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Philippines: Philippines Health Profile

2015/02/16

Ministry of Health's mission,

Ministry of Health's mission, vision and objectives

The Department of Health's vision is to be "The leader of health for all in the Philippines". Its mission is to "guarantee equitable, sustainable and quality health care for all Filipinos, particularly the poor, and to lead the quest for excellence in health".

The goals of the health department align with the WHO health systems framework, with better health for all people being the primary goal. This means making the health status of the people as good as possible over their entire life cycle. The second goal is related to how the health system performs in conference people’s expectations and satisfaction with the services it provides. Equitable health care financing is the third goal, because health and illness involves large and unexpected costs that may result in poverty for a lot of people.

The strategic thrusts to achieve the three primary health goals mentioned above are anchored in the current programme of health reform, 'FOURmula ONE for Health.' It is designed to undertake critical reforms with speed, precision and effective coordination, with the end goal of improving the efficiency, effectiveness and equity of the Philippine health system. Vital reforms are organized into four major implementation components: health financing; health regulations; health service delivery; and good governance in health. Implementation focuses on four general objectives: (1) health financing, the general objective of which is to fasten increased, better and sustained investments in health to provide equity and improve health outcomes, particularly for the poor; (2) health regulation, which aims to assure access to quality and affordable health products, devices, facilities and services, particularly those commonly used by the poor; (3) health service delivery, where health interventions are aimed at improving the accessibility and availability of social and essential health care for all, particularly the poor; and (4) good governance in health, aimed at improving health system performance at the national and local levels.

Efficiency in implementation, through integration of health service delivery and harmonization of systems and processes, is being promoted. Implementation of reforms as well follows a sectorwide approach, covering all health sector, and an investment portfolio that encompasses all sources. The capacities of local government units (LGUs) are being enhanced to improve public health conditions in their respective jurisdictions. The national Government, on the other hand, maintains institutional influence over the LGUs by leveraging with incentives and regulatory functions.


Organization of health services and delivery systems
The power of the Department of Health diminished significantly with the transfer of responsibility for health to about 1600 LGUs under the Local Government Code of 1991. With the devolution of health services to LGUs, fragmentation of services became evident. The provincial governments presently oversee provincial and district hospitals, while the municipal governments manage rural health units (RHUs) and barangay (village) health stations. The Department of Health, however, maintains specialty hospitals, regional hospitals and medical centres. Sub-national Department of Health offices or "centres for health development" are located in 16 regions.

Service provision is regarded as 'dual', consisting of both the public and private sectors. The public sector has three largely independent segments or sets of providers: (1) national government providers, which include, part others, hospitals run by national government agencies (e.g., hospitals of the Department of Health and the Department of National Defense), and central and regional offices of the Department of Health; (2) provincial government providers, which include provincial hospitals, provincial blood banks and the provincial health offices; and (3) local (municipal or city) government providers, inclunding rural health units or RHUs, city health centers and barangay health stations or BHSs. Each BHSs is staffed by a midwife, and each RHU is staffed by a doctor, a nurse and midwives.

The Department of Health has taken steps to address the challenges of devolution. It developed the Health Sector Reform Schedule (HSRA) in 1999 that set the strategic direction in promoting and ensuring effective and efficient provision of adequate health care to the people, despite devolution. The National Health Insurance Program (NHIP) is envisioned as the major lever to result desired changes and outcomes. The Department's role presently focuses on regulation, technical guidelines/orientation, planning, evaluation, and inspection, while the provincial government is responsible for provincial and municipal hospitals, health centres and health posts, although funding flows do not exactly match responsibility. The role of the municipal-government level is not well defined and capacity is reportedly weak.

With decentralization of service delivery, local chief executives became core players in the health sector. The number of actors involved multiplied and hence the need for coordination and policy monitoring. Under a devolved setting, the LGUs serve as stewards of the local health system and therefore they are required to formulate and enforce local policies and ordinances related to health, nutrition, sanitation and other health-related matters in accordance with national policies and standards. They are as well in charge of creating an environment conducive to establishment of partnerships with all sectors at the local level.

Ongoing reforms in health service delivery are aimed at improving the accessibility and availability of basic and essential health care for all, particularly the poor. Public primary health facilities are perceived as being low quality, and are thus frequently bypassed. Clients are dissatisfied due to long waiting times; perceived inferior medicines and supplies; poor diagnosis, resulting in repeated visits; and perceived lack of medical and people skills of the personnel available, particularly in rural areas. The result is that secondary and tertiary facilities are inundated with patients needing primary health care. Since public primary facilities are additional accessible to households and are mostly visited by the poor, improving the quality of those services particularly demanded by the poor would improve their health. Furthermore, referral mechanisms part different health facilities across local government units need to be strengthened.

