Philippines Health System Observatory

Division of Health System and Services Development, Health Policy and Planning Unit Contents 1 EXECUTIVE SUMMARY........................................................................................ 9 2 SOCIO ECONOMIC GEOPOLITICAL MAPPING ............................................................ 14 2.1 Socio-cultural Factors ...................................................................... 14 2.2 Economy .........................................................................................15 2.3 Geography and Climate ................................................................... 15 2.4 Political/ Administrative Structure...................................................... 16 3 HEALTH STATUS AND DEMOGRAPHICS .................................................................... 17 3.1 Health Status Indicators .................................................................. 17 3.2 Demography ...................................................................................18 4 HEALTH SYSTEM ORGANIZATION ........................................................................ .19 4.1 Brief History of the Health Care System............................................ 19 4.2 Public Health Care System............................................................... 19 4.3 Private Health Care System.............................................................. 20 4.4 Overall Health Care System ............................................................. 23 5 GOVERNANCE/OVERSIGHT.................................................................................. 24 5.1 Process of Policy, Planning and management ................................... 24 5.2 Decentralization: Key characteristics of principal types....................... 25 5.3 Health Information Systems............................................................. 15
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5.4 Health Systems Research................................................................. 26 5.5 Accountability Mechanisms .............................................................. 27 6 HEALTH CARE FINANCE AND EXPENDITURE............................................................. 28 6.1 Health Expenditure Data and Trends ............................................... 28 6.2 Tax-based Financing ...................................................................... 29 6.3 Insurance ......................................................................................29 6.4 Out-of-Pocket Payments ................................................................. 30 6.5 External Sources of Finance ............................................................ 31 6.6 Provider Payment Mechanisms......................................................... 32 7 HUMAN RESOURCES ......................................................................................... 34 7.1 Human resources availability and creation ........................................ 34 7.2 Human resources policy and reforms over last 10 years...................... 35 7.3 Planned reforms.............................................................................. 37 8 HEALTH SERVICE DELIVERY................................................................................. 38 8.1 Service Delivery Data for Health services .......................................... 40 8.2 Package of Services for Health Care ................................................. 42 8.3 Primary Health Care ........................................................................ 43 8.4 Non personal Services: Preventive/Promotive Care ............................ 45 8.5 Secondary/Tertiary Care .................................................................. 45 8.6 Long-Term Care............................................................................... 46 8.7 Pharmaceuticals .............................................................................. 48 8.8 Technology...................................................................................... 49 9 HEALTH SYSTEM REFORMS.................................................................................. 50 9.1 Summary of Recent and planned reforms .......................................... 51 10 REFERENCES .................................................................................................. 55 11 ANNEXES....................................................................................................... 56

List of Tables Table 2-1 Socio-cultural indicators ..............................................................................5 Table 2-2 Economic Indicators....................................................................................5 Table 2-3 Major Imports and Exports ..........................................................................6 Table 3-1 Indicators of Health status ..........................................................................7 Table 3-2 Indicators of Health status by Gender and by urban rural...............................7 Table 3-3 Top 10 causes of Mortality/Morbidity............................................................8 Table 3-4 Demographic indicators...............................................................................8 Table 3-5 Demographic indicators by Gender and Urban rural - Year ............................9 Table 6-1 Health Expenditure ................................................................................... 17 Table 6-2 Sources of finance, by percent................................................................... 17 Table 6-3 Health Expenditures by Category ............................................................... 18 Table 6-4 Population coverage by source .................................................................. 19 Table 7-1 Health care personnel ................................................................................22 Table 7-2 Health care personnel by rural/urban and public/private ...............................22 Table 7-3 Human Resource Training Institutions for Health ........................................ 23 Table 8-1 Service Delivery Data and Trends ...............................................................24
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Table 8-2 Health infrastructure ..................................................................................24 Table 8-3 Inpatient use and performance................................................................... 30 List of Abbreviations ADB ADR AIPH AIPS AO AOP APIS ARI ARMM ASEAN BAC BFAD BHC BHDT BHFS BHW BIR BnB BNB BOQ CALABARZON CAR CHC CHD CHED CHITS System CO CON CPR DALE DBM DHS DILG DO DOF DOH DOLE
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Asian Development Bank Adverse Drug Reactions ARMM Investment Plan for Health Annual Poverty Indicators Survey Administrative Order Annual Operational Plan Annual Poverty Indicators Survey Acute respiratory infection Autonomous Region for Muslim Mindanao Association of South East Asian Nations Bids and Awards Committee Bureau of Food and Drugs, Philippines Barangay Health Centre Bureau of Health Devices and Technology, DOH Bureau of Health Facilities and Services, DOH Barangay Health Worker Bureau of Internal Revenue, Philippines Botika ng Barangay: DOH-led community based pharmacies Botika ng Bayan: privately-owned flagship outlets of the HalfPriced Medicines Programme led by PITC Pharma Bureau of Quarantine, DOH Cavite, Laguna, Batangas, Rizal and Quezon Cordillera Autonomous Region City Health Centre Centre for Health Development Commission on Higher Education, Philippines Community Health Information Tracking Capital Outlay Certificate of Need Contraceptive prevalence rate Disability-Adjusted Life Years Department of Budget and Management, Philippines District Health System Department of Interior and Local Government Philippines Department Order Department of Finance, Philippines Department of Health, Philippines Department of Labor and Employment

