O UL RU W 7KH 3 - 長崎大学 · PDF fileLecture about JICA’s activities at JICA Philippines office (March 17, Manila) Cultural Program in Tacloban (March 18 ... EPI Expanded Program

　

Table of contents

Foreword 2

Introduction 3

Photo Album 4

Abbreviation and Terminology 8

Map 10

1. Overview 11

2. Field report 19

2.1 National level 20

2.2 Tertiary level 28

2.3 Secondary level 33

2.4 Primary (Community) level 35

2.5 Sub-regional level actors, External partners 43

3. Lessons learned 48

3.1 Equity 48

3.2 Efficiency 49

3.3 Access and coverage 49

3.4 Quality of services 50

3.5 Sustainability 51

4. Conclusion 52

5. Final presentation 53

References 59

The editors’ note 60

1

The2014-2016EbolaoutbreakthatoccurredinWestAfricahasshownthathealthissuesshouldnolonger

beconsideredasisolatedrealitiesfacedbyagivencommunitysomewhereintheworld.Aspartofglobalization

andmodernizationof transportationsystems,peoplearenowadaysable tomoveeasilyandrapidly froma

pointoftheglobetoanotherandthereforecanspreaddiseasesbutalsobeinfluencedorinfluenceothersto

adoptlifestyleswhichhaveimpactonhealth.

Rich of this experience, allGlobalHealth actors have agreed on the fact that it is important and even

imperativetoinvestinbuildingmoreresilientandresponsivehealthsystems,especiallyindevelopingcountries

whicharealreadyfacingotherissuesrelatedtodevelopmentandpoverty.Oneofthemainpillarsnecessaryto

achievethisglobalcommitmentisthedevelopmentofcompetentandtalentedhealthhumanresourcestobe

deployedeverywheretheyareneeded,havinginmindtheaspectofglobalizationofhumanphenomenonso

thattheycanbeabletodevelopappropriateresponsestohealthissuesthatfacecommunities.

ThroughtheGraduateSchoolinInternationalHealthDevelopment(MasterofPublicHealthcourse)since

2008whichwasrestructuredintoanewgraduateschoolin2015,theSchoolofTropicalMedicineandGlobal

Health(TMGH),NagasakiUniversitycontinuescontributingtotheglobalhealthresponsebyfosteringglobal

healthprofessionals.Theyarecapableofconductingfieldstudies,proposingworkablesolutions,formulating

healthdevelopmentpoliciesthatmeetglobalstandards,andcoordinatingprojectoperationsinthefieldsof

TropicalMedicine, International HealthDevelopment andHealth Innovation (whichmake up threemaster

coursesofTMGH).

The two-year curriculum of International Health Development Course is particularly unique. It is

characterizedby theopportunityoffieldexposures for the students througha two-weekfield training ina

developing country during the first year and long-term practicum conducted in the second year (5month

internshipplus3monthresearch).Suchopportunitiesenablestudentstoconfronttheknowledgeacquiredat

TMGHwiththerealitiesexperiencedinthefield.Thepresentreportissummaryoftheshot-termfieldtraining

whichhasbeencompiledusingthecontentsofthe lecturesheldbythevisitedorganizations,thestudents’

dailyrecords,thesummarypresentation,andothermaterialsgatheredinthePhilippinesduringMarch2017.

This year, the students were accompanied by assistant professor Miho Sato who was in charge of

coordinatingtheentiretrip,aswellasassociateprofessorHisakazuHiraokaandCourseDirectorKazuhikoMoji

(InternationalHealthDevelopmentCourse)togetherwithTMGHadministrativestaff.TheyvisitedManilaand

Tacloban(Leyteprovince),observingandlearningfromvariousactivitiesandorganizations.AlsoIwouldliketo

extendmyprofoundthankstoallwhoprovidedvaluabletrainingopportunitiestoourstudents,namelyWHO/

WPRO,JICAPhilippines,SanLazaroHospital,thePhilippineDepartmentofHealth,variousRuralHealthUnits

andBarangayHealthStations,EasternVisayasRegionalMedicalCenter,ManagementSciences forHealth,

UniversityofthePhilippinesManila,SchoolofHealthSciences,VolunteerforVisayansandmore.

Asafinalnote,pleaseunderstandthatthecontentsanddatainthisreportwerecollectedanddescribedas

apartofthestudents’trainingandlearningprocess.Iwouldliketoaskforyourkindconsiderationifanyofthe

informationcontainedisinadequateorincomplete,andtopleaserefrainfromcitingthisreportinanysituation.

Foreword

Kiyoshi Kita Dean,SchoolofTropicalMedicineandGlobalHealth,NagasakiUniversity

2

The short-term overseas field training trip is a one-credit, requisite coursework for students who areenrolledintheInternationalHealthDevelopmentCourse(MPH)attheSchoolofTropicalMedicineandGlobalHealth(TMGH),NagasakiUniversity.

As in the previous year, the destination for this year’s program was the Philippines where NagasakiUniversityhasstandingMemorandumsofUnderstandingwithSanLazaroHospital(SLH,withtheexistenceofNagasakiUniversity-SLHcollaborationofficewithinthehospital)andtheUniversityofthePhilippines-Manila(especially School of Health Sciences in Palo, Leyte).We believe our visit strengthened the ties betweenNagasakiUniversityandtheseinstitutionsinthePhilippines.

Thetrip tookplace from12to25March2017.SixteenMPHstudents fromtheDemocraticRepublicofCongo,Ghana,Japan,Myanmar,andUgandaparticipated in the trip,accompaniedbysix facultyandstaff,includingthecoursedirector,Prof.KazuhikoMoji.

Theobjectivesofthefieldtripwereforstudentstodeepentheirinsightsofpublichealthcare,toenhancetheirunderstandingontheimportanceoftheapplicationandutilizationofvarioustopicsofglobalhealththatthestudentshadlearnedthroughpreviouscourseworkinNagasaki,andtomotivatestudentstoglobalhealthpracticethroughexposuretomodelhealthimprovementprojectsinthefield.

WhileitwastheresponsibilityofTMGHtodesignandmakearrangementsforthevarioussitevisits,itwasthestudentswhotookchargeofmanagingdailyactivities.Forthisyear’strip,studentsformedfourworkinggroupstofacilitatepreparationsaswellasimplementationofplannedactivities.Inaddition,asadailyroutine,eachstudentwasassignedtoperformcertaintasksaccordingtothedailyschedule,suchasteamleader/sub-leaderoftheday,notetaker,transportationarrangement,etc.Throughperformingthesetasksstudentswereexpected to strengthen their skills in facilitation, timemanagement, stressmanagement, leadership, andfollowershipaspartofagroup. ThefieldtripwasassistedbyanumberofindividualsinJapanandthePhilippines.Inparticular,wewouldliketoexpressoursinceregratitudetotheindividualsmentionedinthisreportforofferingtheirtimeandefforttoaidourstudentsandallowthemthisinvaluableopportunity.

Thisyear,eachstudentwasfinancially supportedbyoneof the followingorganizations:JapanStudentServicesOrganization(JASSO),JapanInternationalCooperationAgency(JICA)/JapanInternationalCooperationCenter(JICE),andtheLiaisonCenterforInternationalEducation,NagasakiUniversity.Weareverygratefultotheseorganizationsinprovidingstipendstothestudentssothattheywereabletomaximizetheirlearninginthefieldwithoutfinancialburdens.

Lastly,wewelcomeyoutoenjoyaglimpseofthetripbyvisitingourFacebookpagefordailyreportsandphotos:https://www.facebook.com/pg/tmghinfo/notes/.

Introduction

Miho SatoAssistantprofessor,inchargeofthefieldtripSchoolofTropicalMedicineandGlobalHealthNagasakiUniversity

3

Lecture about infectious disease control program atWPRO(March13,Manila)

SanLazaroHospitaltour(March14,Manila)

LectureatOldBalaraBarangayHall(March15,Quezoncity)

Photo Album (1/4)

LectureatDepartmentofHealth(March14,Manila)

ExplanationaboutTBpatientsatSanLazaroHospitaltour(March14,Manila)

CulturalProgramatFortSantiago(March15,Manila)

4

Teeth check by an dental hygienist qualified studentduring the smokey mountain barangay visit activity(March16,Manila)

Dailymeetingatthehotel(March16,Manila)

Meetingplaceofthehotel(March17,Tacloban)

Photo Album (2/4)

Tour of Fugoso neighborhood with barangay healthworkers(March16,Manila)

LectureaboutJICA’sactivitiesatJICAPhilippinesoffice(March17,Manila)

CulturalPrograminTacloban(March18,Tacloban)

5

Self-study of preparation for the final presentation(March19,Tacloban)

WrapupsessioninPHO(March20,Palo)

LecturesessionofRHU(March20,Tabontabon)

Photo Album (3/4)

Lecture at Department of Health, Regional office 8(March20,Palo)

LecturesessionofRHU(March20,Jaro)

PhilHealthdepartmentinEVRMC(March21,Tacloban)

6

AfterlectureinUPM-SHS(March21,Palo)

Feedingpreparationinfeedingcenter(March22,Palo)

Question session at final presentation inSLH (March24,Manila)

Photo Album (4/4)

Lecture aboutVFV activities atVFVoffice (March 22,Tacloban)

Hand hygiene teaching session in feeding center(March22,Tacloban)

Groupphotoatfinalpresentation(March24,Manila)

7

AIDS AcquiredImmunodeficiencySyndromeANC AntenatalCareBHMC BarangayHealthManagementCouncilBHS BarangayHealthStationBHW BarangayHealthWorkerDOH DepartmentofHealthDOTS DirectlyObservedTreatment,Short-courseEPI ExpandedProgramonImmunizationEVRMC EasternVisayasReginalMedicalCenterGDP GrossDomesticProductGIDA GeographicIsolatedandDisadvantagedAreaHIV HumanImmunodeficiencyVirusHPV HumanPapillomaVirusHRH HumanResourceforHealthICD InternationalClassificationofDiseasesICU IntensiveCareUnitIUD IntrauterineDeviceIMR InfantMortalityRateJICA JapanInternationalCooperationAgencyJOCV JapanOverseasCooperationVolunteersKMC KangarooMatherCareLAMP Loop-mediatedisothermalamplificationLGU LocalGovernmentUnitMCIP MaternalandChildIncentiveProgramMDG MillenniumDevelopmentGoalMDR/XDR-TB Multidrug-Resistant/ExtensivelyDrugResistantTuberculosisMMR MaternalMortalityRatioMPH MasterofPublicHealthNCD Non-CommunicableDiseaseNGO Non-GovernmentalOrganizationODA OfficialDevelopmentAssistanceOOP Out-of-PocketexpensesPHEIC PublicHealthEmergencyforInternationalConcernPHO ProvincialHealthOfficePHP PhilippinesPesoPNC PostnatalCarePPP PublicPrivatePartnershipPTB PulmonaryTuberculosisQOL QualityofLifeRHU RuralHealthUnitSARS SevereAcuteRespiratorySymdromeSDG SustainableDevelopmentGoalSDN ServiceDeliveryNetworkSLH SanLazaroHospital

Abbreviation list

8

STI SexuallytransmittedInfectionTB TuberculosisTM TraditionalMedicineTMGH SchoolofTropicalMedicineandGlobalHealth(atNagasakiUniversity)UHC UniversalHealthCoverage/CareUN UnitedNationsUNICEF UnitedNationsChildren’sFundUPM-SHS UniversityofthePhilippinesManila,SchoolofHealthSciencesUSAID UnitedStatesAgencyforInternationalDevelopmentVFV VolunteerforVisayans(Nonprofitorganization)WASH Water,SanitationandHygieneWHO WorldHealthOrganizationWPRO WHORegionalOfficefortheWesternPacific

Barangay InthePhilippines:avillage,suburb,orotherdemarcatedneighborhood;asmallterritorialandadministrativedistrictformingthemostlocallevelofgovernment.

GeneXpert The test for short time examination to diagnoseTB, as well as for resistance to anantibioticRifampicin.1)

iSPEED ItisthecodenameofthesoftwarefortheSurveillancePostExtremeEmergenciesandDisasters(SPEED)ofwhichsystemwasinitiallydevelopedbyWHOandthePhilippinegovernment.The systemwas improvedby Japan into J-SPEEDwhich is the base foriSPEEDfeaturinganelectronicformatofmedicalinformation.2)

LAMP ItisamanualassaytoquicklydetectTBcaseswithin1hourandcanbereadwiththenakedeyeunderultravioletlight.3)

Lechon AwholeroastedpigletwhichisaspecialityinthePhilippines.Merienda AlightmealinthePhilippines,usuallytakenintheafternoonorforbrunch.Itfillsinthe

meal gap between the noontime meal and the evening meal, being the equivalentofafternoontea;orbetweenbreakfastandlunch.

PhilHealth UniversalhealthinsuranceinthePhilippines.TyphoonYolanda On8November2013,itmadelandfallinthecentralPhilippineislandsregionandcaused

about6,000deaths,28,000injuredand1,000missingcases.Theeconomicdamagewasestimatedapproximately95billionPHP.4)

1)KanabusAnnabel2017,Information about Tuberculosis: Genexpert Test – TB diagnosis and resistance Testing,

viewed30August2017,https://www.tbfacts.org/xpert-tb-test/2)JapanInternationalCooperationAgency2016,Press Release: JICA helps introduce software in PH to boost

medical record system during disasters, viewed 30August 2017, https://www.jica.go.jp/philippine/english/

office/topics/news/160418.html3)WorldHealthOrganization2016,The use of loop-mediated isothermal amplification (TB-LAMP) for the diagnosis

of pulmonary tuberculosis: policy guidance, WHO,Geneva.4)RepublicofthePhilippines2013,National Disaster Risk Reduction and Management Council: FINAL REPORT re

EFFECTS of Typhoon “YOLANDA” (HAIYAN), NDRRMC,QuezonCity.

