National Health Quarter.5

3. Information and Technology Operation Center

The Information and Technology Operation Centre

operates as a monitoring and reporting center equipped

with a continuous monitoring system. Relevant

information is integrated into one system for maximum

utilization of its activities. Disaster affected areas,

4th March (PM)

34

hospitals, schools, and other related information can be

detected easily through this system. For example, the

latest information on the availability of ambulances

and blood for transfusion can be obtained promptly.

This facilitates the PRC to provide its assistance in a

timely manner through the operation center.

Reflection

The PRC is a well-organized and functioning

organization across the Philippines. It cooperates

and has established a strong partnership with the

government of the country. PRC volunteers are

highly motivated and passionate. The PRC conducts

disaster management training for locals and

professionals as well. Although all of the activities

are going well currently, a monitoring and evaluation

system is still important. An effective monitoring

and evaluation system is needed to assess the

effectiveness of each program. In addition,

harmonized collaboration with the government of

the Philippines is important to avoid duplication and

fragmentation in working areas. Evaluation should

be conducted by presenting the outcomes of

activities to assure their accountability. At the same

time, the organization can learn lessons from

assessing the process of their activities.

References1 Philippine Red Cross. About the Philippine Red

Cross [Internet]. Mandaluyong City: Philippine Red

Cross; [cited 11 April 2016]. Available from:

http://www.redcross.org.ph/about-the-philippine-

red-cross

2 Philippine Red Cross [unpublished lecture notes].

Philippine Red Cross Headquarters; notes provided

at lecture given 4 March 2016.

3 Philippine Red Cross. Philippine Red Cross

[Internet]. Mandaluyong City: Philippine Red Cross;

[cited 11 April 2016]. Available from:

www.redcross.org.ph

4 Philippine Red Cross. Red Cross 143 [Internet].

Mandaluyong City: Philippine Red Cross; [cited 11

April 2016]. Available from:

http://www.redcross.org.ph/get-involved/red-

cross-143

5 Health Services Orientation [unpublished lecture

notes]. Philippine Red Cross Headquarters; notes

provided at lecture given 4 March 2016.

35

Philippine Red Cross (PRC) Leyte Chapter

Site Overview and Background

The PRC has 102 chapters nationwide1 with the

Leyte chapter covering 25 municipalities and 300

barangays. During the Typhoon Haiyan response, it

collaborated with nine international partners including

the Japanese Red Cross Society,2 to conduct disaster

relief. The 180 staff and 300 volunteers who operated

during emergency operations for Typhoon Haiyan

were involved in shelter building, livelihood support,

health, education, and WASH. The places visited were

Barangay 107 (Santa Elena), the Cabalawan Health

Station, and Abango Elementary School which

showcased their achievements.

Agenda

1. Briefing on Haiyan Operations

1-1. Shelter

“Shelter Repair Assistance” aimed at distributing

materials and cash assistance to those whose houses

were damaged by the typhoon. In addition, another

program named “Core Shelter” provided permanent

housing to those who lost their houses entirely. As of

March 2016, 17,724 houses were repaired and 8,440

houses were newly built.2

1-2. Livelihoods

Activities to restore livelihoods were separated

into phases as listed below:

Phase 1:

Provision of conditional/unconditional cash grants

and monitoring

Phase 2:

Skills training for youth and support for enterprises

Phase 3:

Support for community-based enterprises

Phase 1 was implemented for emergencies and

phase 2 and 3 focused on recovery efforts of affected

areas.1

1-3. Health and Education

The PRC provided both hardware and software

support for disaster reconstruction. Reconstructions

of health facilities and schools had proceeded

smoothly and achieved 42% and 56% of the targets

respectively as of March 2016. The hardware support

was more easily accepted by the community people

because facility reconstructions were visible and

concrete. On the other hand, software support such

as health promotion received much less interests

from local communities.2

1-4. WASH

The main activities were rehabilitation and

construction of water facilities and community/

school-based WASH promotion.2

2. Site Visits

2-1. Barangay 107 Santa Elena: “Shelter” building

operational site

Although they were called “shelters”, the houses

provided by the PRC were permanent housings for

people who had lost their houses to Typhoon Haiyan.