DOST DTI EENT EmONC ENT EO EPI EU F1 for Health FAP FDA FHSIS FIC FIES FPS GAA GATT GDP GNP GSIS HALE HIV/AIDS HMO HOMIS HRH HSEF HSRA HTA ILHZ IMS IPP IRA LGC LGU LTO MCP MDG MFO MHC MIMAROPA MOOE MRDP NCDPC NCHFD NCR
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Department of Science and Technology, Philippines Department of Trade and Industry Eye, Ear, Nose, Throat Emergency Obstetric Care Ear, Nose, Throat Executive Order Expanded Programme on Immunization European Union FOURmulaOne for Health Foreign-assisted projects Food and Drug Administration, Philippines Field Health Service Information System Fully-immunized child Family Income and Expenditure Survey Family Planning Survey General Appropriations Act General Agreement on Tariffs and Trade Gross Domestic Product Gross National Product Government Service and Insurance System Health-Adjusted Life Years Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Health Maintenance Organizations Hospital Operations and Management Information System Human Resources for Health Health Sector Expenditure Framework Health Sector Reform Agenda Health technology assessment Inter-Local Health Zones Information Management Services Individually-Paying Programme Internal Revenue Allotment Local Government Code Local Government Unit License to Operate Maternity Care Package Millennium Development Goals Major Final Output Municipal Health Centre Mindoro, Marinduque, Romblon, Palawan Maintenance and Other Operating Expenses Maximum Retail Drug Price National Centre for Disease Prevention and Control, DOH National Centre for Health Facility Development, DOH National Capital Region

NCWDP NDCC NDHS NEC NEDA NEP NFA NGO NHIP NOH NSCB NSD NSO OFW OOP OPB OPD OT OTC OWP PCHD PCSO PGH PHC PHIC or Philhealth PHIN PHIS PIDSR PIPH PITC PMA PNDF PNDP PO PPP PRC PSY PT PTC PWD R&D RA RH RHU SARS
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National Council for the Welfare of Disabled Persons National Disaster Coordinating Council, Philippines National Demographic and Health Survey National Epidemiology Centre, DOH National Economic Development Authority National Expenditure Programme National Food Authority Non-government organization National Health Insurance Programme National Objectives for Health National Statistical Coordination Board Normal spontaneous delivery National Statistics Office Overseas Filipino workers Out-of-pocket Outpatient Benefit Package Outpatient department Occupational Therapist Over-the-counter Overseas Workers Programme Partnership in Community Health Development Philippine Charity Sweepstakes Office Philippine General Hospital Primary Health Care Philippine Health Insurance Corporation Philippine Health Information Network Philippine Health Information System Philippine Integrated Disease Surveillance and Response Province-wide Investment Plan for Health Philippine International Trade Corporation Philippine Medical Association Philippine National Drug Formulary Philippine National Drug Policy Peoples organization Purchasing Power Parity Professional Regulations Commission, Philippines Philippine Statistical Yearbook Physical Therapist Permit to Construct People with disabilities Research and Development Republic Act Reproductive Health Rural Health Unit Severe Acute Respiratory Syndrome

SDAH Health SOCCSKSARGEN Sp SP SPED SRA SSS TB-DOTS TCAM TDF TESDA THE UN UP USAID WASH WHO VAT WHO

Sector-wide Development Approach for South Cotabato, Cotabato, Sultan Kudarat, Sarangani, General Santos City Speech Pathologist Sponsored Programme Special education Social Reform Agenda Social Security System Tuberculosis Directly-Observed Treatment Shortcourse Traditional and Complementary/Alternative Medicine Tropical Disease Foundation Inc. Technical Education and Skills Development Authority Total health expenditure United Nations University of the Philippines United States Agency for International Development Water, sanitation and hygiene World Health Organization Value Added Tax World Health Organization