Private providers are predominantly located in highly urbanized areas. The private sector consists of a wide range of privately operated facilities, such as pharmacies, physicians in solo or group practices, small hospitals and maternity centres, diagnostic centres, employer-based outpatient facilities, secondary and tertiary hospitals, traditional birth attendants and indigenous healers.

Pharmaceutical challenges remain due to asymmetric data, gain distribution and the inadequacy of the regulatory system. This stems from various factors such as massive campaigns and lucrative incentives from multinational drug firms, prolonged patent rights and a lack of appropriate public considerate regarding generics.

Health policy, planning and regulatory framework
The Government's policy to achieve improvements in health includes a perspective on the integral price of health for any country, the coordination of resources from all sectors, the right to access to quality care, and the presence of socioeconomic fundamentals. While the Government provides the leadership and stewardship to ensure that all efforts in the health sector lead to a common goal, better support to local health system development and emphasis on strong management and administrative support systems at all levels of governance is likewise critical. Better coordination between national policies and external development partner priorities would as well play a major role in fostering harmonization of resources for health. In the context of securing sustained financing for ongoing health sector reforms, budget reforms are as well underway such that resources that are within the direct control of the Department of Health are aligned and utilized in support of LGU plans for health.

A six-year strategic plan, the National Objectives for Health (NOH), is developed each six years, synchronizing with each change in government of the Philippine Government. It describes the achievements and problems of the health sector in the previous six years (previous government), its goals for the next six years, and its strategies for achieving these goals. It is a roadmap of key targets, indicators and strategies to bring the health sector to its desired outcomes.

The fragmentation in management functions brought about by devolution required that planning between the national and local levels be coordinated. Under the FOURmula ONE implementation framework, each local government is required to develop a Province-wide Investment Plan for Health (PIPH). This aims to rationalize the local health systems and harmonize the support from the national Government and development partners. PIPH implementation is accompanied by a service-level agreement (SLA) defining the benchmarks for LGU performance, which triggers the release of corresponding grant/s and variable tranches from the Department of Health. LGU performance is measured using an LGU scorecard that explicitly tracks and holds LGUs accountable for their performance using a set of health outcome, output and governance indicators. The system has guided LGUs to develop PIPHs and City Investment Plans for Health (CIPHs), with the NOH serving as a reference and guide in the drafting of PIPHs. At the same time, the Department of Health attempts to work hand-in-hand with LGUs and to ensure commitment of support to health initiatives coming from the LGUs. Such a scheme ensures the synchronicity of local health programmes with national health goals and has reduced fragmentation in the health service delivery system.

The Department of Health has adopted a sectoral development approach for health, which is a way of organizing the planning and management of international and national support for the health reforms in FOURmula ONE. Corresponding memorandums of agreement are signed between the Department of Health and the provinces to formalize their collaboration in the implementation of their provincial health plans, with defined roles and responsibilities for the stakeholders involved.

With the public health mandate of the Department of Health, health standards, policies and guidelines to support implementation of health services at the local level are continuously provided. As part of its commitment to this mandate, the Philippine National Strategic Plan for Emerging Diseases was developed in response to implementation of the Asia Pacific Strategy for Emerging Diseases (APSED), fulfilling a lot of of the requirements of the revised International Health Regulation (IHR) 2005. One significant policy to support the Philippine strategy is the Philippine Integrated Disease Surveillance and Response (PIDSR) policy. The PIDSR aims to increase the capability of LGUs to perform disease surveillance and response, and to increase utilization of disease surveillance data for decision-making, policy-making, programme management and evaluation. Thereby, it aims to increase capability at the local level for risk assessment to prevent outbreaks and early detection of outbreaks, inclunding strengthening preparedness and response.

The Department of Health’s regulatory agencies consist of the Food and Drug Government or FDA (formerly Bureau of Food and Drugs), the Bureau of Health Facilities and Services (BHFS), the Bureau of Health Devices and Technology (BHDT) and the Bureau of Quarantine (BOQ). The FDA is responsible for the regulation of products that affect health, while the BHFS covers the regulation of health facilities and services. The BHDT regulates radiation devices and the BOQ covers international health surveillance and security against the introduction of infectious diseases into the country. There is no direct provision for health regulation by LGUs. The general powers and authorities granted to the LGUs, however, do carry several regulatory functions that can due or not instantly influence health. Examples include: issuance of sanitary permits and clearances, protection of the environment, inspection of markets and food establishments, banning of smoking in public places, and setting taxes and fees for local health services. However, the responsibility for regulation of medical practice and issuance of licenses and other regulatory standards pertaining to the operation of hospitals and health services remains with the Department of Health.