The houses were a mix of concrete and wood, 4m ×

5m in size, and equipped with WASH facilities (water

tank and toilet). To ensure proper usage of WASH

facilities, promotional activities were also conducted

in the community to embed its practice. The barangay

reconstruction committee which was constituted by

residents of the community allocated housing

7th March

36

appropriately to the people, weighing socioeconomic

status and their capacity to re-establish their lives. The

PRC staff and Red Cross Volunteers (RCVs) monitored

the progress of the construction by visiting the sites

daily.

2-2. Barangay 97 Cabalawan: Health Station

The Cabalawan Health Station was rehabilitated

in August 2015 by the PRC in partnership with the

International Federation of Red Cross and Red

Crescent Societies (IFRC). Altogether, around 20

CHVs and/or RCVs were working regularly. The

medical staff, nurses, doctors, and midwives were

not stationed on the site every day, and the frequency

of their visits varied. The health services provided

were ANC, immunization, patient follow-ups, school-

based health education, etc.

2-3. Abango Elementary School: School-based

WASH activities

To promote and advance WASH activities among

pupils and their families, several initiatives were

implemented as a school program. For example,

peer-education, preparing a teacher’s guide, and

social dramas were carried out to educate children

on the importance of personal hygiene and the risks

associated with waterborne diseases. The toilets and

faucets on the school premises were designed not

only for school children but also as the designated

public facilities in case of emergencies.

Reflection

A long-term strategy that incorporates a vision

of health promotion from the very beginning of

disaster response is required. For example, in order

to help rebuild people’s lives, the PRC reconstructed

housing with an emphasis to adopt WASH activities

to promote good health. Health promotion is needed

as much as cash assistance in order to help enrich

people’s lives in disaster response. The PRC showed

good practice of school-based WASH activity. The

key elements for this success were how the PRC

managed to nourish and embed a sense of ownership

in the educational sector.

References1 Philippine Red Cross [unpublished lecture notes].

Philippine Red Cross Headquarters; notes provided

at lecture given 4 March 2016.

2 Haiyan Operations Update 2016 [unpublished

lecture notes]. Philippine Red Cross Leyte Chapter;

notes provided at lecture given 7 March 2016.

37

Institutions related to Project for Strengthening Maternal and Child Health Services in Eastern Visayas, Philippines (SMACHS-EV Project)

Site Overview and Background

The Project for Strengthening Maternal and

Child Health Services in Eastern Visayas, Philippines

(SMACHS-EV Project) is carried out in Leyte Province

(except Tacloban City) and Ormoc City. The purpose

of the visit was to learn how JICA was supporting and

working together with the local government in the

health sector to reduce maternal and neonatal

mortality in Eastern Visayas and how they

implemented the projects in the field.

Agenda

1. Overview of the SMACHS-EV Project

The SMACHS-EV Project (February 2010 - July

2016) is funded and technically assisted by JICA at

the request of the DOH to support ensuring safe

pregnancies, safe deliveries, and postpartum care

services in the targeted areas. In order to achieve the

national target of the MDG 5 as well as to reduce the

consistently high maternal mortality, the SMACHS-

EV Project was launched in collaboration with the

local government and JICA.

The main achievements of this project included:

1) Developed a strong monitoring system on

service quality of basic emergency obstetric

and newborn care (BEmONC) health facilities

2) Obtaining support and commitment from all

LGUs support on health

3) Strengthening the functionality of the

community health team1

2. Good Practice at the RHU and the BHS in Dulag

and Tolosa

Through the site visits, the roles and

responsibilities of the RHU and the BHS and how

they conduct their services in alignment with the

project were presented. At the RHU, progress and

achievements such as the coverage rate of ANC,

were displayed throughout the hospital in the form

of posters and brochures highlighting their efforts in

contributing to the well-being of pregnant women,

mothers, and babies. In the case of Dulag, the

municipal mayor had a strong interest in public

health which was a factor to further enhance the

achievements of this project. Working closely with

the RHU, the BHWs had a very important role in

overseeing the health of the people living in the

community. In Tolosa, students had a chance to meet

and talk with a group of the BHWs to explore how

they perceived their roles and the factors which

drove them to work as a BHW for a long period of

time. They all mentioned that they feel great

satisfaction from serving their communities and take

much pride in their work.