Acknowledgments Health systems are undergoing rapid change and the requirements for conforming to the new challenges of changing demographics, disease patterns, emerging and re emerging diseases coupled with rising costs of health care delivery have forced a comprehensive review of health systems and their functioning. As the countries examine their health systems in greater depth to adjust to new demands, the number and complexities of problems identified increases. Some health systems fail to provide the essential services and some are creaking under the strain of inefficient provision of services. A number of issues including governance in health, financing of health care, human resource imbalances, access and quality of health services, along with the impacts of reforms in other areas of the economies significantly affect the ability of health systems to deliver. Decision-makers at all levels need to appraise the variation in health system performance, identify factors that influence it and articulate policies that will achieve better results in a variety of settings. Meaningful, comparable information on health system performance, and on key factors that explain performance variation, can strengthen the scientific foundations of health policy at international and national levels. Comparison of performance across countries and over time can provide important insights into policies that improve performance and those that do not.

1 EXECUTIVE SUMMARY Geography, Administrative Divisions and Government The Philippines is an archipelago of about 7,100 islands located in the western part of the Pacific Ocean off the coast of Southeast Asia. The country has a total land area of 300,000 square kilometers and is one of the largest islands groups in the world. The three island groupings are Luzon in the north, Visayas in the central area, and Mindanao in the south. Metropolitan Manila, also known as the National Capital Region (NCR), is located in the central part of Luzon. It is the biggest urban center in the country. It is made up of 14 highly urbanized cities and three municipalities. The country is divided into 17 administrative regions: Regions 1 to 5, NCR, Cordillera Administrative Region (CAR). CALABARZON (Cavite, Laguna, Batangas, Rizal, Quezon), and MIMAROPA (Mindoro, Marinduque, Romblon, Palawan) which are in Luzon; Regions 6 to 8 which are in the Visayas; and, Regions 9 to 12, Autonomous Region of Muslim Mindanao (ARMM), and Caraga which are in Mindanao. Regions are composed of 79 provinces headed by governors while provinces are divided into 117 cities and 1500 municipalities, collectively called local government units. The local government units, headed by mayors, make up the political subdivisions of the Philippines. They are divided into villages or barangays totaling 41,975. These are headed by barangay chairpersons (NSCB, 2004). It must be noted that regions are administrative units only and the political units aside from the national level are the provinces, cities and municipalities, and barangays. The Philippines is a republican state with three branches of government- executive. legislative and judicial. The executive power is vested in the President, who is the head of state and the commander-in-chief of the Armed Forces. The President appoints the Cabinet members of who assist the President in executing laws, policies and programs of the government. The lawmaking power is vested in a bicameral Congress composed of the Senate and the House of Representatives. The Senate has 24 senators directly elected nationwide by the people. The House of Representatives has 250 members elected by congressional districts and by party list system. Judicial power is vested in the Supreme Court and a system of several lower courts. The Supreme Court is composed of the Chief Justice and 14 associate justices (NOH, 2005-2010). The Climate The countrys climate is generally hot and humid and favors the existence of disease vectors and parasites. On the average, the temperature is 32 with March to June as the hottest months when temperatures may reach 38C. On the other hand, November to February provide cooler weather with temperatures around 23C. The Philippines is prone to natural disasters brought about by volcanic eruptions, earthquakes, floods and typhoons. Rains and typhoons prevail from July to October (NOH, 2005-2010). Demographic Characteristics The population of the Philippines in the 2000 census was 76,504,077, a 58 percent increase from the 1980 census. The population grew at the rate of 2.4 percent annually between 1995 and 2000 while it grew at 2.1 percent between 2000 and 2005. The population is projected to increase to
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91,868,309 in 2010. The NCR has an estimated 13.3 percent of the total population of the Philippines. It has the greatest population concentration with 16,091 people per square kilometer, a ratio that is 63 times the national average. The least population areas are the CAR and Region 2 with a population density of 70 and 90 people per square kilometer, respectively. Five out of the 17 administrative regions have growth rates higher than the national average: Region 3, MIMAROPA and CALABARZON, Region 7, Region 11 and ARMM. NCR has the lowest population growth rate of 1.06 percent and ARMM has the highest at 3.86 percent. In comparison with other countries, the Philippine ranked twelfth among the countries of the world in terms of total population. The Philippines is ranked fifth among Southeast Asian countries in annual population growth rate (PSY, 2004 and NOH, 2005-2010). Approximately 52 percent of the Philippine population live in rural areas. However, urbanized areas now attract migrants from rural