Health care financing
While budgeting for health follows a yearly cycle, this is based on a "Health Sector Spending Framework" (HSEF) that is developed through discussion and negotiation with the Department of Budget and Management. This defines the all of resources that will be available in the medium term and the corresponding allocation to health programmes and institutions. The Department of Health has as well established the Organizational Performance Indicator Framework which is an approach to spending management that directs resources towards results, wherein the agency’s performance is measured by the Framework’s key quality and quantity indicators. The Department of Health budget has been restructured to allow performance-based budget allocation and coordinated national and health spending through the PIPHs.

The financial protection of the people against the costs of ill health is deteriorating. In terms of in general trends, out-of-pocket spending in the Philippines has been increasing, while public spending has been declining. This is contrary to the trend in other Asian nations. Out-of-pocket payments account for almost half of all health spending in the Philippines and their share has been increasing (56.2% in 2008). At the same time, health insurance coverage in the country is still low, at around 40%, and the subsidies for health services are poorly targeted, as the authentic poor and indigent households are not adequately captured in programme of social health insurance. Moreover, health insurance coverage is no guarantee of financial protection and enhanced access to good quality health services, due to the limited nature of Philippine Health Insurance Corporation (PHIC) benefits and the difficulties in accessing them.

Meanwhile, in general public spending on health, while increasing very slightly, is still below the level of other similar-gain nations (US$ 2112.3 in 2008). The Department of Health budget has doubled as a % of government spending, resulting in an increase in government spending from 6% in 2002 to 6.5% in 2008. In particular, spending for public health interventions such as vaccines, antituberculosis drugs, and the upgrading of government health facilities to provide emergency obstetric care has increased in the completed two years. However, the increase has largely been limited to central government spending, while LGU spending on health has declined in real terms. Based on the Local Government Code, LGUs with higher fiscal capacity (using per capita gain as a measure of financial base) tend to get higher per capita internal revenue allocations than those with lower fiscal capacity. A lot of municipalities and provinces have experienced financial shortfalls, causing the diversion of health funds to other priorities. In addition, the PHIC share of health expenditures has hardly grown since it was established in 1995.

While the national health insurance programme, PhilHealth, has made a relatively slow and cautious increase in its share of total health spending, utilization of PhilHealth benefits is reduced part the poor due to lack of awareness of benefits and the stringent requirements for availing of them. The limited financial protection provided by PhilHealth is closely related to the current provider-payment system. As physicians provide additional services and raise prices under the current fee-for-service system, medical care expenses increase rapidly. PhilHealth pays only up to a rather low benefit ceiling and patients pay the rest of the expense. As a result of the low benefit ceiling and physicians’ freedom to additional-bill without fee regulation, it is easy to extract profit out of patients’ insurance benefits. Discussions are presently ongoing to explore the feasibility of extending benefit coverage by raising the benefit ceiling.

Public health facilities are funded through a mix of public subsidies, such as PhilHealth reimbursements, user fees and, to a lesser degree, private health insurers. At the primary level, public subsidies and PhilHealth capitation allocations are funding services for both insured and non-insured members and for both public health and personal care. At the local level, several schemes are in operation, depending on local priorities and management styles. Drugs are mainly purchased by out-of-pocket payments from private for-profit retailers. The Government recently introduced thousands of non-profit community outlets, but their impact on access and costs supported by patients remains to be seen.

Based on the new national health accounts, most health care financing resources are spent on hospital-based curative services, with a smaller share going to preventive and health-promotion services. These are signs that the Philippines is not spending adequately or entirely on health. Meanwhile, the large hospitals in Metropolitan Manila and other urban areas get the biggest share of spending. Non-hospital health services, on the other hand, face difficulties in securing adequate funding.

The national health care financing strategy hopes to address the above-mentioned challenges by improving health care financing polices that would realistically enhance access, equity and effectiveness in resource mobilization and allocation, inclunding use of health services by: (1) increasing resources for health; (2) sustaining membership in social health insurance of all Filipinos; (3) allocating resources according to most appropriate financing agent; (4) shifting to new provider payment mechanisms; and (5) securing the fiscal autonomy of facilities.