Terminology

9

MAP

Source:MapsNWorld.com,Asia,Philippines,WhereisPhilippines?http://www.mapsnworld.com/philippines/where-is-philippines.html

Source:MartinW.LewisonJanuary27,2016–9:31amBase-MapsofthePhilippines&Linguistic/RegionalControversiesintheArchipelagohttp://www.geocurrents.info/wp-content/uploads/2016/01/Philippines-Regions-Map.png

10

Overview of the Field Trip1. Objectives

▷To deepen students’ insight and to enhance their understanding on the importance of the practicalutilizationofbasicknowledge

▷Tomotivatestudentstopursueglobalhealthpracticesthroughexposuretomodelhealthimprovementactivitiesandresearchfields

2. Method

▷From12thMarchto25thMarch2017,studentsvisitedseveralorganizations.▷Studentshadanopportunitytositinonlecturesateachplace,toattendaconference,andtodiscusshealthissuesinthePhilippines.

▷Studentsgainedexperienceregardinglogisticmanagementanddevelopednecessaryskillsforactivitiesrelatedtoglobalhealth.

▷Studentsacquiredgroupdiscussionandfacilitationskillsbyparticipatingindailyrecapmeetingsaswellasbymakingafinalpresentation.

▷Students discussed their ideas regarding each facility then visited andwrote a report onwhat theylearnedthisfieldtrip.

3. Supporting Organization and people

LocalCoordinator

Ms.ChisakiSato TMGHconsultant

SupportingOrganizations

JICAandJapan InternationalCooperationCenter (JICE) for the international students’scholarship

JapanStudentServicesOrganization(JASSO)

StudentSupportDepartment,NagasakiUniversity

4. Participating Students: name (country of origin)

▷ Robinah Ajok (Uganda) ▷ Miwa Nakajima (Japan)▷ Issac Annobil (Ghana) ▷ Nang Mon Hsai (Myanmar)▷ Kenshi Furushima (Japan) ▷ Shafiq Siita (Ghana)▷ Heri Aimé Bitakuya (DR Congo) ▷ Aya Takase (Japan)▷ Tomomi Igari (Japan) ▷ Thi Thi Aung (Myanmar)▷ Chisato Masuda (Japan) ▷ Takuya Yamanaka (Japan)▷ Kazuchiyo Miyamichi (Japan) ▷ Yeboah Eugene Osei (Ghana)▷ Sachiko Nagata (Japan) ▷ Kyoko Yoneda (Japan)

12

Agenda of the visits (schedule)

Date Place of visit Persons met(in alphabetical order)

Location

March12 Sun FlightfromFukuokatoManilaMarch13 Mon WPRO Ms.KaoriDezaki

Dr.JunGao,RegionalAdviserforHealthInformation,EvidenceandResearchPolicyMs.MinaKashiwabara,TechnicalOfficer,TobaccoFreeInitiativeMs.RyoKobayashi,intern,TMGHstudentDr.FranciscusKonings,TechnicalOfficer,LaboratoryDr.TomohikoMakino,MedicalOfficerDr.NobuyukiNishikiori,RegionalAdvisorforTuberculosisandLeprosyDr.YuLeePark,TechnicalOfficer,TraditionalMedicineDr.SarahPaulin,TechnicalOfficer,AMRMs.NicoleSarkis,ProgrammeManagementOfficer

Manila

March14 Tue DOH Ms.ReneeLynnM.Cabañero,HealthPolicyDevelopmentandPlanningBureauMs.HannaTheaF.CayabyabDr.JuanitaH.Fandiño,HumanResourceManagementOfficer,HealthHumanResourceDevelopmentBureauDr.ShogoKanamori,HealthAdvisor/JICAMs.JocelynT.Socito,SeniorHealthProgramOfficer,BureauofInternationalHealthCooperation Dr.LesterM.Tan,MedicalOfficerV,BureauofLocalHealthSystemDevelopment

Manila

SLH Dr.VirginiaO.Dimapilis,MedicalOfficerV,HospitalChiefTrainingOfficeratSLHDr.NobuoSaito,SLH-NagasakiOffice

Manila

March15 Wed OldBalarahealthcenterandBHMC

Dr.LynetteP.Adorio-Arce,TechnicalAdvisor,MSHMr.MehmoodAnwar,CountryProjectDirector,MSHDr.KarenGemmaSee,HealthCenterPhysician,OldBalaraHealthCenterDr.ArthurB.Lagos,SeniorTechnicalAdvisor,MSH

Quezon

Culturalprogram:FortSantiago,SanSebastianChurch,etc. ManilaMarch16 Thu Smokeymountainhealth

center, lying-in clinic,Fugosohealthcenter

Dr.RomeoCando,HeadinManilaHealthCenter,DistrictOfficerMs.DidingEscueta,BHWDr.BernadetteS.Maniebo,BoFugosohealthcenterDr.EvelynV.Rimando,HeadinSmokeyMountainClinic,PhysicianIn-ChargeSmokeyMountainClinicMs.MamaSaraya,BHWMs.WenefredaA.Udtuhan,NurseTrainingOfficer

Manila

FromSLH-NagasakiOfficeMs.MaryRoseGayosoBaleinDr.NobuoSaitoMr.JohnPaulS.SolanoMr.JeffUreta

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Date Place of visit Persons met(in alphabetical order)

Location

March17 Fri JICAPhilippinesoffice Ms.FleridaChan,SectionChief,HumanDevelopmentSectionMs.RiekoHara,NGODeskMs.EriAsadaSolleza,NGODeskMs.NaokoSuzuki,HealthAdministrator

Makati

FlightfromManilatoTaclobanMarch18 Sat Culturalprogram TaclobanMarch19 Sun Self-study TaclobanMarch20 Mon DOHRegionaloffice8

(EasternVisayas)Dr.CarmenP.Garado,ChiefofLocalHealthSupportDivisionDr.MinervaP.Molon,DirectorIV

Palo

RHUs Dr.RusticoB,Balderian,theMayorofTabontabonMunicipalityDr.RosalCinco-Caimoy,MunicipalHealthOfficer,Tabontabon,RHUDr.MaLourdesF.Opinion,MunicipalHealthOfficer,Jaro,RHU

Tabontabon

Jaro

PHOofLeyte Dr.OfeliaC.Absin,ProvincialHealthOfficerII,ChiefofLeyteprovincialHospitalMs.MarinaP.Alvaran,MNCHN,coordinator,ProvincialHealthOfficeofLeyteDr.EdgardoE.Daya,ProvincialHealthOfficerIMs.CelestinaPaca,ILHZcoordinator,ProvincialHealthOfficeofLeyte

Palo

March21 Tue EVRMC Mr.JoseM.JocanoJr.Mr.AkihiroKaneko(JOCV)Dr.MaTeresaC.LitaDr.JeanevieveMolonDr.LoryL.RuetasDr.RandzyCSardraDr.GlendaG.Vilches

Tacloban

UPM-SHS Dr.SumanaBarua,alumnusDr.SalvadorIsidroB.Destura,DeanDr.AdelaidaG.Rosaldo,Chair,MedicalDepartmentDr.FeleditoD.Tandinco,CollegeSecretary

Palo

March22 Wed NGOVFV Mr.JudelitoSoriloBersoza,VolunteerProgramCoordinatorMs.HelenaClaire“Wimwim”A.Canayong,DirectorofOperations

Tacloban

March23 Thu FlightfromTaclobantoManilaMarch24 Fri FinalpresentationinSLH Ms.JoyCalayo,Headofmedicaltechnician,

SLHlaboratoryMs.NaokoSuzuki,JICAPhilippinesofficeDr.KoheiToda,HeadofEPI,WHOcountryofficeinthePhilippines

Manila

FromSLH-NagasakiOfficeMs.MaryRoseG.Balein Ms.AriannePatriciaLintagDr.NobuoSaitoMr.JohnPaulS.SolanoMr.JeffUretaDr.ManamiYanagawaA/Prof.LauraWhite

March25 Sat FlightfromManilatoFukuoka,Japan

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General Background

Nameofcountry RepublicofthePhilippinesSurfacearea 300,000sq.km1)

Population 103.32million(2016)1)Annualpopulationgrowthrate:1.6%(2016)1)

Language Filipino(official;basedonTagalog)andEnglish(official).Eightmajordialects:Tagalog,Cebuano,Ilocano,Hiligaynonorllonggo,Bicol,Waray,PampangoandPangasinan2)

Religions Catholic (82.9%), Muslim (5%), Evangelical (2.8%), other Christian (4.5%) (2000census)2)

Adultliteracyrate Definition:age15overcanreadandwrite,male:95.8%,female:96.8%,bothsexes:96.3%(2015est.)2)

Naturalhazards Typhoons,cyclones,landslides,activevolcanos,destructiveearthquakes,tsunamisEconomy Grossdomesticproduct(GDP,currentUSdollars):304.9billion(2016)1)

GDPpercapita(currentUSdollars):2,951(2016)1)

GDPgrowthrate:6.8%(2016)1)

Povertyheadcountratioatnationalpovertyline(%ofpopulation):25.2%(2012)1)

Education Schoolenrollment,bothsexes(%gross):Primary116.8,Secondary88(2013)1)

Health Lifeexpectancyatbirth(years),total:69.2,female:72.9,male:65.7(2016)2)

Maternalmortalityratio(modeledestimate,per100,000livebirths):114(2015)2)

Underfivemortality(per1,000livebirths):28(2015)1)

1)TheWorldBank2017,Data,Philippines,viewed28August2017,

http://data.worldbank.org/country/philippines2)CentralIntelligenceAgency2017,The World Factbook, East and Southeast Asia, Philippines,viewed28August2017,

https://www.cia.gov/library/publications/the-world-factbook/geos/rp.html

Philippines Health Profile and Health System

ThePhilippineshealthsystemisbuiltonastrongdecentralizationanddevolutionofresponsibilitiesfrom

theNationalleveltothelowestadministrativeunitswhicharetheBarangays.Intermofresponsibilitiesinthe

healthpyramid,thecentrallevelrepresentedbytheDepartmentofHealth(DOH)isinchargeofdeveloping

healthpoliciesandprograms,regulationofhealthcareprovision,performancemonitoringandstandardsfor

publicandprivatesectorsaswellasprovisionofspecializedandtertiarylevelcare.Atregionallevel,theDOHis

represented by the DOH Centers for Health and Development which are the implementing agencies in

provinces,citiesandmunicipalities,andlinknationalprogramstoLocalgovernmentunits(LGUs).Theyassist

theLGUsintheplanningprocessconsideringnationalpolicies,provideguidelinesontheimplementationof

nationalprogramsattheLGUlevels,monitorprogramimplementation,anddevelopsupportsystemforthe

delivery of services by LGUswho are responsible of delivering secondary andprimary health care (WPRO,

2012).

Figure1belowshowsgeneralviewofthepresenthealthsysteminthePhilippines.Oneofthecharacteristics

ofthehealthsystemisanadvancedfeatureofdecentralizationinhealthsector.Deliveryofhealthservicesis

devolvedtoLGUsandtheDOHisresponsibleforcoordinationandregulationofhealthsectoractivities.

15

Achievement in regard to MDGs related to health sector

ThePhilippines’performancesinhealthsectorregardingMDGsaresummarizedinthetablebelow.Except

forUnder-fivechildmortality,MDGtargetssetfor2015havenotbeenachievedbythePhilippinesdespiteits

rapidimprovementofperformanceinhealthsector.

Table 1. Some achievements of MDG health related goals 4, 5 and 6

MDGs Achievements Target Achievement (2015)

Goal4 Reducechildmortality

Underfivemortality=27,IMR=19,(per1,000livebirths)Fullyimmunized

=100%

U-5mortality=27,IMR=21,

Fullyimmunized=83%

Goal5 Improvematernalhealth

MMR=52,(per100,000livebirths)

Proportionofbirthsattendedbyskilledhealthpersonnel=100%

MMR=11486.0%

Goal6 CombatHIV/AIDS,Malariaandotherdiseases

Prevalenceassociatedwithtuberculosis=0

(per100,000population)

461(year2013)

(source:presentationslidesbyDr.L.Tan,14thMarch2017atManila;PhilippineStatisticalAuthority2017)

Figure 1. Health System and its devolution – an organigram

(source:presentationslidesbyDr.L.Tan(DOH),14thMarchatManila)

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Current health problems

ThePhilippinesarecharacterizedbyatripleburdenofdiseasemadeofinfectiousdiseases,ahighrateof

NCDsanddiseasesduetorapidurbanization.ThetripleburdenofdiseasetogetherconstitutetheTop10causes

ofmorbidityandmortality,whichareshownFigure2andFigure3below(WHO,2015).

Figure 2. Morbidity: Leading causes


Figure 3. Mortality: Leading causes


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The goals for strategic plan

Manyimprovementshoweverhavebeennoticedinareassuchchildhealth,TBcontrol(withachievement

oftheMDGs)aswellasmaternalhealth.Theincreaseofnumberoffacilitybaseddeliveryaswellasskilledbirth

attendancewhenadeliveryhappinginthecommunityhavebeenmaindeterminanttoensurethedecrease

noticedinmaternalmortalityalthoughdidnotmeettheMDGtarget.Moreover,theprovisionofpreventive

andtreatmentofcommunicablediseaseisbeingimprovedtogetherwithexpansionofcoverageofimmunization

forvaccinepreventablediseases,butanotableincreaseinneglectedtopicaldiseasesisreported,occasioning

thereforemassdrugadministrationactivitiesaspartoftheresponse.ToaddresstheNCDs,theDOHadopted

in2011theWHOPackageforEssentialNon-communicableDiseaseInterventionsforPrimaryHealthCarein

Low-ResourcesSettinginordertoensureaccessoftheseservicesinprimaryhealthcarefacilities(WPRO,2017)

Forthelast5years(2011-2016)theDOHwasimplementingtheAquinoHealthAgenda(meaningUniversal

HealthCare for all Filipinos) based on 3main strategic pillars: increasing financial protection for Filipinos,

improvingaccesstoqualityhealthcareandattainingMDGs(DOH,2016).Followingthelatter,anewagenda

hasbeenrecentlylaunchedbytheDOHtocovertheperiod2016to2022.Thisoneisbuilton3guarantieswhich

are(DOH,2016):

1.All life cycle stages and triple burden of disease: implyingtoprovidehealthforallhealthyandsick

peoplewithafocusfrompregnancy,newborn,child,adolescent,adulttoelderlies.Thisinadditionto

theconsiderationof3maincategoriesofdiseasesthatincludecommunicable,non-communicableand

thoserelatedtorapidurbanizationandindustrialization.