3. Leyte Provincial Health Office and Leyte

Provincial Hospital

The Leyte Provincial Hospital was severely

damaged by Typhoon Haiyan in 2013. Since they

received no aid from any organization for several

days, they suffered greatly after the typhoon.

Furthermore, in the following year, another large

typhoon hit the island and thus the reconstructed

hospital was again destroyed. The bitter experience

highlighted the importance of comprehensiveness in

the rapid assessment of disasters and the necessity

of sustainability for disaster preparedness.

8th March

38

Reflection

Maintaining motivation among health workers

across all levels of the system is extremely important

and a fundamental element that influences how well

the projects operate. Throughout the site visits, it

was clear that a sense of satisfaction and confidence

built by being recognized are essential factors to

enhance their motivation. This could trigger a higher

sense of responsibility and willingness to lead the

project on their own. In this sense, JICA emphasized

the effective utilization of national staff who knew

and were familiar with the situation in the local

context in order to build local ownership.

Furthermore, in order to avoid the projects from

becoming a one-time effort, it was essential to

engage relevant actors, including policy makers,

from the very beginning to foster and obtain their

commitment. This ensured that projects were not

only carried out but also the effects of the projects

were sustained even after they were completed.

Reference1 The Project for “Strengthening Maternal and Child

health Services in Eastern Visayas” (SMACHS EV)

[unpublished lecture notes]. Japan International

Cooperation Agency; notes provided at lecture

given 8 March 2016.

39

World Health Organization Regional Office for the Western Pacific (WHO / WPRO)

Site Overview and Background

Same as the report for 1st March. The roles of

WHO/WPRO were presented through three specific

initiatives on TB, tobacco, and filariasis.

Agenda

1. The Roles of WHO/WPRO

WHO has three core functions:

1) Normative guidance

2) Public service at regional level

3) Country support

WHO is responsible for developing health

guidelines based on evidence. In order to develop these

guidelines which can be applied across a vast spectrum

of situations, WHO sets up commissions to ensure that

the voices of various experts are incorporated. This

process takes about one to two years.

Once certain guidelines have been developed,

WHO supports each member state to adapt and

implement the guidelines and strategies. The

situations, however, vary country by country requiring

more specific factors to be considered and reflected

before the guidelines to be implemented. Thus, to

identify and help member states to overcome similar

challenges at a regional level, WPRO serves to develop

a regional framework for action.

2. The Challenges of the Health System through

an Example of MDR-TB

Drug-resistance is a result of failed treatment

caused by a weak health system. Consequently, it

can be said that MDR-TB is a man-made phenomenon.

In the Philippines, MDR-TB accounts for

approximately 4.0% of the total number of new TB

cases.1 There are many patients being treated in the

private sector. Due to the nature of the current Filipino

health system and the relationship between the DOH

and private sectors, the quality of the treatment

carried out by private hospitals are not fully captured

by the DOH. Therefore, the number of patients who

may be mistreated are unknown. It can be assumed

that those patients have a higher risk of suffering from

TB drug resistance. Unfortunately, the weak health

system has created a hotbed for MDR-TB.

Through the case of TB drug resistance, it is evident

that having a strong health system is fundamental to

controlling diseases, while many factors such as early

diagnosis, prevention, communication, advocacy, and

surveillance should also be considered. In the MDG era,

interventions were provided to reduce certain diseases.

In the SDG era, a good health system is needed to

control diseases sustainably.

11th March

40

3. Tobacco Free Initiative

Tobacco has killed 100 million people in the 20th

century. If the current trend continues, tobacco could

kill up to one billion in the 21st century unless urgent

action is taken. The Western Pacific Region holds the

greatest number of smokers, 430 million, which is about

one-third of the world’s smokers.2 In this region, two

people die each minute from a tobacco-related disease.

About 600,000 people die prematurely each year

as a result of exposure to second-hand smoke. It is

estimated that 50% of all children in this region are

regularly exposed to second-hand smoke at home

and in public places.