communities due to more economic, educational, recreational opportunities. Rural-to-urban migration causes much pressure on government to provide basic social services like health care, shelter, water, sanitation and education. The congestion and pollution in urban areas are harmful to health. In frontier areas where more migration is also noted, the peoples health is affected by difficult access to health services and the presence of locally endemic diseases like malaria, filariasis and schistosomiasis (PSY, 2004 and NOH, 2005-2010). The median age of the Philippine population is 21 years old. This makes the Philippines a country of young people with, half of its population below 21 years old. Males outnumber females with a sex ratio of 101.43 males for every 100 females. There are more males than females in the age groups 0-19 and 25-54 years.The age structure of the Philippine 10 population is typical broad base at the bottom consisting of large numbers of children and a narrow top made up fairly small numbers of older persons. The dependency ratio is 69, which means that every 100 persons in the working age group (15-64 years old) have to support about 63 young dependents and about six old dependents. Young dependents (65 years old and over) account for 3.8 percent, while 59.2 percent comprise the economically active population (15-64 years old). Women of reproductive age comprise around 51 percent of the total number of females in country (PSY, 2004 and NOH, 2005-2010). Economic Characteristics The Philippines is a developing country. Per capita Gross National Product (GNP) was P56, 109 and per capita Gross Domestic Product (GDP) was P52, 241 in 2003. The 20022003 GNP growth rate was 5.6 percent and GDP was 4.7 percent. In 2000, the annual per capital poverty threshold was estimated at P11, 605, an 18 percent increase over the 1997 threshold of P9,843. With this threshold, a family of five members should have a monthly income of P4, 835 to meet its food and non-food basic needs. Average annual family income reached P148, 757 in 2003, increasing by 2.5 percent over the P145,121 average in 2000. As earnings rose across all income levels, from the 27.5 percent revised estimate from 2000 down to 24.7 percent in 2003 (NSCB, 2005). Unemployment and underemployment rates have increased in the past three years.
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Unemployment rates stood at 10.2 percent in October 2002, it has gone up to 10.9 percent as of October 2004. Underemployment has also gone up from 15.3 percent in October 2002 to 16.9 percent in October 2004. Average inflation rate has also gone up from 3.5 percent in 2003 to six percent in 2004 (PSY, 2004) Organization of the Health Care System The Philippines recognizes health as a basic human right. It protects and promotes the right to health of the people and instills health consciousness among them. Although this provision is guaranteed by the 1987 Constitution (Article II, Section 15) and the health care system in the Philippines is generally extensive, access to health services, especially by the poor, is still hampered by high cost, physical and social-cultural barriers (NOH, 2005-2010). To address these concerns, reforms in the countrys health care system have been instituted in the past 30 years: the adoption of Primary Health Care in 1979; the integration of public health and hospital services in 1983 (EO 851); the enactment of the Generics Act of 1988 (RA 6675); the devolution of health services to LGUs as mandated by the Local Government Code of 1991 (RA 7160); and the enactment of the National Health Insurance Act of 1995 (RA 7875). In 1999, the DOH launched the Health Sector Reform Agenda (HSRA) as a major policy framework and strategy to improve the way health care is delivered, regulated and financed(NOH, 2005-2010). The Philippines has a dual health system consisting of : the public sector, which is largely financed through a tax-based budgeting system national and local level and where health care is generally given free at the point of services (although socialized user charges have been introduced in recent years for certain types of services), and the private sector (consisting of forprofit and non-profit providers), which largely market-oriented and where health care is paid through user fees at the point of service. The expansion of social health insurance in recent years and its emergence as a potential major source of health financing will have a positive and private sectors and in terms of the peoples health-seeking behavior (NOH, 2005-2010). Under this health system, the public sector consists of the DOH, LGUs and other national government agencies providing health services. The DOH is the lead agency in health. Its major mandate is to provide national policy direction and develop national plans, technical standards and guidelines on health. It has a regional field office in every region and maintains specialty hospitals, regional hospitals and medical centers. It also maintains provincial health teams made up of DOH representatives to the local health boards and personnel involved in communicable disease control (NOH, 2005-2010). With the devolution of health services under the 1991 Local Government Code, provision of direct health services, particularly at the primary and secondary levels of health care, is the mandate of LGUs. Under this set-up, provincial and district hospitals are under the provincial government while the municipal government manages the rural health units (RHUs) and barangay health stations (BHSs). In every province, city or municipality, there is a local advisory body to the local executive and the sanggunian or local legislative council on healthrelated matters (NOH, 2005-2010).