2.Service delivery network:meaningthatservicesaredeliveredthroughanetworkoffacilitiesthatare

fully functional, practicing gatekeeping, located closed to people, compliant to the clinical practice

regulations,available24hoursadayand7daysoftheweekregardlessofdisasters,andreinforcedby

telemedicine.

3.Universal health insurance:whichaimstoensurefinancialfreedomwhenaccessinghealthservicesby

makingPhilHealththegatewaytofreeaffordablecare.Throughthisaim,thegovernmentistargetinga

100%coverageofthepopulationwithpremiumofthosefromformalsectordeducteddirectlyfromtheir

payrollwhilethosefromnon-formalsectorarecoveredbytaxsubsidies

These3guarantiesareimplementedthroughanewstrategywhichacronymiscalled“ACHIEVE”,forwhich

themeaningofeachletterisgiveninthetablebelow:

A Advancequality,healthpromotionandprimarycare

C CoverallFilipinosagainsthealth-relatedfinancialriskH HarnessthepowerofstrategicHRHdevelopmentI InvestineHealthanddatafordecision-makingE Enforcestandards,accountabilityandtransparencyV Valueallclientsandpatients,especiallythepoor,marginalized,andvulnerableE Elicitmulti-sectoralandmulti-stakeholdersupportforhealth

(Seep.59forthereferences.)

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Summary of activities

This section presents the organizations/ facilities visited during the field trip according to the level of

interventionbyeachorganization. Thebelowfiguregivesageneralviewwith thenamesof thestructures

visited.

2.1 National level Department of Health (DOH)

Location ManilaVision/Mission Promotethehealthandwell-beingofeveryFilipino,preventandcontroldiseasesamong

populationsat risk,protect individuals, familiesandcommunitiesexposedtohazardsand risks that could affect their health, treat, manage and rehabilitate individualsaffectedbydiseaseanddisability.

Levelofintervention

National

Objectives Todevelopnationalplans,technicalstandards,andguidelinesonhealthservices.MainActivities Threemajorrolesinthehealthsector(1)leadershipinhealth;(2)enablerandcapacity

builder; (3) administratorof specific services andalsoprovides special tertiaryhealthcareservicesandtechnicalassistancetohealthprovidersandstakeholders.

1) Current focus of the organization

• Philippinehealthagenda:-AllforhealthtowardshealthforallthroughUHC.

• Thehealthsystemthrough:-Financialprotection,healthoutcomesandresponsiveness.

• ImplementationofactivitiesforachievingSDGs.

Figure 4. Visited organization presented by level of intervention

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2) Success and challenges

▷ Success

• EstablishmentofPhilHealth

• HighcoverageofPhilHealth92%

• IncreasingDOHbudgetthrough“sintax”from44billionPHPin2012to144billionPHPin2017

• Theytargetthevulnerableinthesociety(personswithdisabilities,indigent,lowerquintilepopulation)

▷ Challenges

• PhilHealth coverage is high (92%) butOut of Pocket expenses (OOP) is still determinantmeans of

payment(56%ofthetotalhealthexpendituresin2014)becausethecontentofpackageislow.

• Anappropriatepackageofcoverageisneededtobedeveloped

• MostprivatehealthfacilitiesarenotyetincludedinPhilHealth;thus,benefitsarenotpaidbythescheme

forclientswhoutilizesprivateservices.

• PhilHealth package ismore geared towards inpatient coverage and as such clients resort to staying

longerinthewardssotheirmedicalcostcanbeadequatelyreimbursedbythescheme.Thishowever

leadstoovercrowdinginthewards,i.e.lowqualityofhealthservices.

• Further,45%oftheinsurancebeneficiariesareindigentswhodonotpayanypremium.Thegapcreatedis

compensatedthroughthegovernmentbudgetgeneratedfromthesintax,however,iftheyweretopay

somepremium,morefundswillbeavailabletoincreasethehealthservicesthatarecoveredbythescheme.

• ThePhilHealthschemeispro-poor,butthereisdifficultyinidentifyingandclassifyingactualpoorpeople

andthehomeless.Alsoinsomecases,localpoliticiansregistertheirfriendsandcommunitymembers

whoarenotpoor,inordertobenefitfromtheschemeandtheyarereferredtoas“politicallypoor”.This,

however,underminesthegoalofthescheme.

3) Summary of discussions in regards to suggested guiding points

▷ Governance

Devolutionanddeconcentration(i.e.decentralization)givesflexibilitytotheLocalGovernmentUnits

(LGUs)whichinitiatetheirownstrategytotacklehealthproblemsinthelocalsettings.LGUs,therefore,

hasthepowertohireandfirehealthworkforces.TheDepartmentofHealth(DOH)alsohiresanddeploys

doctorstoLGUstosatisfytheirneedsandisusuallyexpectedthataftertwoyearsofservices,theLGUswill

employandmaintainthedoctorsinthedistricts.Thisautonomy,however,createsseveralproblemssuch

asnon-alignmentofhealthstrategiesandfragmentationofhealthinterventionsandservices.

▷ Health financing

ThesourcesoffundingforhealthareOOP(56%,in2014),governmentsubsidy(17%),socialhealthinsurance

(14%),otherprivateschemes(12%)andODA(1%).ItwashoweverdiscussedthatthehighOOPcouldbedueto

richclientspayingmoreatprivatehealthfacilitiesandthechargingofcosmeticsashealthproductsbypharmacies

andhealthfacilities.Thisisquitegreyasenoughdataisnotavailabletoactuallymakeacleardistinctionbetween

cosmeticsandactualhealthproductsandmedicinesbeingconsumedandchargedasOOP.

21

▷ Health workforce

Healthprofessionaltrainingprogramsaredominatedbyprivatecollegesanduniversities.Thelargest

categoryofhealthworkersinthePhilippinesarenursesandmidwivesduetooverseasdemandforFilipino

nurses.Withtheoversupplyofnursesinthecountry,manynewlygraduatedorlicensednursesareunable

to find employment.Conversely, there is an underproduction in other categories such as doctors and

dentists.Asthere isstillnosystemtotrackhealthprofessionalswho leavethePhilippines,statisticson

healthcarehumanresourcesbasedongraduatesorlicensesneedtobeinterpretedwithcaution.

▷ Medical product and technology

The DOH supplies essential commodities such as vaccines, TB drugs, and other public health

commoditiestoLGUsatnocost.Butotherdrugsandproductsforroutineandspecializedtreatmentare

procuredbyLGUsandsuppliedbydrugcompaniesdirectly tothehealth facilities.Therearenocentral

medicalstoreswheredrugsarebought,storedandsuppliedasinotherjurisdictions.Theabsenceofpooled

procurementofhealthproductsandmedicinesincreasescost.

▷ Health information

Thedepartmentofsocialwelfareconductssurveystohelpidentifyandclassifypoorpeopleinorderforthem

tobenefitfromPhilHealthandother interventions.Butpeopleonthestreetsandthosewithoutpermanent

addressareusuallymissedout.Also,thereareseveraldatamanagementtoolsforcapturingawiderangeof

healthindicatorsandthesearenotintegratedandsynchronizedthusmakingthehealthdatafragmented.

▷ Service delivery

• HealthfacilitiesneedaccreditationfrombothPhilHealthandtheDOHinordertooperate.Toenhance

qualityofservice, thestandard foraccreditationwas raisedandthissawsomehealth facilitiesbeing

reduced to infirmaries. Service delivery by the public health facilities is devolved to LGUs and their

peculiaritiesinthechallengestheyfacesuchaspoorqualityservice,longwaitinghours,lesshygienic

restroomsandovercrowding,theseamongotherfactorsdon’tmakeitafirstchoiceformostFilipinos.

• TheDOHexpressedtheircommitmenttocontinueprogramstocontrolinfectiousdiseaseslikeAIDS,TB,

Malaria,DengueandRe-emergingDiseaseslikeZikaVirus.Toensurethattheirpeoplehaveaccessto

servicesandmedicinesthatwillprotectthemfromtheconsequencesofNCDssuchascancer,diabetes

andheartdiseases.

• TheyaimtocontinuetoprovideinterventionsthatwillreducetheriskofeveryFilipinoindeveloping

NCDs through health promotion and prevention and also changing the built-in environment that

contributes to poor health. They further intend to address the diseases of rapid urbanization and

globalization which includes injuries, substance use and mental health, protect people from global

pandemicsandtheimpactsofclimatechange.

22

Department of Health (DOH), Region 8

Location TaclobanVision/Mission Promotethehealthandwell-beingofeveryFilipino,preventandcontroldiseasesamong

populationsat risk,protect individuals, familiesandcommunitiesexposedtohazardsand risks that could affect their health, treat, manage and rehabilitate individualsaffectedbydiseaseanddisability.

Levelofintervention

Region

Objectives Todevelopnationalplans,technicalstandards,andguidelinesonhealthMainActivities Threemajorrolesinthehealthsector(1)leadershipinhealthintheregion;(2)enabler

andcapacitybuilder; (3)administratorofspecificservicesandalsoprovides technicalassistancetohealthprovidersandstakeholders.


• GuaranteeinguniversalaccesstoqualityhealthcareinRegion8(EasternVisayas)through:

1.Formulationofpoliciesandsettingstandardsforhealth

2.Preventionandcontrolleadingcausesofhealthanddisability

3.Develop disease surveillance and health information system and promote health and well-being

throughpublicinformationandtoprovidethepublicwithtimelyandrelevantinformationonhealth

risksandhazards.

• ThreeguaranteesforattainingthegoalsofthePhilippineshealthagendaframeworkare:

1.Answeringtheneedsforalllifestagesfrompregnancytoelderlyandtripleburdenofdiseases

2.Servicedeliverynetwork

3.PhilHealthinsurance

• Thestrategiesforitsimplementationiscalled“A.C.H.I.E.V.E”.

• Withthedevolutionofhealthservicesfromcentralleveltoprovinciallevel,theDOHRegion8isrequired

toplaytheroleofcoordinationamongactorsatregionallevel.

Students’conversationafterdiscussionofPhilippinesHealthSystematDOH

SpecialmeriendaatDOH

23


▷ Success

• Increasedinfacilitybaseddeliveriesfrom66%in2012to90%in2016inRegion8throughmainlycash

incentivesgiventopregnantwomen,Barangayvolunteerswhoregisterandtrackpregnantwomenand

healthfacilitiesthatconductthedeliveries.

• Rateofdeliverieswithskilledhealthprofessionalattendanceachievedat90%in2016.Also,LGUshave

institutedbye-lawswhichstipulatesthatalldeliveriesmustoccurinahealthfacility.

• AccordingtoannualreportoftheDOHRegion82016,theMDGcutoffforunder-5mortalityandInfant

mortalityratewassetat25/1000livebirths.Theregionwasabletoachieveandmaintainanaverageof

under-5mortalityrateof9.6/1000livebirthsfrom2012to2016.For infantmortalityrate,theregion

achievedandmaintainedanaverageof6.1/1000livebirthsfrom2012to2016(DOH2016).

• Contraceptiveacceptanceandutilizationhas seen some steady improvement for thepastfiveyears

from28.23%in2012to45.17%in2016.Thoughthisisbelowthetargetof60%,thereligiouscontextof

thePhilippineswhichismostlyCatholicsmustbeconsideredasaninhibitingfactor.

• TBdetectionandtreatmentsuccessrateshavebeenquiteremarkableasboth indicatorswhichhave

beensteadilyrisingsince2012andhitapeak in2015withcasedetectionrateof92%exceedingthe

targetof90%,witha treatmentsuccess rateof91%, therewashowevera slightdecline in2016 for

detectionandtreatmentsuccessratesbothat88%and89%respectively.

• ThereexistotherprogramsinordertostrengthenHRHintheregion(NurseDeploymentProgram,Public

HealthAssociate,MedicalTechnologist,etc.).Asaresult,thenumberofmidwivesintheregionsatisfies

therecommendedratioof1midwifeto5000peoplein2015.Arapidincreasewasobservedfrom173in

2015to415in2016thankstoRuralHealthMidwifePlacementProgram.

▷ Challenges

• MMRstillhigh(105)comparedtotheMDGtargetof52/100,000livebirths.

• Proportionofpregnantwomenwith4ormoreANCvisitsisquitelow(52.2%)comparedwiththetarget

of90%,PNCvisitsalsohasnotseenanyimprovement(61.9%)comparedwiththetargetof90%allin

2016.ThesechallengesarehoweverbeingtackledthroughhealtheducationandpromotionbytheLGUs

throughtheBarangayhealthworkers(BHWs)andvolunteers.

• Vaccinationcoverage(FIC:FullyImmunizedChild)targetshavenotbeenmetsince2012to2016withan

averagecoverageof67.6%forthepastfiveyearsasagainstthetargetof90%peryear.

• Asperhumanresources,aspecificcadreknownasUniversalHealthCareImplementerswhoaretrained

doctors deployed to the Geographically Isolated and Disadvantaged Area (GIDA) but usually most

doctorsareunwillingtoserveinthoseareas.Asof2016only6doctorsserveintheGIDA.

• Onhealthinformationsystems,thereisnowell-establishedhealthsystemdataplatformforcapturing

andreportingonhealthindicatorssofar.NowtheDOHRegion8isintheprocessofcapacitatingLGUs

inutilizationofthePhilHealthInformationSystem.

• Fragmentation of health services (with devolution process started since 1992) results in difficult

coordinationforeffectiveservicedeliveryintheregion.32Inter-LocalHealthZones(composedof3-5

24

municipalitieswith similargeographical settings) are setup inorder to improve communicationand

coordinationofhealthserviceproviders.