The WHO Framework Convention on Tobacco

Control (WHO-FCTC) is the most powerful tool to

reverse the tobacco epidemic. As a priority on the public

health agenda, WHO-FCTC establishes tobacco control

measures such as demand-reduction through high

taxation, supply-reduction, and suggesting alternative

crops to grow for tobacco farmers.3 Other activities

include global tobacco surveillance and monitoring,

developing prevention strategies to protect people

from tobacco and its smoke (e.g. smoke-free laws and

initiatives using mobile phones to provide cessation

services),4 and enforcing bans on tobacco advertising.

Among these measures, data indicates that

raising taxes on tobacco is the most cost effective

measure. A 10% increase in tobacco prices decreases

about 4% consumption in high-income countries

and about 8% in low and middle-income countries.5

Furthermore, there is a need to regulate the use of

electronic cigarettes, water pipe tobacco, etc.

4. Global Programme to Eliminate Lymphatic

Filariasis (GPELF)

The GPELF was launched in 2000.6 According to

WHO, in 2014 alone, 139 million people were reached

with ivermectin through GPELF in 18 sub-Saharan

African countries and 109 million people were

treated globally with ivermectin for onchocerciasis.7

Currently, 73 countries are considered endemic

for lymphatic filariasis (LF).8 The GPELF’s goal is to

eliminate LF by 2020, and its strategies are to stop

the spread of infection and to alleviate the suffering

of affected populations.8 The three steps being taken

to reach this goal are:

1) Mapping

2) Mass drug administration (MDA)

3) Surveillance6

The role for each level of the GPELF is as follows:

❖ WHO sets policy strategies

❖ Donors offer financial support

❖ The health departments and ministries

implement programs

❖ NGOs offer support in the field while academia

provides evidence

Through this approach, various actors collaborate

to eliminate LF. As for the Philippines, it has 100%

geographical coverage of the MDA.9

Reflection

There were three main findings from the lectures.

Firstly, the role of WHO is like a conductor of an

orchestra. It assembles member states, academia,

civil societies, and private sectors and drive them to

work towards a common goal. By collaborating and

complementing the strengths of each actor, WHO

aims to develop a global agenda and strategies that

could feed into the advancement of global health.

Secondly, all three initiatives mentioned in the

agenda above emphasized the importance of

strengthening a strong and stable health system.

Focusing only on specific health issues is not enough,

there is a definite need to view the health system in its

entirety. By taking a closer look, the root causes and

41

core solutions of particular health issues can be found.

Lastly, knowledge itself is insufficient. The skills

to think logically and comprehensively using

obtained knowledge to understand the scope of the

problem and the factors behind them are even more

important. This way of constructive thinking is

essential when developing any health strategies in

the field of global health.

References1 World Health Organization. Tuberculosis (TB), The

Philippines [Internet]. Geneva: World Health

Organization; [cited 15 April 2016]. Available from:

http://www.who.int/tb/publications/2009/airborne/

philippines/en/

2 World Health Organization Western Pacific Region.

Health Information and Intelligence Platform,

Tobacco Control [Internet]. Manila: World Health

Organization Western Pacific Region; [cited 12

April 2016]. Available from:

http://hiip.wpro.who.int/portal/Dashboards/

Tobaccocontrol.aspx

3 World Health Organization. Tobacco Free Initiative

(TFI), Tobacco control economics [Internet].

Geneva: World Health Organization; [cited 15

April2016]. Available from:

http://www.who.int/tobacco/economics/background/

en/index2.html

4 World Health Organization. Tobacco Free Initiative

(TFI), Checking your mobile phone for messages just

became good for you [Internet]. Geneva: World Health

Organization; [cited 22 April 2016]. Available from:

http://www.who.int/tobacco/communications/

highlights/mhealthleem/en/

5 World Health Organization. WHO global health days,

World No Tobacco Day - 31 May 2014 [Internet].

Geneva: World Health Organization; [cited 15 April

2016]. Available from:

http://www.who.int/campaigns/no-tobacco-

day/2014/event/en/

6 World Health Organization. Lymphatic filariasis,

Global Programme to Eliminate Lymphatic Filariasis

[Internet]. Geneva: World Health Organization;

[cited 10 April 2016]. Available from:

http://www.who.int/lymphatic_filariasis/disease/en/

7 World Health Organization. Neglected tropical

diseases, WHO welcomes Nobel Prize in Physiology

or Medicine 2015 for discoveries of drugs against

tropical diseases [Internet]. Geneva: World Health

Organization; [cited 10 April2016]. Available from:

http://www.who.int/neglected_diseases/news/

nobel_prize_2015/en/

8 World Health Organization. Lymphatic filariasis

[Internet]. Geneva: World Health Organization;

[updated February 2016; cited 10 April 2016].