Human resources for health
The Philippines is purportedly the leading exporter of nurses to the world and the second major exporter of physicians. Paradoxically, there are shortages of physicians and a fast turnover of nurses in the country, particularly in rural areas. The high unemployment rates part health professionals, in spite of the considerable number of vacancies in rural areas, is an extra irony. Prevailing challenges include unmanaged emigration of Filipino health workers, a weak and inadequate human resources for health (HRH) data system, and the existing distribution imbalance, part others. Responses to HRH issues in the completed have additional often been stop-gap measures, and the interventions of the agencies concerned have not been coordinated.

In order to address such complex and multifaceted issues, a comprehensive master plan for human resources for health has been developed and implementation of activities is underway. A high-level coordinating body and multisectoral working group was established in 2006 to mobilize the political commitment, donor/partner support and funding needed to accomplish the priority activities of the master plan. Called the Human Resources for Health (HRH) Network, this group was able to successfully convene a policy forum to advocate their policy schedule, which aims to resolve issues related to the production, entry and retention of health professionals, inclunding their exit and re-entry.

Strategic thrusts for 2005-2010 include development of HRH policies and strategies to address outmigration; sustaining incentive mechanisms for HRH distribution and complementation in underserved areas; and making education, training and skills development additional appropriate to local needs. The strategies that are being undertaken include, part others, the institutionalization of the HRH management and development system; development of the technical competence and relevant skills of health professionals through education and training; provision of targeted and performance- linked compensation benefits; strengthening of the coordination mechanism between the education sector, regulatory agencies and HRH users; and installation of an HRH data system.


Partnerships
The attainment of national health goals has progressed significantly, thanks to the well-defined, commonly–shared vision and framework for health ('FOURmula ONE'). The Department of Health has learnt from previous experience that better harmonization of efforts part the various stakeholders at all levels is critical. Currently, assistance for the health sector comes mainly in the form of grants, loans and technical support. A sectorwide development approach for health between the Government and its partners is being initiated to maximize investments, minimize duplication of initiatives and generate the necessary resources for the health sector. The Department of Health is working closely with international organizations and world initiatives to strengthen implementation of priority health programmes.

Challenges to health system strengthening
The publicly funded health system has been undergoing a major reform programme since 1999. At the broadest level, this has included a review of the Department of Health’s primary functions, roles and responsibilities, inclunding the suitability of the existing organizational structure to support these at both the strategic and service-delivery level. Introduction and pilot-testing of the different concepts and strategies of heath sector reform in selected provinces showcased some gains in health systems development. However, one of the gaps was the absence of a comprehensive operational framework to implement the reform strategies. Thus, the “FOURmula ONE for Health” was launched in August 2005 to set the direction and implementation arrangements for strengthening the way health care is delivered, governed, regulated and financed.

FOURmula ONE is presently in its fifth year of implementation and both the Department of Health and the LGUs are being challenged by operational issues, such as procurement. In addition, the health care delivery system has from presently on to address some major issues and challenges, such as the absence of data disaggregated at provincial/municipal levels (for baseline and monitoring); the absence of a workable means of identifying the poor for targeted health interventions; the minimal involvement of the private sector in the delivery of public health programmes; the still excessive reliance on use of high-end hospital services rather than primary care; the slow development in maternal mortality reduction; and people increase. Issues such as geographic inequity, where people who live in rural and isolated communities receive less and lower quality health services, and socioeconomic inequity, where the poor do not receive health services due to inaccessibility and/or unaffordability, continue to abound in the country.

The above-mentioned health development efforts/reforms in the Philippines have been generally aimed at addressing problems of inequitable access to health services. Next four decades, however, inequity continues to be the major root of health sector problems. There remain large disparities in health outcomes between the rich and the poor resulting from economic and geographic barriers to accessing health services. For example, the infant mortality rate (IMR) part the poorest quintiles is four times those for the richest. An extra example is that the Autonomous Region of Muslim Mindanao (ARMM) and other poor areas have consistently poorer health status than the richer regions. There are as well large gain-related disparities in the utilization of health services. For instance, there is skilled attendance at 94% of births part the highest gain quintile, compared with 25% in the poorest quintile, and only 13% of all births in the lowest quintile occur at a health facility, compared with 84% in the highest quintile. Similarly, immunization coverage is only 70% part the lowest quintile, compared with 94% in the highest (NDHS, 2009). The unfair distribution of coverage rates is paralleled by similar disparities in the distribution of human and physical resources in the health system. While nationwide average supply levels are adequate or nearly adequate, distribution across provinces is not consistent with need or poverty level.