• MMR is the highest in Northern Samar province due to geographical (island and mountainous

municipalitiesinGIDA)andtransportationdifficulties.Thesefactorscausedelayinreferralofpregnant

womentoseekappropriateandtimelylifesavinginterventions.Also,mostofthematernaldeathsoccur

in thehospitals thus indicating that the three stagesof delay areprominently featuring inmaternal

deathsandstepsshouldbetakentomitigatetheproblem.

• Hemorrhagewasalsotaggedasthemajorcauseofmaternaldeath in theregionandoccuredat the

hospital level (secondary level and above).Somemeasures by theDOH to tackle the problemwere

reactivationofbloodbanksattheprovincial level(strengtheningbloodsupplyatlowerlevelthanthe

regionalhospital),scalingupofambulanceservicesanddeploymentofhealthworkerstoareasmost

needed.HealthFacilityPlacementProgrambythegovernmentalsotriestoimprovethedistributionof

facilities.

• TBdetectionandtreatmentinvolvesBHWsandvolunteers,thisensuresthattheTB-DOTSstrategyis

implementedoptimallytoreducetheTBburdenintheregion.Itwasstatedthatthecollaborationwith

privatepractitionerswasalsobeingimprovedthroughmeetingsandpresentinggovernmentprotocol.

• Inrelationtocoldchainmanagement,coldchainisprovidedatprovincial,cityandmunicipalitylevels.

Thevaccinesareprocuredbynationallevelandthenaredistributedtolowerlevel.

• RelationshipbetweenLGUsandtheDOH(nationalpolicy).TheDOHRegion8disseminatesinformation

toactorsinthehealthsystematregionallevelthroughInter-LocalHealthBoard(ILHB)ofeachzone.

ILHBisthevenuefordisseminatinginformationandischairedbytheprovincialgovernor.Themembers

aremayorsof concernedmunicipalitiesand theDOHRegion8advocates for the implementationof

importantDOHpolicies.Inaddition,eachProvincialHealthOffice(PHO)hascoordinatorsforadvocacy

campaign of respective vertical program, for example EPI.The coordinators conduct supervision of

activities,implementationatmunicipallevelandcapacitybuilding.

• AsperBHWs(17,500intheregionin2015),theyarevolunteerswithoutanymedicalbackgroundand

differentfromBarangaynurses.TheyaretrainedbytheDOHbeforeandnowbyRHUsandreceivesome

incentivesfortheiractivities.ThetargetratioofBHWstohouseholdis1to120(theratiois1to250in

2015). The challenges are how to access to 24 disadvantages municipalities in addition to 500

disadvantagedBarangay. BHWs’ roles are: (1) basic health services, (2) to refer patients/ families to

healthfacilitiesand(3)advocacyactivitiessuchashealtheducation.

• PhilHealth has various packaged applicable at RHUs and municipality level such as maternal care

package,TBDOTSpackageandoutpatientbenefitpackage.Fordepressedfamilies,thegovernment

enrolls National HouseholdTargetingSystem for poverty reduction for which the government pays

premiumandindigentfamiliescanbenefitfreeserviceoncetheyareadmittedbyhealthfacilities.

• Fordisastermitigationmeasuresinhealthsector,HealthEmergencyManagementUnits(1doctorand6

to8nurses)wereestablishedanddeployedincaseofemergencytoassistLGUs.Disasterriskreduction

25

forhealthplanshouldbepreparedbyeachLGU.USAIDisnowprovidingassistancetomunicipalitiesto

establishtheplansfornon-highlandareas.Atregionalofficelevelwhichisamulti-sectoralstructure,an

emergencyplanispreparedandcommunicatedtoLGUs.Thereisalsoprepositionofresourcesonsiteat

provinciallevel(medicines,food,etc.)fordeploymentincaseofemergency.

University of the Philippines Manila, School of Health Sciences(UPM-SHS)

Location Palo,LeyteVision/Mission Aglobalcenterofexcellenceandleaderinsustainabletransformativehealth

professionseducation/achievinghealthequityandimprovingtheQOLinthePhilippinesandcountriessimilarlysituated

Levelofintervention NationalObjectives Promotescienceandtechnologyresearchanddevelopmentinhealth

PromotethedevelopmentofstudygroupsandresearchprogramsEstablishe mechanisms for the dissemination and utilization of researchoutputsComplementgraduateprogramsandfacultyresearchhumanresourcetrainingintheuniversityEnsure that the results of health research and development activities areutilizedtoimprovethehealthofpeople

MainActivities Totraincommunity-orientedhealthworkers


• Implementationof a special curriculum toproducehealthhuman resourcesdesignated to serveand

respondingtotheneedoftheircommunities(especiallydepressedandunderservedareasofthecountry)

• Givingeducationalopportunitytostudentswhohavefinancialdifficultiesthroughascholarshipcosponsored

bythenationalgovernmentandmunicipalitiesbasedonthesocialcontractmakewiththecommunity

(approvalby75%ofcommunitymembersandrecommendationbythisoneforadmissiontotheschool).


▷ Success

• Thisprogramiscontributingtotheimprovementofqualityofhealthservicesinthecommunitiesofthe

Philippines.

AskingroleofBHWsattheDOHRegionalOffice8 GroupphotoattheDOHRegionalOffice8

26

• Through39annualbatches,ithastrained1,837scholarsfrom71provincesalloverthecountryandone

fromBangladesh.Fromthegraduatedstudents,therehavebeen1,702midwives,662nurses,453as

BachelorsofScienceofHealthand165studentsasmedicaldoctors.Furthermore,fromthestatistics

datain2015oftheuniversity,ithasbeenestimatedthat95%ofstudentsarestillworkinginthecountry.

• Theprogramprovidededucationalandworkingopportunitiestomanydisadvantagedpeople inrural

areasbutalsorespondedtotheneedsoftheircommunitiesthroughthatsocialcontracts.

• Medicaldoctorsproducedthroughthisprogram(whowereconsideredas“secondclassdoctors)have

demonstrated good performances in their communities, this constituting a good promotion for

expansionandownershipbyotherLGUs.

▷ Challenges

• IttakesmoretimetotheschooltorecoverfromthedamageoftyphoonYolanda(buildings,materials

andbooksetc.).

• Effectivetrackingsystemandstrongsupportofthegraduatedstudentsarerequiredtoensurethatthey

continue towork in the communities (because some students go outside the country to gainmore

moneyandsupportbettertheirpoorfamilies).


• UPM-SHSwasestablishedin1976tocorrespondthecountry’sseriousproblemsofbraindrainandmal-

distributionofhealthworkforce

• Thefeatureisthestepladdercurriculumwhichiscontinuouscurriculumandintegratedthetrainingof

thebroad rangeofHRHfromthemidwife (1year9months),nurse (1year3months)anddoctorof

medicine(5years).AdoctorofmedicinegraduatedfromUPM-SHSisconsideredtobeequivalenttoa

doctorfrommedicalschool.

• Throughtheserviceleave(minimum3months)instudent’sowncommunity,studentscanlearncurrent

community’ssituationandneeds,alsocanintegrateandappytheirknowledgeintherealsettingsaswell

asstrengthentheirlinksandpartnershipwiththecommunity.

• Recruitmentandadmissionsarenominatedbyacommunitybasedonitsneedinhealthworkersanda

co-sponsoredscholarshipisprovided.

• Conditionofadmissionasscholar:

1.Entersasocialcontractwiththecommunitytoreturnandserveafterthetraining

2.Endorsetotheschoolthrougharesolutionsignedby75%ofhouseholdheads

3.Familyincomeisnotmorethan80,000PHPperyear

• Someagenciesareinvolvedthisprogram(suchasUniversityofHealthSciences,DepartmentofInterior

and Local government, theDOH, LGUs, identified barangay andNGO including JapaneseNGO) for

supportthebudget

• TheyhavestrongpertnershipwiththeSakuCentralHospital,Nagano,Japan

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2.2 Tertiary level San Lazaro Hospital (SLH)

Location ManilaVision CenterofexcellenceininfectiousdiseasesandtropicalmedicineLevelofintervention TertiaryMission Providequalitypatientcareamongclientsafflictedwith infectiousandtropical

diseasesaccordingacceptedstandardsoftreatmentProvidea comprehensive,qualityeducation, trainingand researchprogramontheinfectiousandtropicaldiseasesProvide relevant and updated information on health promotion and diseasepreventionontheinfectiousandtropicaldiseases

MainActivities Itisinvolvedinhealthcaredeliveryservice,especiallyforthepoorsufferingfrominfectiousdiseases.It has a continuous medical training and research program for medical andparamedicalpersonnel.Someof itsshortand long-termprogramsare infrastructure improvementandstrengtheningofitsfrontlineservices.


SLHisoneoftheoldesthospitalsinthePhilippinesfoundedin1577bytheSpanishasaleprosydispensary

andin1918managedbythePhilippines.Thehospitaliscurrentlyretainedasanationaltertiaryreferralfacility

forinfectiousandtropicaldiseasesandisoneofthepublichospitalssubsidizedbytheDOHinthePhilippines.

• Emergencycareservices

• Infectiousdiseasescriticalcareservices

• Outpatientsandinpatientsservices

• Specialclinicalservices;animalbitecenter,private-publicmixDOTSforpulmonarytuberculosis(PTB)

includingMDR/XDR-TB

• Dentalservices

• HealthEmergencyManagementServicese.g.Earthquakes.

• Haemodialysisservices

• LaboratoryservicescollaboratingwithNagasakiuniversity;

AskingthesituationofbraindraininUPM-SHS GroupphotoatUPM-SHS

28

• National reference laboratory testsonHIV/AIDS,hepatitis andSTIs throughSTD/AIDS cooperative

centrallaboratory

• Publichealthandmedicalassistanceservicesforindigentpeople.

• Medicaltrainingandresearchprogramformedicalandparamedicalpersonnel.

• AcademiccollaborationwithNagasakiuniversity;Bacteremiastudy,Leptospirosis,TB,Diphtheriaand

AMR.


▷ Success

• Good preparedness for management infectious diseases

Eachdepartmenthasa separate triagesectionand thespecialdepartmentsare set suchasHIV/

AIDS,Dengue,andTB.Incaseofemergencyandemergingdiseases,thestaffsatthemainentranceare

given some education about the symptoms and signs of the diseases in order to identify suspected

patientswhoneedtobeisolatedtopreventthespreadofsuchinfectionslikeTB.Inaddition,thehospital

hasseparateadmissionareasforTBpatientsandotherpatientsforoutpatientconsultations.

• Specialized services for Animal bite and Rabies

SLHprovidesclinicalservicesforoutpatientswhogetanimalbitesandinpatientsofrabies.Animal

bitesconstitutesthehighestnumberofconsultationsinSLH(morethan200bitesaday)whileRabiesis

ontopofthelistforconsultationcasesinemergencyroomin2016.Theoutpatientsgetafirstconsultation

at animal bite consultation, headed by a family medicine doctor, and get vaccination for rabies at

Injectiondepartmentarea.Allsectionsareclosetoeachotherandthestreamfromfirsttouchtothe

treatment is concluded at the ground floor, thus the burden of the patients and waiting time are

minimized.Inaddition,inpatientswithrabiesinseveresymptomsareservedprivateroomwelldesigned

toensuresafety.

• Referral services for TB patients

TB department mainly consists of DOTS clinic which ensure outpatient care andTB triage for

admissionintheTBward,wherecomplicatedcasesandMDR-TBpatientsaremanaged.Around2,305

casesofPTBand65casesofTBmeningitiswereadmittedin2015.Thehospitalseparatestheinpatients

asmuchaspossibleaccordingtoseveralcategorieswhich include;theroomforsputumtestpositive

patientsandtheoxygenroomforsputumnegativepatients, ICUroomforTBpatientswiththeother

complications,andtheroomforpatientswithHIV/AIDS.

▷ Challenges

• Limited medical products and coverage of health insurance

The number of vaccines of rabies provided by theDOH is sometimes insufficient,which require

patienttobuythevaccinefromtheirOOP.Thereforethissituationaffectstheadherenceofthepatients

totreatment.

29

• Limited capacity of the facility

Thehospitalhas500bedcapacity,howeverintimesofemergencysuchasDengueoutbreaks,the

hospitalreceivesover1,000patientswhichleadstoovercrowdingduetolimitedspace.

• Increasing number of complicated and MDR-TB cases

Duetoinadequatetreatmentatlowerlevelofthehealthsystemanddelayinreferral.Also,MDR-TB

casesrequirespecialandintensivecarethatareveryexpensiveandinvasiveforpatients.


Top5admissioncasesinemergencyroomare:

1.Animalbite(newcase):Forthis,asystematicclinicalprocedureisestablishedfromconsultationto

treatment

2.Animalbite(follow-up)

3.Pneumonia

4.Denguefever

5.Upperrespiratorytractinfection

Eastern Visayas Reginal Medical Center (EVRMC)

Location TaclobanVision/Mission Towardsagloballycompetitivecenterofexcellenceinhealthcareservicedelivery.

Recognized for innovativepatient center services and relevant researches thatcontributemedicalbreakthroughandhealthpolicydevelopment.TheleadinghealthprofessionstrainingresourceinRegion8

Levelofintervention TertiaryMainfunctions Training:Itprovidesaccreditedresidencytrainingprogramformedicalstudents.

Research:EVRMCisinvolvedinClinicaltrialsbutalsoconstitutesaresearchsiteforresidencystudentsandcandidatesforMasterofPublicAdministrationStudies.Servicedelivery:Asatertiaryhospital,theCenterconstituteareferallevelforalllowerhealthunitsofferingsecondaryorprimarycareservices.

ExplanationofHealthServicesatSLH GroupphotoinfrontofSLH

30

MainActivities implementationoftheKangarooMatherCare(KMC)program,disseminatedandtrainedpediatricsdoctors,nursesandsocialworkersontheKMCprotocols,andcoordinatedwithotherunitsoftheHospitalforlogisticalsupportandcooperation.

1) Main functions of the organization

EVRMCisaTertiaryreferralhospitalservingregion8whichiscomposedofsixprovinces.