Available from:

http://www.who.int/mediacentre/factsheets/fs102/en/

9 Global Programme to Eliminate Lymphatic Filariasis

(GPELF) [unpublished lecture notes]. World Health

Organization Western Pacific Region; notes

provided at lecture given 11 March 2016.

42

3. Presentation

Introduction

The theme of the presentation was “Sustainability”.

The Philippines has been steadily developing its

health status but there are still certain challenges

that need to be improved. Based on this context, we

realized the importance of sustainability in the global

health as we conducted our field trip. This diagram

summarizes our learnings.

Sustainability in global health is supported by

these five pillars:

❖ Preparedness

❖ Human resources

❖ Partnership

❖ Ownership

❖ Finance

The pillars are standing on the local context,

such as the culture, values, perspectives, etc. of local

communities.

Preparedness

Preparedness is important for supporting the

sustainability of disaster and disease management.

Some examples of counter disaster preparations can

1. Presentation Overview

2. Guests

DOH: Ms. Jocelyn T. Sosito

JICA: Mr. Shogo Kanamori

RITM: Mr. Ryosuke Kojima

SLH: Dr. Carina H. Frayco, Dr. Flora P. Marin, 5 Medical students

WHO Country Office in the Philippines: Dr. Kohei Toda

NU-SLH Collaborative Office: Dr. Nobuo Saito

Report of the Final Presentation

Title Presentation of the Field Trip to the Philippines

Place NU-SLH Collaborative Office in San Lazaro Hospital

Date 11 March 2016

Program 14:00-14:30

14:30-15:10

15:10-15:30

15:30-16:00

Opening

Presentation

Q&A / Comments from the guests

Reception

44

include residents practicing evacuation drills regularly

and participating in the making of hazard maps,

volunteers being trained in first-aids, and nurses being

trained for disaster care management. Adding to

these “soft” components of preparation, examples of

“hard” components include; reconstruction and

rehabilitation of disaster-resistant facilities, and also

building infrastructure such as public transportation

system to reduce traffic jams in cases when urgent

evacuation and emergency assistance are needed.

Information is a key to preparedness. Therefore,

it is advisable to disseminate lessons learned from

past disaster experiences and have a network among

related organizations through everyday operation to

share information and work together smoothly in

case of emergencies.

We noted some examples of preparations in

disease management from our field trip, which

included building WASH facilities, offering WASH

promotion, and awarding best practices. When it

comes to specific diseases such as TB, practicing and

promoting DOTS, and improving techniques of chest

radiography were also used. RITM offered their

research findings such as new methods for treating

local diseases as prevention measures. Health

insurance could also be a factor to promote resilience

against the future diseases.

From these learnings, we found that prevention,

resilience, dissemination of information, and training

as the four key components of “preparedness,”

which creates a state of being ready for unpredictable

future disasters and diseases that can affect the

sustainability of global health.

Human Resources

According to the WHO Health Systems Building

Blocks,1 health workforce is one of the most

important blocks of the health systems. Yet, as

WPRO pointed out, many countries in the Western

Pacific Region including the Philippines continue to

struggle to address the need for more health

professionals to meet health challenges.2 Through

visiting several sites including the DOH, WPRO, SLH,

local communities and meeting with various health

works across different levels, two issues were

highlighted as the core challenges of the current

Filipino health workforce situation.

Firstly, there are quantity and quality issues:

“how to secure necessary number for work force”

(quantity), and “how to enhance the quality of

medical professionals and health workers” (quality).