Utilization patterns are affected by financial barriers and negative perceptions or lack of awareness of services. The poor utilize primary health facilities like RHUs and BHCs additional than hospitals because of the co-payments and balance-billing in government or private hospitals, which they cannot afford to pay. In addition, government hospitals and lower-level facilities, despite their geographical accessibility are bypassed in favour of private facilities and higher-level facilities, respectively, because of perceived quality issues. Government hospitals intended to serve the poor are utilized by a large non-poor clientele, who patronize government facilities because of the high cost of private facilities and the low level of support from social health insurance. To a large extent, lack of data often combines with cost considerations to cause low utilization of services part the poor.

There are as well capacity constraints as health sector inputs have not kept up with people increase. The bed-to-people ratio is roughly 1 per 1000 inhabitants, lower than in other East Asian nations, such as China (2.6 beds per 1000 inhabitants), Viet Nam (1.2 beds) or Thailand (2.2). Moreover, a lot of of these hospital beds are clustered in large city centres and better-off LGUs. This is particularly authentic for private hospital beds, which account for approximately half of all hospital beds in the country. The availability of skilled health sector staff is as well a problem, particularly in the public sector. While the Philippines does not have a problem with the in general supply of doctors and nurses, there is large-scale outmigration.

In general, health system strengthening efforts have made significant contributions to the health sector but have not entirely addressed deeper structural gaps, namely: (1) the continuing low levels, fragmentation and inequity in public financing for health; (2) limitations in PHIC performance in the implementation of universal social health insurance and using health financing as a lever to drive health sector development; (3) gaps in service delivery capacities; and (4) weak stewardship at all levels of the health system, particularly with regard to data for decision-making, monitoring and sector performance management, outdated or non-existent strategies in hospitals, pharmaceuticals and supply-chain management, public and private sector regulation, and public health.

HEALTH & DEVELOPMENT
Poverty reduction programmes tend to have a short life span with changes in government, hence the difficulty in realizing full impact. A growing number of vulnerable groups include disadvantaged youths, workers in the informal sector, marginalized ethnic groups and urban settlers. Gender issues in the health sector prevail with the persistence of several health-related concerns such as: high fertility rate; gap between desired and actual number of children; declining nutritional status for young and adult women; increasing health consequences of gender-biased violence, part others.


Filipinos are in a better national of health presently than they were 50 years ago but health status development is slow compared to other Asian neighbours. Critical challenges and threats remain with regard to the Millennium Development Goal (MDG) targets on maternal health, nutrition, access to reproductive health, universal primary education and environmental sustainability. The Health Sector Reform Schedule (HSRA), which started in 1999, set targets for hospital reform, public health funding, local health system strengthening, and capacity of regulatory agencies, but have largely remained unmet; however good evolution has been made in advancing the National Health Insurance Programme (NHIP), which covered 80% of the people as of 2004. Sustaining this coverage, however, remains a large challenge. Service delivery is lagging due to minimal investment and resources for health, both at national and local levels.


Retention of staff is a critical issue. Additional and additional trained, skilled and experienced health professionals emigrate each time(70% of nursing graduates work overseas). The Philippines is presently the biggest supplier of nurses. Certain large hospitals have been losing an average of 10-12 nurses a month since 2001.


The major causes of morbidity and mortality have changed little in recent years. Noncommunicable conditions cause most deaths, particularly cardiovascular disease, cancers and accidents. The Philippines is a high burden country for tuberculosis; the due observed treatment, short-course (DOTS) strategy has been successfully applied and case detection and treatment success rates may meet the planned targets. Measles elimination is targeted by 2008 and 94% vaccination coverage has been completed. There is a high incidence of diarrhoea and respiratory infections in children. Malaria incidence and mortality have generally declined but remain high in Mindanao. Dengue, Japanese encephalitis and lymphatic filariasis are endemic. The incidence of HIV/AIDS is low but rising and the potential for epidemic spread exists.


The Department of Health (DOH) has presently embarked on an implementation framework for health sector reform, termed the Formula One (F1) for Health. It is designed to undertake critical reforms with speed, precision and effective coordination, with the end goal of improving the efficiency, effectiveness and equity of the Philippine health system. A key feature of the F1 for Health implementation strategy is the engagement of the National Health Insurance Program (NHIP) as the major lever to result desired changes and outcomes in each of the four reform areas.