Theyhavethree-mainfunctionswhichare:

1. Training

Accredited residency training program for medical students at the following departments (internal

medicine, paediatrics, surgery, obstetrics and gynecology, pathology, family medicine and emergency

medicine).Patientsattendingforpsychiatryandophthalmologyarenotyetenoughtoenablethehospitalto

obtainaccreditation,butservicesforthese2specialtiesarealreadybeingoffered.

2. Research

TheHospitalisinvolvedinClinicaltrialsandconstitutesaresearchsiteforresidencyformedicalstudents

andcandidatesforinMasterofPublicAdministrationStudiesaspartoftheirfinalevaluationforgraduation.

3. Services delivery

Asatertiaryhospital,theyconstituteareferrallevelforalllowerunitsthatoffersecondaryorprimarycare

services,butalsoreceiveoutpatientsleavinginTacloban.Theyareaccreditedasa500bedscapacityhospital

butareplanningtoextenttheircapacityto1,000bedsatthetimeoftransferinthenewbuildingbyOctober

2017.

2) Summary of discussions and lessons learned from EVRMC

• TheEVRMCengagesinPPPprogramswithothercompaniestoofferqualitylaboratoryservicessuchas;

tumormarkers,bloodbankandclinicalserviceslikehemodialysis.

• TheeventoftheTyphoonYolandaresultedinthesupportfromdonorswhichconsequentlyimprovedthe

infrastructureandequipmentenablingthehospitaltoperformitsdesignatedroleasatertiarylevel.

Human resources

Thehospitalisfacedwiththechallengeoflimitednumberofspecialists.

Financial budgets

ThemainsourcesoffundingatEVRMCare:(i)SubsidiesfromDOHthatcoversprovisionofequipment,

drugsandcommoditiesaswellasstaffsalary,(ii)Fundsgeneratedfromthetrainingschoolsupportsthefunding

ofpatientsentitledtoNoBalanceBilling.(iii)HospitalincomesincludingreimbursementfromPhilHealth,and

revenuesproducedbytheprivateward.

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Referral System

EVRMCfacestwomainproblems:(i)Receptionofmanycasesfromthelowerlevelwhichdonotrequire

referraltotertiarylevel,resultingtoanincreasingworkloadforhealthprofessionalswithpotentialimpacton

the quality of services provided.This situation also reflects an underutilization of primary and secondary

facilities.(ii)Receptionoflatereferralcasescomingwithseverecomplicationsduetoinadequatetreatment

andpooraccesstoappropriatediagnosticservicesinthelowerlevelfacilities.

TheServicedeliverynetworkprogramwiththesupportofDOHwaslaunchedatEVRMCasoneofthepilot

projectsinthecountryforimprovingreferralsystemsandqualityofcareinprimaryandsecondarycarefacilities.

This program includes: (i) capacity building (through supervisions and trainings) of lower level health

professionalsbyEVRMC.(ii)increasedcollaborationwithstakeholdersintheregion(includingprivatesector)

toshareexistinglaboratoryfacilitiesandimprovemanagementofcases;(iii)regularmeetingsformonitoring

andevaluation.

TB treatment

Thelaboratorycapacityofthehospital isabletoprovidedifferentmeansofdiagnosis includingsputum

smear,X-rayandGeneXpertforbetterdiagnosisofTB.Afterdiagnosis,patientslivingoutofTaclobanareaare

referredtotheirnearestRHUsforDOTSservicesandfollowup.Applyingthesestrategiesenabledthehospital

torealiseatreatmentsuccessrateof96%in2016.

Disaster risk reduction management Department

Afterthetyphoonthisdepartmentwasreinforcedinordertoensurepropermanagementofdisasterrisks

by improvingpreparedness, response, rehabilitation and recovery. EVRMCandTondoMedical centerwere

selectedaspilothospitalstouseiSPEEDDisasterMedicalMissionOperatingSystem,thissystemwasplanned

tobelaunchedinJuly2017withsupportfromJICAandTokyoElectronicComputerSystem(TECS-Toshiba).

Maternal health Department

Asatertiaryreferralhospital,servicesforsevereandcomplicatedcasesareprovidedinadditiontoANCand

PNC.Themaincauseofmaternaldeathisduetodelayinreferralfromprimaryandsecondarycareunits.In

addition, shortage of human resource and equipment in lower level facilities consequently, limiting their

capacitiestomanageevennormalcases,resultinginunnecessaryreferrals.

Quality insurance committee

Given the ambitionof providinghighquality care thehospital has a quality insurance committee, that

conductsregularmeetingstomonitorthewayservicesareprovided,identifytheproblemsandcomeupwith

solutions.Improvedpatientcasemanagementisprovidedthroughpropercommunicationandensuringthat

emergencycasesaretreatedaspriority.

32

2.3 Secondary level Leyte Provincial Hospital and Provincial Health Office (PHO)

Location Palo,LeyteVision/Mission Aclientfriendlyinstitutionprovidinghealthcareservicesforallmannedbytrained

&competenthealthpersonnelwiththefullsupportoftheprovincialgovernmentofLeyte.Todeliverqualityadequateandaccessiblehealthcareandotheressentialservicesataffordablecostwithoutrestrictionofage,sex,creedandsocialstatus.

Levelofintervention SecondaryObjectives Toensurehealthylives&promotewell-beingforallatallages.MainActivities Financialriskprotection,betterhealthoutcomesandresponsiveness(responsive

healthsystem)toensureaccess,efficiencyandquality.


LeyteprovinceisthebiggestinthewholeoftheVisayaswithatotalof40municipalitiesandisthefirst

provincetoproducea5-yearLeyteLocalInvestmentPlanforHealth2017-2021inlinewithPhilippineHealth

Agenda2016-2022.

ThroughthisplantheircurrentfocusisonachievinghealthrelatedSDGstargetstoensurehealthylives&

promotewell-beingforallatallages.Thiswillbeaccomplishedthrough:1)Financialriskprotection,2)Better

healthoutcomes,3)Responsiveness(responsivehealthsystem)toensureaccess,efficiencyandquality.

Theprovinceisplanningtorelyondifferentstrategiesthatincludes;

• Managetripleburdensituation:

1. Infectiousdiseases–diseasefreeprovinceoffilaria,malaria,leprosy(currentreality).Tobedeclared

2019–schistosomiasisandrabies

2.NCDs.Tobedeclared2019–smokefreeprovince

3.Conditionsarisingfromrapidurbanizationandindustrializationsuchasmentalillness,injuriesandsuicides.

• Ensureuniversalhealthinsurance

• InstallservicedeliverynetworkProvince-wide

• Provisionofappropriateservices(throughlifecycleapproach)

• Implementandprovide6freebenefitsforthepoorest20millionFilipinos

• ImproveLeytehealtheconomics

• Conductprovincialprogramimplementationreviews

• Emergency/disasterresponse

• Philippinehealthagenda(ACHIEVE)

• 5E’sofhealthworkers:

1.Efficient;musthavesufficientknowledgeofwork

2.Effective;mustproducedesiredresults

3.Economical;mustachievemaximumbenefitsataminimumcost

4.Ethical;mustworkmorallyrightandlegallycorrect

5.Expeditious;servicedelayedisservicedenied

33


▷ Success

• Thedevelopmentofthe5yearslocalinvestmentplanforhealth2017-2021

• Facility based deliveries in 2016 was at 95.45% above 92.86% target because of institutionalized

pregnancytracking

• Monitoringandaccountability through theLGUscorecard2015was introduced to trackprogresson

healthindicators

• Theprovincehasbeendeclareddiseasefreefromfilaria,malaria,leprosyandhasbeenaimingtowards

provincefreeschistosomiasisandrabiesin2019

• Householdswithaccesstosafewater:93.4%(Benchmark88%)

• Householdswithsanitarytoilets:87.22%(Benchmark90%)

• TBcasedetectionrate:97%(significantincreaseovertheyears).

• TBtreatmentsuccessrate:91%

▷ Challenges

• Theprovinceexperiencedanincreaseinteenagepregnanciesat15%in2016(youngest12yearsoldand

oldest19).

• Severeacutemalnutritionofchildrenthatis;

• Underweight(WeightforAge):12.04%(<10%Benchmark)

• Stunting(HeightforAge):23.58%(<20%Benchmark)

• Wasting(WeightforHeight):6.7%(<5%Benchmark)

• TripleburdenofdiseaseafterTyphoonYolandawhichincreasedmentalillness,injuriesandsuicidefrom

urbanization.

3) Summary of discussions in regard to suggested guiding points

TheDOHactivitiesareadvocatedthroughPHO.

HospitalsunderLeyteprovincewillhaveprogrammanagersundereachdepartment.

▷ Local Investment Plan for Health

Healthrelatedinformationof41municipalitiesandcitiesiscollectedandconsolidatedthrough10Inter

LocalHealthZonefor theutilizationatprovincial levelmeetingsuchasstrategicplanningworkshopto

formLocalPlanforHealth.Eachmunicipalityandcityalsoproducesitsmunicipalinvestmentplanandcity

investmentplan.

▷ Schistosomiasis

Thecontrolstrategiesarebelow:

1.Cut-offofitslifecyclebyendingopendefecation

2.Massdrugadministrationfor5to65yearsoldinendemicbarangays(medicinesprovidedbytheDOH).

3.Controlofhostsnails(environmentalapproachdonebytheDOH).Thetargetforschistosomiasisfree

is2019.

34

▷ Malnutrition

SevereacutemalnutritioncanbetreatedatRHUlevelasoutpatienttreatmentcentreandpatientswith

complicationsaretreatedasinpatienttreatment.

▷ Birthing facilities

RHUsarenotbirthingfacilitiesandneedtobelicensedtobecomebirthingfacilities.

▷ private facilities

Scorecard(recordofaccomplishment)isalsosubmittedbyprivatefacilitiestotheRHUfortheirquality

monitoring/supervision.

▷ Emergency Preparedness Response Recovery Plan

PHO said that therewasnoepidemicof infectiousdiseasesafter super typhoonYolanda thanks to

variousinternationalaids.TheplancalledHealthEmergencyPreparednessResponseRecoveryPlancovers

4clustersofinterventionswhicharehealth,nutrition,WASHandmentalhealthpsychosocialservices.

2.4 Primary (Community) level Management Sciences for Health (MSH) / Old Balara Barangay Health Management Council (BHMC) / Quezon city

Location ManilaVision/Mission Ensuringaccesstoprimaryhealthcaretoalldepressedpopulationleavingin142

BarangaysLevelofintervention CommunityObjectives ProvidingprimaryhealthcareMainactivities Preventiveservices(immunization),curativeservicesandoutreachactivities


Since 2011 this health center has been benefiting support fromMSH through a project (Systems for

DiscussingabouthospitalmanagementofPHO GroupphotoinfrontofMacArthurStatue

35

ImprovedAccesstoPharmaceuticalsandServicescoveringtheperiod2011-2016)aiminginstrengtheningthe

BHMCinordertoimprovehealthleadership,managementandgovernance.

Apartoftheprojectmentionedabove,therewereotherpriorities:

• TBcontrol:increaseaccesstoTBtreatmentandensuredecentralizationofMDR-TBtreatmentbasedon

theDOHpolicy.

• Maternal health: decreasing home delivery and teenage pregnancy, health promotion for pregnant

womenandteenager’swalkforhealth.

• Malnutrition:avoidingunder-andover-weightmainlyamongchildrenbyhealthpromotionatchurches

andschools.


▷ Success

• Increased access toTB treatment through active case finding activities regularly carried out in the

community(usingchestX-rayfordiagnosisespeciallyforsmearpositive)butalsoimprovementinTB

successratebyrelayingonHomeDOTSwithBHWs.

• IncreasedavailabilityandbetteruseTBcareregistersystemaswellasestablishmentofdatabaseforall

TBpatients.

▷ Challenges

• Providing health services to the community in terms of availability, accessibility and affordability

especially for the vulnerable people such as the poor and the elderly because even if the costs for

treatments in the Barangay health center are free of charge, the transportation costs have a heavy

burdenforthem.

• Lackofresources,willingnessoflocalpeopletohavetreatmentandlowmoralityduetolackofeducation

amongBHWs.


ThroughthisvisitwehadthechancetodiscussthefunctioningofBHMCregardingthesupportprovidedby

MSH’sproject.Itwasshowntousthatthecompositionofthiscommitteeincluded:localgovernmentmembers,

NGOs,private sectors,BHWsand school teacherswith theaim toenhanceparticipation in tacklinghealth

issuesinthecommunity.

Aspartoftheprojectthecouncilisfocusingon:

• Buildingleadershipandgovernancewithpublicprivatepartnership

• Informationsystemtoprovideevidencebasedintervention

• Capacitybuildinginthecommunity

Discussionatthiscenterpointedoutsomeaspectsrelatedhumanresourcesincludingthefactthat:

• MostoftheBHWsareworkingasavoluntarywork

36

• Theirmotivationsaremainlyfromcompensationandrecognition

• Visitingtheirhomesandremembering/callingtheirnamearethemostimportantandeasiestwayto

hireasaBHWandkeeptheirmotivation

Smokey mountain Clinic

Location ManilaatthefootofSmokeyMountainitselfVision/Mission Ensuringaccesstoprimaryhealthcaretoaround25,326peopleaccommodates4

depressedareasLevelofintervention CommunityObjectives ProvidingprimaryhealthcareMainactivities Preventive services (immunization, ANC, etc.), curative services and outreach

activities


Clinic and primary health service deliveryANC, delivery service, PNC, EPI, outreach programs, family

planningservices,andTB-DOTSservices.


▷ Challenges

• Difficulties in controlling disease transmission especially respiratory diseases due to variability of

population.

• Insufficienthumanresourcesatthefacilityleadingtohighworkload.

• MedicalexpensesstillbeaburdenforpatientscomingtothehealthcentersincePhilhealthcoversonly

25%ofpopulationofthisarea,andthepackageofferedstilloccasioningconsiderableOOPespeciallyfor

outpatientservicesandaccesstodrugswhicharenotavailableinthefacility.