To address the issue of quantity, the Philippines must

tap into the country’s most valuable resource, the

people, and mobilize them into the health sector

through a mass recruitment. When doing so, they

should carefully consider ways to emphasize the

core characteristic of their people and apply the

Filipino “helping each other” spirit to full potential

beyond the framework of the BHWs. A hook to

attract people to commit to the medical/health

sector is essential. What are the values for the Filipino

people to engage in this sector? This is something

the national and local governments, as well as the

private sector should think seriously about and

define well in order to secure a robust health

workforce. A majority of the BHWs are currently

women and it would be beneficial to recruit more

men to encourage male participation. There are

gender specific health issues and more male BHWs

are needed to support the vulnerable male population

at a community level.

Secondly, to tackle the issue of quality, it is vital

to implement necessary measures to elevate both

the skills and motivation of health workers along

with the people in the communities. Capacity

building programs such as skill trainings and

educational trainings must be considered to improve

the quality of the workers and minimize the gap

45

between those who are skilled and satisfied with

their work and those who are unskilled and

unsatisfied. Thus, in order to tackle current

challenges and to further strengthen the existing

human resource framework, we have identified the

following four components as necessary measures:

1) Knowledge-sharing

2) Coordination

3) Monitoring and evaluation

4) Motivation

Active knowledge-sharing and coordination

among the health workers across different levels will

generate a smooth and transparent flow of

information and knowledge which will help to create

an environment where relevant information

dissemination is possible, thus allowing professional

skills to be enhanced through the exchange of

experiences and best practices. To maintain workers’

motivation and quality of their work, a monitoring

and evaluation system to regularly evaluate their

performances and progress is fundamental. The

system should be standardized and act as an enforcer

for the health workers to fully maximize their

potential as a skilled professional. If each component

can function and integrated effectively, we believe

the Filipino health workforce management will be on

the optimal track to sustainability.

Partnership and Ownership

Here, the term “partnership” is used interchangeable

with “coordination”, “collaboration”, “cooperation”,

and “relationship.” The importance of partnerships

among stakeholders at each level was recognized

through the field trip. For example, at the regional

level of the TB program, WPRO takes the leadership

role in its covering region while the countries of the

region cooperate to tackle the TB problem. There are

also vertical and horizontal collaborations at the

national and community levels respectively. An

example of vertical collaboration at the national

level is the referral system between SLH and BHS. In

terms of the horizontal collaboration at the

community level, local NGOs and BHS have meetings

to share information about their activities. Engaging

multiple stakeholders runs the risks of duplication

and fragmentation of service delivery, but if these

stakeholders are aligned as partners such risks can

be prevented and it can magnify the scope of their

services. Good coordination among the organizations

and activities lead to a positive outcome of the

projects and it motivates people to manage their

problems by themselves. Moreover, the communities

will be empowered and a sense of ownership will

grow within themselves.

Finance

The PhilHealth is a government-owned and

controlled corporation that deals with healthcare

financing.3 It aims to implement the NHIP for all

Fillipinos. A part of its revenue is covered by sin tax,

which is a taxation on tobacco and alcohol products.4

The PhilHealth allows patients to receive free

healthcare and reduces economic burden on them,

however, when we consider the sustainability of the

system, high dependency on sin tax is not

recommended. If the sin tax amount influences the

availability of health care provision, this might affect

the health status of financially vulnerable populations

as well as taxpayers. Therefore, the more people

consume tobacco and alcohol, the more money goes

to the government and the PhilHealth for health

care provisions. This results in a situation where the

poor can receive free healthcare and become

healthier while the taxpayers continue their bad

habits and become unhealthy. In conclusion, high

dependency on sin tax creates a situation where one

population’s health status is compensated by

deteriorating the other population’s health. For

46

long-term operations of the health insurance system,

a more sustainable way to cover the expenses is

needed.

Conclusion

The five pillars: preparedness, human resources,

partnership, ownership, and finance are the key

concepts supporting the sustainability of the health

system in the Philippines. We should not forget,

however, that the base of these pillars is the local

context of the country. Through the observations at

the sites visited and our discussions, we learned how

each institution operates and strives to contribute to

achieving sustainable development of the health

sector in the country. By making use of the lessons

learned in the country, we, the MPH candidates, are

strongly motivated to take an active part in

contributing to the advancement and development

of the global agenda.

4. Questions and Answers, Comments from

the Guests

Questions and Answers

Q. How can we sustain programs that tackle health

related issues?

A. Community empowerment is important. Since

Filipinos are very active and kind, they have the

potential to achieve this. One of the examples

that we learned through the field trip was training

local people to detect TB suspicious cases. Sin tax

is one source of securing financial budget to tackle

health relate issues.

Q. How can we solve problems of human resources?

A. One of the solutions could include the younger

generation. To involve the young people, more

information should be disseminated to them.

Comments

· Connections among the governments at the

national, provincial, and municipal levels are

important.

· It is important to keep in mind questions such as

“when can we say that a country has recovered

from a disaster?” and “how should we determine

when to withdraw aid?” when considering about

external aid.

· The framework for sustainability might not be for

the case of the Philippines. It might be more

suitable for less developed countries.

5. Reflection

Throughout the field trip, all students were

required to not just learn about the health issues in

the Philippines, but to take part in the discussions,

and to be a leader and facilitator at each occasion. At

the very end of our trip, we prepared a final

47

presentation as a compilation of what we have

learned. The following steps were taken by the

students to organize the presentation:

1) Sharing the objectives of the presentation

2) Discussing the overall framework of the

presentation

3) Brainstorming the keywords of our findings

4) Drafting the presentation concept based on

identified keywords to develop the pillar

model

This “concept-based” procedure enabled us to

sum up our learnings from various institutions

dealing with different health issues into several

common key word. Through the process of preparing

for this presentation, our perspectives were broaden,

which allowed us to think more about various

approaches to global health issues.

Lastly, we would like to express our deepest

gratitude to everyone who supported our field trip.

References1 World Health Organization Western Pacific Region.

Health services development, The WHO Health

Systems Framework [Internet]. Manila: World

Health Organization Western Pacific Region; [cited

10 March 2016]. Available from:

http://www.wpro.who.int/health_services/health_

systems_framework/en/

2 World Health Organization Western Pacific Region.

Human resources for health [Internet]. Manila:

World Health Organization Western Pacific Region;

[cited 10 March 2016]. Available from:

http://www.wpro.who.int/hrh/en/

3 Asia Pacific Observatory on Health Systems and

Policies. The Philippines Health System Review,

Health Systems in Transition Vol. 1 No.2 2011

[Internet]. Manila: World Health Organization

Representative Office Philippines; [cited 4 April

2016]. Available from:

http://www.wpro.who.int/philippines/areas/

health_systems/financing/philippines_health_

system_review.pdf

4 World Health Organization. “Sin Tax” expands

health coverage in the Philippines [Internet].

Geneva: World Health Organization; May 2015

[cited 10 March 2016]. Available from:

h t t p : / / w w w . w h o . i n t / f e a t u r e s / 2 0 1 5 / n c d -

philippines/en/

48

49

50

51

The short-term field training trip has been a part of the International Health Development course since the

inception of the School of International Health Development in 2008. At the time, the destination was

Bangladesh, however, this was changed in academic year 2015/2016 to the Philippines due to security concerns

in Bangladesh. In addition to the destination, the field trip’s program had a series of changes from previous

years. We were a large party of 20 individuals including accompanying faculty members, which was twice the

size of previous trips. Furthermore, the language of instruction was English in compliance with the rest of the

coursework at the School of Tropical Medicine and Global Health (TMGH). In essence, both students and faculty

had to navigate through new arrangements during the field trip this year.

The objectives of the field trip, as mentioned earlier in this report, are for students to deepen their insights,

to enhance their understanding on the importance of the practical utilization of basic knowledge, and to

motivate students to global health practice through exposure to model health improvement activities and

research fields. While faculty members design and make arrangements for the site visits, it is the students who

are in charge of running daily activities under the supervision of the accompanying faculty members. For this

year’s field trip, students formed four working groups to facilitate preparation as well as implementation of

planned activities. In addition, as a daily routine, each student was assigned to perform certain tasks according

to the daily schedule, such as team leader/sub-leader of the day, note taker, and someone to arrange transport,

etc. Through performing these tasks students were expected to strengthen their skills such as facilitation, time

management, stress management, leadership, and followership from the group work.

“How could we have used the limited time more efficiently?”

“Did I do a good job as team leader/facilitator?”

“What were better ways to engage more people in the discussions?”