• Mainhealthproblems:itwasreportedthatDenguefever,InfluenzaandTBwerethemostprevalentand

thefacilitycouldreceive30to50patientsadayforconsultation.Thehealthcenterhas3deliverytable

withmaximumof6bedscapacityforhospitalization.

ExplainingforTBcasemanagementatBHMC Sharing the information for maternal healthservicesbyMSH

37

• TBcontrol:thecenterprovidesTBpreventionandtreatmentservicesandrelaymoreonafacilitybased

TB-DOTSstrategywhichseemednottoensuregoodsuccessrate(in2016only84%curerateforTBwas

achieved). Patients requiringGeneXpert are referred to the hospital for the test and comeback for

treatmentinthehealthcenter.

• Otherservices:Growthpromotionandimmunizationactivitiesareconductedmonthlythroughhouseto

housevisitstotheresidentsandquarterlytotheresidentsontheSmokeymountain.

• External support: the area attracts number of NGOs working to improve living condition of those

depressedpopulationbyprovidingfamilyplanningprogram,feedingprogram,scholarshipsforchildren

toensureaccess toeducation,microcredit to families,etc. Unfraternally itwasshownthatall these

supportswerenotcoordinatedwithlocalgovernmentactors,makingitdifficultforthehealthfacilityto

capitalizethemforimprovingthehealthstatusofthecommunitytheydeserve.

Fugoso Health Center

Location Manila,LualhatiStreet,Moriones,Tondo.Vision/Mission Ensuringaccesstoprimaryhealthcaretoapopulationof78,699regroupedin39

barangays.Levelofintervention CommunityObjectives ProvidingprimaryhealthcareMainactivities Providing preventive services (immunization,ANC, etc.), curative services and

outreachactivities


Thisclinicdidnothaveprojectongoingapartofroutineservicesprovidedaspartofprimaryhealthcare:

maternalandchildhealthservices,familyplanning,HPVpapsmearscreening,earlyinfantscreening,andTB-

DOTSservices.


▷ Success

• TBcontrol:achievementof90%and92%forcurerateandtreatmentsuccessraterespectively.

• ProvisionofHPVvaccinationtogirlsfrom9-14yearsoldwithsupportfrom“MédecinsSansFrontières”

(MSF).

• Monitoring of Influenza-like Illness, inwhich samples collectedwere sent to the research center for

infectioustropicalmedicinesforstrainidentification.

▷ Challenges

• Congestionofthefacilityduetoinsufficientspace,thisrequiringitsexpansionorprobablyrelocationto

meetthedemandofthepopulation.

• PersistenceofhighnumberofhomedeliveriesduetoOOPfacedbypatients,forexampleforcharges

requestonlaboratorydiagnosiswhichisconductedatprivatefacilities.

38

• Periodicshortageofvaccinesforimmunizationactivitiesespeciallyforpolioandpneumonia.


• Activitiesofthecenter:itwasmentionedthatthehealthcenterwasestablishedin1953asatemporary

clinicformedicalmissions.ThenbecameapermanenthealthcentermadebyPresidentMarcosthatis

fundedbynationalbudget.Ithas4deliverytableand8maximumbedcapacities.Dailyoutpatientsat

thefacilityapproximate50to60whileonly16staffwereavailable(included2-Doctor,4-Nurses,3-BHWs,

1-Dentist,7-Midwifesand1-Med.Tech),thisbeinginsufficientforthepopulationcoveredinregardtothe

WHOstandardof23healthstaffper10.000population.

• TBcontrol:thefacilityisaTB-DOTScenterwith238patientscurrentlyontreatmentandamongwhich3

whereMDR-TB.Thetreatmentsuccessratewasreportedtoreach92%forthepastyear.

• Otherservices:thefacilityconductsaround16vaccinationsadayforchildren,though,thereareperiodic

shortage of some vaccines. They are supported by UNICEF to conduct Reaching Every Child for

immunization in five communities and streets.As part of theUNICEF’s project, BHWs are tasked to

follow-up on pregnant women and also register 50 children under two years and follow up for the

ReachingEveryChildprogramtoensuremaximumcoverageofimmunizationactivities.

Jaro Rural Health Unit (RHU/ BHS)

Location Jaro,LeyteVision/Mission Ensuringaccesstoprimaryhealthcaretoapopulationofabout47,900regrouped

in9Barangays.Workforce:1doctor,2publichealthnursesand9midwivesAnnualfinancialsupporttoJaroRHUfromlocalgovernment:25,000PHP/year

Levelofintervention CommunityObjectives ProvidingprimaryhealthcareMainactivities Preventive services (immunization,ANC, etc.), Curative services and outreach

activities


• IncreasethecoveragerateofthePhilHealthandtargetingtheespeciallyindigentpeople.

• StrengthencommunityhealthactivitiesbyBHWstoreduceMMR.

• EnsureearlydetectionandthetreatmentforTB

• Carryoutpregnancytrackingtoimproveantenatalandpostnatalservices


▷ Success

• The improvement of informationmanagement,made possiblewith the presence a statisticianwho

worksoncollectingandanalysingthedatarelatedtohealth. Itwaspossibletovisualizetheprogress

madebytheRHUthroughgraphsandpiechartsdisplayedinthebuilding.

39

▷ Challenges

• Provisionofthetreatmentofanimalbite:althoughtheyhavealreadyacquiredthequalificationforthe

treatmentofanimalbitesfromthegovernmenttheyhavenotyetstartedtoprovidetheservicedueto

thelimitedhumanresources.Thissituationhappenswhileanimalbitesareamongthehighestsourceof

morbidityinJaroMunicipality.

• HighMMR: inspiteofhighproportionofthefacilitybaseddelivery(reachingmorethan90%),MMR

remainshighinJaro.


• EncouragementofBHWs:theyworkandtheircommitmentstothecommunityareappreciated,however

ithasbeenchallengingtokeepthemmotivatedgiventhelimitedfinancialsupporttheyreceive.TheBHWs

benefit only small amount of money,Christmas gifts, and awards as incentive.Another way used to

motivatethemwastoinvitethemsometimestopartiesheldbythelocalgovernment.Fromtheinformation

provided,itwasclearthatsustainablefinancingtoBHWsactivitieswouldbeanissueinthefuture.

• MaternalandChildIncentiveProgram(MCIP):JaroRHUprovides1,500PHPtoawomanwhodeliversat

healthfacilityand525PHPtothehealthfacility.Moreover,municipalgovernmentgetsapproximately

9,600 PHP as incentive from the national government thanks toMCIP.The 40% of the incentive is

allocatedtoprofessionalfeesandthe60%forRHU.MCIPsupportsencouragethehealthworkersand

thepregnantwomen,andalsocontributetoimprovetherateoffacilitybaseddeliveryinJaro.

Tabontabon RHU/ BHS

Location IntheMunicipalityofTabontabonVision/Mission Ensuringaccesstoprimaryhealthcaretoapopulationof10,800,habitantsfrom

16Barangay.Levelofintervention CommunityObjectives ProvidingprimaryhealthcareMainactivities Preventive services (immunization,ANC, etc.), Curative services and outreach

activities

Tabontabonexistssince1878andagricultureisthemaineconomicactivity.ThisRHUwasreconstructed

withtheassistanceofUSAIDin2014aftertheattackofsupertyphoonYolandtothemunicipality.


• Reproductivehealth

• Delivery

• TBDOTS

40


▷ Success

• Achievementoffilariasis(since2013)andmalariafree.

• 100%Facility-baseddeliveries,distributedamongRHU(52%),hospital(45%)andbirthingclinics.Itwas

shownthat45%ofthesedeliverieswereassistedbymedicaldoctorsathospitaland55%bymidwives.

• Veryhighclientsatisfactionrate(over95%).Thisoneismeasuredonthebasisofquestionnairesprovided

topatientsanddistricthospitalsupervisions(throughinterviewofpatients).

• TBdetectionrateattained100%in2016,thankstotwomedicaltechnologist.perweekavailablenowat

RHU,whichincreasedthefrequencyofexaminationfromoncepertwoweekstotwiceaweek.

• 100%ofexclusivebreastfeedingachievedineachofBHSsandatRHU.

• 69%contraceptiveprevalence rate inoverallmunicipalitybecauseof commodity availability at local

level(oralcontraceptivepills,injectionandIUD).

• CommunityHealthTeamsarefunctional100%thankstotheJICAproject

• 100%E. Colifreedrinkingwaterrealizedin2016(considerableimprovementcomparedto7%reportedin2015).

• 100%PhilHealthcoverageattainedbytheendofDecember2016.


• Community outreach activities:Community HealthTeams were introduced by the JICA project and

targetprimarilypregnantwomenbypregnancytracking.

• LowrateofTBDOTS:Somepatienttransferredtootherareas(patientswithcomplication)andcannot

befollowedup,butsomenursesareassignedatBarangaylevelforclosefollow-up.

• ForNCDscontrol:healthpromotionisneededthroughactivitiesofenforcingadvocacy,improvinglife

styleaswellaspromotionofphysicalexercises.

• Familyplanningservices:arefreeforwhichmedicinesareprovidedbythenationalprogramforPhilHealth

enrolled.Therearealsoexternalsupport(USAIDandothers).Oralcontraceptivepillsaremostpopular.

However,itisnecessarytotakeintoconsiderationofexistenceofstrongreligiousbodies(mostlycatholic).

Volunteer for Visayans (VFV)

Location TaclobanVision/Mission LocalNGOhavingmissiontocontributingtowardssustainabledevelopmentLevelofintervention CommunityObjectives Improvethequalityoflifeofthecommunitybyprovidingresponsive,efficientand

high-qualitycommunity.Mainactivities childwelfare,communitydevelopment,educationandpublichealth


Theorganization is focusing as usual on 3main areas of intervention that include:Voluntary program,

communityactivitiesandsponsorshipactivities.

41


▷ Success

• Establishmentof a “contingency fund” to ensure continuity and sustainability of their activities.The

NGOfundingsystemisbasedonsocialentrepreneurshipmodelwhichconsistininvestingallthebenefits

theymakeinsocialactivities.

• Assuch,allthemoneycollectedfromproductsofactivitiesruninthecommunitycentres,fundraisingcampaigns,

contributionfromvolunteersaswellasdonationsarecapitalizedtoconstitutethiscontingencyfund.

• Participationofsomeformerbeneficiaries intheactivityoftheNGO(caseofthecoordinatorsofthe

Dumpsitefeedingcentres).

• EstablishmentoffourcommunitycentresfunctioninginTacloban(onehostingmainoffice)and2others

aroundTacloban(PaloandDumpsite),allcentresrunnutritional/feedingactivity.

• 47builthomeprojectsforsponsoredchildrenandanotherplannedinJune2017,4adaptedschoolsbuilt,

16medicalmissionsorganized,75sponsoredchildrenundertheSponsorshipprogramsand48sponsored

childrenundertheDumpsiteprogram.


• The organization has been able to create a “contingency fund” and run the social entrepreneurship

Model,butalsorunfundraisingcampaignsthroughsocialmediaandothermeans.

• AsmostofthesechildrencomefrompoorfamiliestheyareautomaticallycoveredbythePhilHealthasindigents

andsomealsobenefitactivitiesrunduringmedicalmissionsorwhenthereisamedicalvolunteerwhocomes.

• TheNGOrunpromotionalandawarenesscampaignstoshareitsactivities,butalsorelyonvolunteer

testimonieswherevertheygo.

• Althoughitisknownthatchildrenandwomenarevulnerable,theNGOprovideaholisticsupporttoall

familymembersofthesponsoredchildtoensuresustainabilityoftheirinterventions(especiallychildren

recruitedfromDumpsitesareasothattheydonotgobacktothisactivity).

InadditiontothediscussionwiththeVolunteerProgramCoordinatortwogroupswereconstitutedtovisit

2differentsites:

San Joaquin Community center and Palo feeding center.

• Thisteamassistedtothecookingforfeedingprogram.Inthecentervisited,childrenareprovidedfoodeveryday

withthehelpofoneVFVstaffsupportedbyaforeignvolunteeraswellassomemothersofsponsoredchildren.

• Ordinary,thereare27enrolledchildrenfromaged2to13yearsold.However,thereweremorethan30

childrenonthedayofvisit

• Dailystaffsinchargeoffeedingactivitiesprovidehealthpromotionactivities(encouragethechildrento

washtheirhandswithliquidsoapcorrectlybeforethelunchandbrushtheteethaftereating).Inaddition

tofood,childrenalsoreceivegummymultivitamins.

• Afterthefeedingcenter,theteamvisitedaBarangayhealthcenterinthesurrounding.Thisonewasbuilt

by internationalorganizationafterthetyphoonYolanda. Ithasadeliveryroom,recoveryroomwhich

havenotstartedtobeusedbecauseoflackofsomedevices.

42

Dumpsite feeding center

• ThisgroupalsovisitedthefeedingcenterclosedtotheDumpsite.Herestudentsparticipatedtobuying

foodinthemarket,cookingactivityandorganizedhandswashingforchildrenwhowerewaitingforfood.

• Normallychildrenattendingthiscenterare35,butonly24werepresentassomeothersdidnothave

schoolthedayofthevisit.Theyoungestwas6andtheoldest20yearsold.

• Fromthehandwashingactivitydemonstration, itwasnoticedthatchildrenhadpreviousknowledge

abouthandswashingwhichmadetheactivityeasytoperform.

2.5 Sub-regional level actors, External partners WHO Western Pacific Regional Office (WPRO)

Location ManilaVision/Mission WHO’smissionistosupportallcountriesandpeoplesintheirquesttoachievethe

highestattainablelevelofhealth.Levelofintervention InternationalObjectives To lead the regional response to public health issues on all fronts - medical,

technical,socio-economic,cultural,legalandpolitical-towardstheachievementofWHO’sglobalhealthmission.

MainActivities Act as a catalyst and advocate for action at all levels, from local to global, onhealthissuesofpublicconcern.Workingtogetherwithabroadspectrumofpartnersfromallsectorsofsociety.Involved inahostof closely relatedpublichealthactivities, including research,databanking,evaluation,awarenessraisingandresourcemobilization.