“Why did I feel so frustrated regarding something that usually does not bother me?”

I believe these questions came across the minds of many students during and/or after the field trip. I hope

that each student will keep their individual reflections in mind and apply them towards their forthcoming

internship and/or future endeavors.

The field trip program is assisted by a number of individuals every year. In particular, I would like to

acknowledge the individuals listed in the beginning of this report for having spent the time and effort for the

benefit of the Nagasaki TMGH students.

The field trip program is a one-credit, requisite coursework for the MPH students at Nagasaki University.

This year, each student was financially supported by one of the following organizations: Japan Student Services

Organization (JASSO), Japan International Cooperation Agency (JICA)/Japan International Cooperation Center

(JICE), and the Student Support Department, Nagasaki University. I would like to extend our sincere gratitude

to these organizations in helping the students participate in the field trip program.

Afterword

Miho SatoAssistant Professor, School of Tropical Medicine and Global Health, Nagasaki University

52

On the way back from Caloocan City to our hotel in the Malate district in Manila, our bus passed the place

where the notorious landfill called Smokey Mountain used to be. Soon after the view of the mega city of Manila

came into the picture with dozens of high-rise buildings towered behind thousands of poor housings spread

rampantly like weeds in a neglected garden. The scene seemed very symbolic illustrating the discrepancy

existing in the Philippines which we experienced during this two-week field trip.

As we had opportunities to visit many sites and see various dimensions of the Philippines’ health system, it

was challenging to capture the core essence of each site and we consumed a great amount of time and effort

consolidating different perspectives and takeaways of 16 students into one report. Yet, through this process,

we, the five of us in the editorial team realized that this time was needed to recap and to really process what we

observed and learned during the field trip. As we deepened our understanding, we felt how fortunate we were

to have our experiences in the Philippines. A fellow student said that “by hearing the opinion directly from local

people and observing the health situation in both urban and rural areas with my own eyes, I could deepen my

insights and develop my knowledge from textbooks to more applicable one”. This resonates well with us in

thinking that we would not be able to understand a reality in any given context unless we observe and pay

attention to details of different aspects of a health system. As the MPH candidates, we are expected to have the

eyes, ears, and minds to question the current situations and to willingly explore the solutions to even those that

are undetected problems of the people.

We would like to take this moment to thank all the people who have supported us in the field trip and during

the making of this report. At a point, we felt it was not possible that this report will see the light of day! A big

thank also goes out to all the fellow students who made this trip a memorable one in every sense(!) and helped

us put this report together. And, last but not least, let’s give ourselves well-deserved pats on our back for

completing this journey of endless nights of learning, exhaustion, agony, and friendship. We own ourselves a

big party to celebrate the launch of this publication!

Sincerely,

Kumiko Takai

Meguru Yamamoto

Reiri Tsumura

Ryo Kobayashi

Satomi Ichino

Editor’s Note

53

Field Trip Report 2016, The Philippines

Published by School of Tropical Medicine and Global Health, Nagasaki University

Edited by Kumiko Takai, Meguru Yamamoto, Reiri Tsumura, Ryo Kobayashi, Satomi Ichino

Photographs edited by Noriko Tamari, Asuka Miyazaki

Cover design by Aiko Inoue, Takuya Shizume

References checked by Shoko Ogino, Erika Yoshimoto, Khin Zar Wai, Masanobu Ono, Nobuya Goto,

Yasue Yoshino, Zar Lwin Hnin

English proofread by Mengya Li (Academic support staff at TMGH)

Supervised by Hisakazu Hiraoka, Miho Sato

© 2016 by School of Tropical Medicine and Global Health, Nagasaki University

All rights reserved.

First printing on 20 July 2016

Printed by IN-TEX Co. Ltd. Nagasaki, Japan

School of Tropical Medicine and Global Health

Nagasaki University

1-12-4 Sakamoto, Nagasaki City

852-8523, Japan

Tel: +81(0)95 819 7583

http://www.tmgh.nagasaki-u.ac.jp/?lang=en

1-12-4 Sakamoto,Nagasaki City 852-8523,JAPANTel:+81(0)95 819 7583 Fax:+81(0)95 819 7892http://www.tmgh.nagasaki-u.ac.jp/?lang=en