• UniversalHealthCoverage(UHC)

• ImplementationofInternationalHealthRegulation

• Increasingaccesstomedicalproducts

• Improvesocialeconomicandenvironmentaldeterminants

• SustainableDevelopmentGoals(SDGs)

• Non-communicablediseases(NCDs)

ExplainingaboutSponsorshipProgrammeatVFV GroupphotoinfrontofVFV

43

• MDR/XDR-TBcontrol

• Tobaccocontrol

• Traditionalmedicines(TM)

2) Successes and challenges

▷ Successes

• OnTobacco control, using the “MPOWER” strategy, an estimated 14.8million people quit smoking

resultingin7.4millionlivessaved.

• AchievementofthebasicTBservicesandreducingTBburdeninmanyplaces.

▷ Challenges

• Difficultyoftheregiontocontroltobaccousebecauseofinterferenceofthetobaccoindustrieswiththe

tobaccocontrolpolicy.

• DifficultiesinreachinghighriskpopulationinTBcare

• HugeburdenofMDR/XDR-TBtothehealthsystem.

• WeakcollaborationwiththeprivatesectorinTBmanagement.

• HealthSystemfailureintheareaofIdentificationandtreatmentofMDR-TB

• Limitationofinformationandcommunicationacrossmemberstateshinderingregulatorystrategyfor

traditionalmedicinessincedifferentcountrieshavedifferentcultures.


▷ TB

• Resistancetoantibioticsareasaresultofnaturalprocessofmutationandtreatmentwithinsufficient

combinationtherapy.

• It is importanttoensureTBpatientsareonrightmedicationsandadhereto fullcourseof treatment

because:

1.FirstlineregimencombinationforTBarethemosteffectiveandtolerable,moreover,useofmicroscopy

and6monthstreatmentiscosteffective.

2.Secondlinemedicinesarefarlesseffective,withseveresideeffects.Althoughnewerdrugsareinthe

systemwithbettertolerance,theyareverycostlyandrequirelongtermmedication.

• HugeexpenseshavegoneintoMDR-TBbutwearenotdoingenoughtoensuretheappropriateused

medicinestoavoidMDR-TB.

• Engagementofpublic–privateisveryimportantinaddressingappropriationandstandardizedtreatment

ofTBandreporting.

• DespitefreeTBtreatment,thecostofseekingcare,diagnosisandcontinuoustreatmentisstillaburden

onTBpatientsinmanycountries.

• TheestimatednumberofMDR-TBcasesintheregionis71,000ofwhich13,000aredetected,8000are

enrolledandonlyhalfistreatedsuccessfullygivingatreatmentsuccessrateof46%.Threepillarsusedin

theendTBstrategy:

44

1. IntegratedcenteredTBcareandpreventionwhichfocusonTBservicedelivery

2.Boldpoliciesandsupportivesystems,thus,thehealthsystemsandthesocialsystemsthatsupportTB.

3.Research

▷ Tobacco Control

Country regulations normally restrict and control the strength of tobacco contents but monitoring

mechanismsmustbeput inplace to checkon their implementations. WHO frameworkaction for tobacco

controlhas180countriessigned-toreducethetobaccouseasmuchaspossibleusingtheMPOWERStrategy

M–Monitoringthetobaccouseandpreventionpolicy P–Protectingpeoplefromtobaccosmoke O–Offeringhelptoquittobaccouse W–Warningaboutthedamagesoftobacco E–Enforcingbansontobaccoadvertising,promotionandsponsorship R–Raisingtobaccotax

Andthereisregionalmonitoringofeachcountryprogressandimplementingpolicieseverytwoyear.

▷ Traditional Medicines (TM)

ConcernhasbeentorecognizetheplaceofTMinthenationalhealthsystem.Thereistheneedtointegrate

TMintotheUHCusingthesixbuildingblocks.Sixkeystrategicobjectiveshavebeendeveloped:

1. IncludeTMaspartofthenationalhealthcaresystems.

2.PromotesafeandeffectiveuseofTM,strengthentheevidencebaseofTraditionalChineseMedicine,

andstrengthenregulationsandstandardsforTraditionalChineseMedicineproducts.

3. IncreaseaccesstosafeandeffectiveTM,enhancetheservicedeliverysystemtoprovideTMservices

appropriately,integrationofTM,ensurethatTMpractitionersarewelltrained.TMisapotentialfor

NCDandpalliativecare.

4.PromoteprotectionandsustainableuseofTMresourcesdevelopment;monitorandenforcepolicies

andregulationsofpractitioners.

5.Strengthencooperationingeneratingandsharingtraditionalmedicineknowledge.

6.DevelopinformationsystemofTM

Theconcept is toensuresafety,effectivenessandqualityofTManddeveloping informationsystemfor

memberstatestoshare.

▷ Antimicrobial Resistance (AMR)

Thereare5maincauseofAMRintheworld,thatis,overthecounterdrugsofantibiotics,prescribedby

irrational use, stock-out of antibiotics, counterfeit and weak infection control.To resolve this,WHO have

implementedtheGlobalActionPlanonAMRwhichhavestimulatedcountriestoformulatedtheirownnational

plansandregulations.

TheGlobalActionPlanonAMR:

1. Improveawarenessandunderstandingofantimicrobialresistance

45

2.Strengthenknowledgethroughsurveillanceandresearch

3.Reducetheincidenceofinfection

4.Optimizetheuseofantimicrobialmedicines

5.Developtheeconomiccaseforsustainableinvestment

▷ Health and Security

• Focusesoninternationalhealthregulationslegalframework.Formulatedin1969andrevisedandmade

practicalin2005.

• InternationalHealthRegulation(IHR)isaninternationalagreedframeworkforprotectingglobalsecurity

focusingonjointcommitmentandsharedresponsibility.

• PublicHealthEmergencyofInternationalConcern(PHEIC)–Itisanextraordinaryeventdeterminedas:

(i)Toconstituteapublichealthrisktootherstatesthroughtheinternationalspreadofdisease.

(ii)Torequireacoordinatedinternationalresponse.

• FourcriteriadecisioninstrumentsareneededtoreportonPHEIC,thus,serious,unexpected,potentially

spreadandimpactontravelandtrade.

• SpecialcommitteeisneededtodeclarePHEIC,thoughmajordecisioniswiththedirectorgeneraloftheWHO.

• Smallpox,Polio,HumanInfluenzafromnewstrainsandSARSmaynotneedanycriteriatobereported

asemergencysituation.

• Global alert and response system for commination such as the event information site notification is

sharedwithcountriesgloballyasatoolfordiseasenotification

Japan International Cooperation Agency (JICA)

Location Makati,MetroManilaVision/Mission JICA,withitspartners,willtaketheleadinforgingbondsoftrustacrossthe

world,aspiringforafree,peacefulandprosperousworldwherepeoplecanhopeforabetterfutureandexploretheirdiversepotentials.Inaccordancewiththedevelopmentcooperationcharter,willworkonhumansecurityandqualitygrowth

Levelofintervention Externalaid

DiscussingaboutAMRatWPRO GroupphotoatWPRO

46

Objectives HighqualityandsustainableinfrastructuredevelopmentRoadmapfortransportinfrastructuredevelopmentforMetroManilaImprovingbusinessandinvestmentenvironmentDisasterriskreductionmanagementAgricultureandfoodsecurity Safetynetsincludinghealthcare

MainActivities Achieving sustainable economic growth through further promotion ofinvestmentOvercomingvulnerabilityandstabilizingbasesforhumanlifeandproductionactivity


Currently,JICAisfocusedonseveraltargetssuchashighqualityandsustainableinfrastructuredevelopment,

improvingbusinessandinvestmentenvironment,disasterriskreductionmanagementandsoon.

JICAissupportingsomeLGUstostrengthentheirhealthsystem.

This is done through provision of health equipment and staff training.Comprehensive epidemiological

studyonacuterespiratoryInfectionsinchildrenfromApril2011toMarch2017to:

• Determinetheetiology,diseaseburdenandriskfactorsofpneumoniaamongchildren.

• Establisheffectiveinterventionstoamelioratemorbidityandmortalityduetopneumoniainchildren.

• AssistforexternalmonitoringofEPI.

▷ Disaster response

• Program grant for rehabilitation and recovery from TyphoonYolanda (2014 – Oct 2016) Including

reconstructionofoutpatientdepartmentofEVRMCandRHUinSamarandLeyte.

• CollaborationprogramwiththeJapaneseprivatesectorfordisseminatingJapanesetechnologyinthe

Philippines.

• ImplementationofnewtechnologyfornewTBdiagnosticalgorithmtohelpincasedetectionofTB.The

DOHiscollaboratingwithEikenChemicalcompanyLtd.andNiproCooperationtoimplementthisnew

technology(2016–2018).

• Tokyo Electronics Systems Corporation is also collaborating with the DOH to disseminate iSPEED

disastermedicalmissionoperatingsystem (2016–2018). iSPEEDcansupport triage, treatmentand

transportationindisasterareaandalsoenabletosharemedicalinformationamonglocalgovernment,

hospitalsanddisastersites.Pilotstudyhasalreadybeen launchedatseveralhospitalssuchasTondo

MedicalCenterinManilaandEVRMCinReyte.


Alloftheaboveprojectsarestillon-goingandhavereachedvariouslevelsofcompletion.


AsthePhilippineshealthsystemisdevolvedtotheLGUs,theeffectivenessandefficiencyofthelocalhealth

systems largely depends on local capacity and the local government’s interest in health. JICA is therefore

47

aligningitstechnicalcooperationtotheneedsofthelocalgovernmentstohelpthemstrengthentheirhealth

systems.

OneofthemainareasofinterestofJICAistoimprovematernalandchildhealthindicatorsinthePhilippines

andassuch,JICAissupportingtheCordilleraregiontostrengthenitshealthsystemtodelivereffectiveand

efficient maternal and child health services. JICA is implementing this project by strengthening health

governanceandfinancingintheregionandthroughtheprovisionofhealthequipmentandtrainingofhealth

workersofhealthfacilitiestofacilitatetheircertificationandaccreditationtoofferBasicEmergencyObstetric

andNewbornCareservices.

JICA, through its private-public partnershipmodule, is also helping the Philippines to improve its case

detectionoftuberculosis.Throughthisproject,theDOHispartneringwithaJapaneselocalcompany–Eiken

ChemicalCompanyLtd–todevelopacosteffectivediagnosticequipmenttohelpimprovethecasedetection

oftuberculosiscases.

3. Lessons learned

Inthischapter,wearepresentingthelessonswelearnedfromthedifferentinteractionsduringthefieldtrip

basedontheWHOhealthsystemperformancecriteriaestablishedin2003.Itisimportanttoacknowledgethatthe

informationwecollectedandmethodologyweusedtobenotconsistentenoughtomakesubstantialjudgementon

PhilippinesHealthsystem,butusingthesecriteriaseemedforusmorepracticalastheyaremadeinawaytoprovide

aholisticviewofahealthsystemandreflecttheinterrelationshipofeffectofitscomponents(USAID,2012):

3.1 Equity

Fromthediscussions,wehadwiththeDOHandothershealthprovidersalongourtripwecouldmakethe

followingcommentsgivenintablebelowregardingequity:

DiscussingaboutDisasterRiskManagementatJICA GroupphotoatJICAoffice

48

Table 2. Analysis of equity aspects regarding health services.

Horizontal equity Vertical equity- Although PhilHealth exist (with 92% coverage)andtendtocoverindigents,itdoesnotensureforthe latter access to all health care servicesirrespective of providers as the private facilitiesarenotincludedintheHealthinsurancesystem;

- The fact that some remote areas doesn’t haveadequatehumanresourcesorequipmentdonotguaranty provision of proper health care to thepopulationinneed.

- Their isolation has been reported to be a factorthatpreventthemofbenefitingnecessaryservicessuchasvaccination,comparedtothosewhoareinurbanoreasilyaccessibleareas.

- Through the “No balance billing” policyimplementedinallthefacilitieswevisited,wecansaythattheDOHtendtoensureverticalequitybyproviding freeaccess tohealthcare to indigentspeopleevenifthisoccursonlyinPublicfacilities.

ThenewHealthagendaalsoreflectstheintentionoftheDOH,giventhefactthatoneofitsaimistoensurecoverageofpremiumsofpeoplefromthenon-formal sector by tax subsidies while thosefromtheformalsectorarededucteddirectlyfromtheirpayroll.

- In EVRMCwe got testimony of a local initiativethatleadtoredistributionofresources,inasensethat the hospital reallocate a part of resources/benefitsgeneratedfromPrivateWards(occupiedbysocalled“richpeople”)tocoverexpenditureofsomeindigentspatients.

3.2 Efficiency

• TheexperiencesharedbytheOldBalaraBHMCinQuezonCity(supportedbyMSH)intheimplementation

oftheTBControlprogramis in factagreatexampleofefficiency.Throughactivecase identification,

relayingoninformalpersonalsforlaboratoryanalysis,usingX-RayfordiagnosisofTBandCommunity

DOTS,theycouldincreasecoverageoftreatmentintheyBarangaybutalsogettoachievehighsuccess

rateforTBtreatment.Thisstrategyfocusingonearlydetectionofcasesandusingexistingmeanscan

helptoreducemorbidityandmortalityduetoTBwithoutinvolvingbigamountofmoney.

• TheotherexampleistherotationsupportsystemamongBarangayHealthCentersthatwassharedin

SmokeyMountainasameantodealwithshortageofhumanresources.Thisstrategyconsistsininvolving

BHWs from others Barangay to support outreach or immunization activities due to high density of

populationsintheirrespectiveareas,andwhichinnormalcircumstanceswouldrequiremanydaysto

coverifrelyingonexistingstaffs.

Moreover, in a general view, the new strategy of Service Delivery Network that have been recently

launchedbytheDOHwouldbeanopportunitytoensureeffiencyintheprovisionofhealthservicesinthesense

that facilities belonging to a given network would easily benefit equipment or qualified human resources

existing in it,providingthatthereferralandcoachingsystemsareeffective.TheexperienceofTBprogram,

whereGeneXpert is not available in each facility would rely on this networking system to ensure proper

diagnosis,especiallyforpatientswithsputumsmearnegativeatthetimeofmicroscopyexamination.Thisin

additiontoinclusionoflaboratorytestinthePhilHealthpackagetoremovethefinancialbarrier.

3.3 Access and coverage

Inthetablebelow,Accessandcoveragearediscussedbasedontheinformationcollectedfromfieldvisits.

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Table 3. Analysis of access and coverage of health services

Financial Access Physical access- FromtheexchangewithallfacilitiesitisclearthatPhilHealthdonotensureproperfinancial accesstohealthservicesgiventhefactthatoutpatientsconsultations are not covered and even foradmissions only public hospitals are included inthe Health Insurance system while most ofpatientsfirstvisitprivatehospital.

AllthisleadingtoahighrateofOOP(57%healthfundingsources) inacontextwhere92%of thepopulation are supposed to be covered by theinsurancesystem.

- Theexampleshared,atSLH,aboutsmearnegativeTB patients not accessing appropriate diagnosis(GeneXpert) due to high cost (5000 PhilippinesPesos) is also a proof that access to health carestill facing challenges in the country even forprograms that are highly supported by externalfund,thisleadingtoworstevolutionofthediseasewithbadconsequencesonboththepatientsandhealthproviders.

- Asdiscussontheequityaspecttherestillbesomeareasofthecountrywherequalityservicesarenotaccessible due to lack of human resources,insufficientequipmentordifficultiesintransportationtoreachreferralhospitals.Thisleadingtoinadequatetreatment, increased complicated cases or deathsfrompreventablediseases.

InEVRMC,weweregiventhetestimonyofwomenwhotook8hourstoreachthehospitalduetolackoftransportation.

- Despitetheinformationabove,wenoticedagreatinitiativeoftheMareofTabontabonMunicipalitywho provided an ambulance to his community.The use of the ambulance was based on theprovisionof1kgofplasticwaste.

This was a notable intervention which togetherwithincentivesofferedtowomendeliveringinthefacilityenabledthemunicipalitytoensure100%facility based delivery but also improve wastemanagement as part of primary prevention andenvironmentalcontrol.

3.4 Quality of services

Whenlookingtothequalityofservices,weobservedthefactsbellow:

Tertiaryhospitals (EVRMCandSLH)areofferinghighquality servicesandareequippedwithnecessary

infrastructureandlaboratorymaterialstoensureprovisionservicesappropriatetotheirlevel.Theexistenceof

qualityinsurancecommitteeinbothfacilitieswasaproofoftheattentiongiventothesatisfactionofpatient’s

expectations.

ButasshownintheEVRMC,thescarcityofqualifiedhumanresourcesstillbeabigchallengetoguaranty

theprovisionofallrequiredservices.ThisissueofHumanresources,socalled“braindrain”havebeenreported

inmostofthefacilitieswevisitedandconstitutesabigbarriertoensurequalityofhealthservicesprovidedto

thepopulation,especially inpublic facilities. InFugosohealthcenter forexample, theteamwasmadeof2

MedicalDoctors,4-Nurses,3-BHWs,1-Dentist,7Midwifesand1-LaboratoryTechniciantodeliverservicesfor

apopulationestimatedat78,699people,thisbeingfarbelowtheWHOstandardof23skilledhealthstaffsfor

10,000people(WHO,2016).Theriskinsuchasituationisahighworkloadwhichcanimpactonthequalityof

servicesprovidedandindissatisfactioninthesideofpatientswhomayeitherdelayinseekingfortreatmentor

gotoprivatefacilitieswheretheywillfacefinancialconstraints.Theseriousnessofthesituationhasevenlead

tothecreationofaspecialprogramoftrainingofhealthprofessionalsintheUniversityofPhilippinesthatwe

visitedinTacloban.Thisinitiativeconstitutesanappropriateresponsetotheproblemidentifiedasitfitswith

theneedofpopulations,buildingonthesocialtrustbetweenhealthprofessionalsandtheircommunities.

Despite the human issue resource issue,we think that an effective functioning of theServiceDelivery

Networkwillhelpimprovingthequalityofservicesinthelowerlevelsthroughsupervisionsandtrainings,and

thereforehelpinreducingunnecessarytransfersandcomplicatedcasesinthetertiarylevel;thisinadditionto

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anenhancedtrustofpopulationinthepublicfacilitiesassuminganimprovementincasemanagement.

3.5 Sustainability

• OneofourobservationregardingsustainabilityofongoinghealthprogramsinthePhilippinesisrelated

tothemechanismoffinancingPhilHealth.Themainsourceoffundofthishealthinsurancewassaidto

besintax(collectedfromtobaccoindustries)andwhichwasshowntobeincreasingacrosstheyears.But

the fact is that this increasingwill not be unlimited, this requiring thus the government to develop

additionalmechanismstomobilizedomesticresourcestoensurecontinuityoftheservices,havingalso

inmindtheperspective,ofexpansionofthepackagewhichcurrentlyseemtobeinsufficienttoensure

financialprotectionasproneintheHealthagenda(57%ofOOP).

• Theadverseeffectofdecentralization in regardto inappropriateallocationof fundsat local levels to

supporthealthactivitiesisanimportantfactortoraiseasitcanconstituteabarriertosustainongoing

interventions.Thefactthatpoliticianonlyfocusoninterventionsthatensurevisibilityoftheiractionsput

thehealthsectorinalowerpositionintermofpriorities,consideringthatinvestmentsmadeinthelatter

donotleadtoimmediateimpact.Thinkingofdefiningagivenquotaofthelocalbudgettodevoteto

healthissuesineachLGUandincreasedadvocacyandfollowupbytheDOH,strongparticipationand

involvementofthepopulationinthemanagementoflocalresourceswithprioritizationofhealthissues

mightbeamongtheoptionsusedtomitigatethisrisk.

• ElementsinsupporttosustainabilitywasobservedfromEVRMC’sexperiencewenoticedanincreased

PPPtoimprovethequalityofservicestheyprovideandwethinkthatthiscanbeagoodwaytoensure

sustainability considering the limitation that faces the government and the decreasing trend of

internationalsupportasalreadyannouncedbytheGlobalFundinthecaseofTBcontrolforexample.

TheothercaseofPPPwenoticedistheprojectofdiagnosisequipmentforTB(LAMP)underresearchwith

thesupportofJICAincollaborationwithEikenChemicalCo.Ltd.andNiproCooperation.Thisonecouldbean

alternativetoGeneXpertinensuringcontinuityandexpansionofdiagnosisregardlessofinternationalfunding.

ThetechnicofferinginadditionbetterspectraandlargesensibilityforthediagnosisofTBaswellashighchance

ofaffordabilitygivenitslowercost.

AlthoughthegovernmentcometoensuremobilizationofsufficientfundingthroughPhilHealthorincreases

itseffortsinestablishingstrongPPP,therestillbesomeothersystemicissuesthatrequireattentionlike:

• Thehealthinformationsystemwhichseemtobemadeofmanyparallelsystemsthatdonotenables

properuseofinformation.Acceleratingtheprocessofintegrationwouldbebeneficforbothplanning,

monitoringandevaluationactivities.

• Ineffectivenessofthesupplychainfordrugsandcommoditiesrelatedtonationalprograms(vaccination,

TBandothers)leadingtoinappropriatecoverageofservicesneedtobeaddressedtoensureequitable

accesstoservices.

• InclusionofprivatefacilitiesinthePhilHealthsystemwouldalsobeabigpathinimprovingaccessto

qualityhealthcareforpopulationandensuringtherespectofnationalstandardsintheprivatesector.

• Reinforcingtheleadershipofthecentralleveltoensurethathealthpoliciesareimplementedproperlyby

allLGUsismorethanrequiredgiventhedisparitiesobservedfromaBarangaytoanother.

51

4. Conclusion

Asaconclusion,havingthisopportunityofexposuretothePhilippines’healthsystemhavebeenagreat

experience for all of studentswhoparticipated to thisfield trip.Wecould learna lot from interactionwith

different categoriesof healthprofessionals andorganizations that are involved in thePhilippines from the

globalleveltotheLHUwhichistheBarangay.Inadditiontohealthaspectsfromvisitswemade,thisactivity

alsogavethechancetoeachofustoperformsometasksandparticipateinactivitiesthatwillbeinthefuture

an integral part of our professional life.These include: team leading, logisticmanagement, presentations,

groupdiscussionsaswellasreportingofmainsfindingthatresultedfromactivitieswewereinvolvedin.

Amongthetakehomeexperience,wecanmentionthedecentralizationanddevolutionthatcharacterize

thePhilippines’healthsystem,whichhavetheiradvantagesanddisadvantagesaswecouldobserveduringour

visits.Asanexample,wecouldnoticethatbringingthedecisionlevelclosertothepopulationcanimprovethe

waycommunitiesmanagetheirhealthproblems(caseofTabontabon)butalsocanbesourceofdisparitiesor

inadequateresponsetohealthissuesexistingintheareaofinterest,asallocationofresourcesdependstotally

onpoliticalinterestandpriorities.Also,thepowerofthecentrallevelinthishealthsystemmodelseemstobe

dilutedsuchthatensuringimplementationofnationalpoliciesbecomechallengingwhennocontrolonfinancial

resources.

AnotherkeyelementthatkeptourattentionistheambitionoftheDOHtoensurehealthforallFilipinos

through PhilHealth. However, this ambitious goal still need a lot of improvement in terms of financing

mechanisms (toensuremobilizationofmoredomestic resources),packagecovered(toconsideroutpatient

deliveryandotherservicessuchaslaboratory)andexpandfacilitynetworkbytheinclusionprivatesector;all

withaimtoachieveitsmissionofpreventingpeopleinfallingintopovertyduetocatastrophicexpenditurefor

healthbutalsoensureaccessforalltoqualityhealthcare.

Strengthenedbythisexperience,itisimportantforustothanksallfacultymembers,administrativestaffs

andallotherkeypersonsinthePhilippinesthatwereinvolvedbothinthepreparationandrealizationofthis

activity.As future global health professional, we value the benefit of this field trip activity as part of the

curriculumofourtrainingandencouragefutureparticipantstotakefullbenefitofitthroughactiveparticipation

and strong interactionwith health professionals theywill have tomeet.Thiswill give them the chance to

developtheircapacitytoconductcriticalanalysisofhealthissues,lookingatthemfromdifferentperspectives

and levels, get familiar with challenges that face health systems and communities, and moreover get to

understandthatcontextualaspectsareimportanttoconsidereverytimetheywillhavetoapplytheknowledge

thattheywillacquirefromschool.

52

Final presentation of the Field Trip (version of the presentation at TMGH)

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55

56

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References

DepartmentofHealthofthePhilippines2016,PhilippinesHealthAgenda2016-2022,viewed30March2017,

http://www.doh.gov.ph/sites/default/files/basic-page/Philippine%20Health%20Agenda_Dec1_1.pdf

DepartmentofHealthofthePhilippines2016,KALUSUGANPANGKALAHATAN2010-2016:Anassessment

Report,viewed30March2017,

http://www.doh.gov.ph/sites/default/files/publications/Kalusugan_Pangkalahatan2010-2016_An%20

Assessment_Report.compressed.pdf

PhilippineStatisticalAuthority2017,MDGWatchStatisticsataglanceofthePhilippines’Progressbasedon

theMDGindicatorsasofSeptember2015,viewed25May2017,

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

USAID2012,ThehealthsystemAssessmentApproach:Ahowtomanual,Version2.0,viewed20March2017,

https://www.hfgproject.org/wp-ontent/uploads/2015/02/HSAA_Manual_Version_2_Sept_20121.pdf

WHOWesternPacificRegionalOffice2012,ThePhilippineHealthsystemreview,viewed28March2017,

http://www.wpro.who.int/asia_pacific_observatory/Philippines_Health_System_Review.pdf

WHO2014,FactsheetonPhilippinesHealthstatistics,viewed31March2017,

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

WHO2016,HealthworkforcerequirementsforUniversalHealthCoverageandtheSustainableDevelopment

Goals,viewed1April2017

http://apps.who.int/iris/bitstream/10665/250330/1/9789241511407-eng.pdf?ua=1

59

FieldTripReport2017,ThePhilippines

PublishedbySchoolofTropicalMedicineandGlobalHealth,NagasakiUniversity

EditedbyHeriAiméBitakuya,KenshiFurushima,KazuchiyoMiyamichi,KyokoYoneda

PhotographseditedbyTomomiIgari,KenshiFurushima,AyaTakase,ThiThiAung

CoverdesignbySachikoNagata

ReferencescheckedbyMiwaNakajima,AyaTakase

EnglishproofreadbyRobinahAjok,IssacAnnobil,MengyaLi(AcademicsupportstaffatTMGH)

SupervisedbyHisakazuHiraoka,MihoSato

©2017bySchoolofTropicalMedicineandGlobalHealth,NagasakiUniversity

Allrightsreserved.

Firstprintingon12/09/2017

PrintedbyIN-TEXCo.Ltd.Nagasaki,Japan

SchoolofTropicalMedicineandGlobalHealthNagasakiUniversity

1-12-4Sakamoto,NagasakiCity

852-8523,Japan

Tel:+81(0)958197583

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

The editors’ note

WeareveryproudofhavingbeenpartoftheeditingFieldTripReport2017ThePhilippines.Infact,

itwasnoteasyatall,eventogetherwiththehighlymotivatedcolleagues,toeditareportofsuchrich

individual and group field experiences.Although the report looks verymuch formal, we wanted to

produceitfromalltheparticipant’scontributions.Wewouldliketoreiterateourgratitudetothosewho

havebeensupportivetothework,theprofessors,TMGHadministrationpersonnelandofcourse,the

classmates.AlsoaspecialthankstoSachi,forherwonderfulcoverpagedesign.

EditorialTeam:HeriAiméBitakuya,KenshiFurushima,KazuchiyoMiyamichi&KyokoYoneda

60

　

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