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The passage of the 1995 National Health Insurance Act expanded the coverage of the national health insurance program to include not only the formal sector but also the informal and indigent sectors of the population. The program founded under the principle of social solidarity where the healthy subsidizes the sick and those who can afford to pay subsidize those who cannot. PhilHealth, a government-owned and controlled corporation attached to the DOH, is the agency mandated to administer the national health insurance program and ensure that Filipinos will have financial access to health services (NOH, 2005- 2010). The private sector includes for-profit and non-profit health providers whose involvement in maintaining the peoples health is enormous. Their involvement include providing health services in clinics and hospitals, health insurance, manufacture and distribution of medicines, vaccines, medical supplies, equipment, other health and nutrition products, research and development, human resource development other and other health-related services (NOH, 20052010). Health Care Facilities Various health facilities serve the health needs of the Filipinos. The total number of hospital, both government and private, increase from 1,607 in 1980 to 1,738 in 2002. Though the number of hospitals increased nationwide, the number of beds per 10,000 population decreased from 18.2 in 1980 to 10.7 in 2002 (PSY 2004). The number of government hospitals nationwide increased from 623 in 2000 to 661 in 2002, while private hospitals slightly decreased from 1,089 in 2000 to 1,077 in 2002. Although only 661 or 38 percent of hospitals are government hospitals, these contribute 45,395 beds or 53.3 percent of bed capacity nationwide (PSY, 2004 and NOH, 2005-2010). ARMM has the least number of hospitals, consisting of three private hospitals and 11 government hospitals in 2002. CALABARZON and MIMAROPA have the most number of hospitals with 176 private hospitals and 95 government hospitals (PSY, 2004 and NOH, 20052010). 12 In terms of government hospital beds, NCR has the most number of 9,965 beds followed by CALABARZON and MIMAROPA at 6,295 beds and Region 3 at 3,385 beds. The regions with the least number of government hospital beds are ARMM at 870 beds, Region 10 at 1,150 beds and Region 12 at 1,195 beds. The government hospital bed to population ratio is worst in Region 11 in Mindanao with one bed for every 3,575 people while it is best in NCR with one bed for every 807 people (PSY, 2004 and NOH, 2005-2010). There is increasing trend in the number of BHSs from 9,184 in 1988 to 15,343 in 2002 while there is a decreasing trend in the number of RHUs in the country from 1,962 in 1986 to 1,879 in 2001. NCR has the most number of RHUs while the Central Mindanao has the least number of RHUs. On the other hand, CALABARZON and MIMAROPA have the most number of BHSs while NCR has the least (PSY 2004). On the average, each RHU serves around 41,000 people while each BHS serves around 5,100 people (PSY, 2004 and NOH, 2005-2010). Health Human Resources

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Human resources for health are central to managing and delivering health services. They are crucial in improving health systems and health services and in meeting the desired health outcome targets. Human resources for health are enormous but unevenly distributed in the country. Most health practitioners are in Metro Manila and other urban centers. Compared to most Asian countries, the Philippines is producing more and better human resources for health (NOH, 2005-2010). The number of physicians per 100,000 populations slightly increased from 123.8 in 1998 to 124.5 in 2000, which translates into one physician for every 803 people in 2000. The number of dentist per 100,000 population almost remained unchanged at 54.2 in 1998 and 54.4 In 2000 or one dentist per 1,840 people in 2000. The number of pharmacists per 100,000 populations improved slightly from 55.8 in 1998 to 58.1 in 2000. This means one pharmacist for every 1,722 people in 2000. The number of nurses per 100,000 populations almost remained constant from 442.7 in 1998 to 442.8 in 2000, a ratio of one nurse per 226 people for both 1998 and 2000 (SEAMIC, 2003 and NOH, 2005-2010). In 2002, there are 3,021 doctors, 1,871 dentist, 4720 nurses and 16,534 midwives employed by LGUs. Other health personnel employed by LGUs consist of 3,271 engineers/sanitary inspectors, 303 nutritionist, 1,505 medical technologist, 977 dental aides and 2,808 nontechnical staff. Assisting these health personnel at the grassroots are 195,928 volunteer barangay health workers and 54,557 birth attendants (FHSIS, 2002 and NOH, 2005-2010). The Philippines has traditionally been a major source of health professionals to many countries because of their fluent English, skills and training, compassions, humaneness and patience in caring. The country is purportedly the leading exporter of nurses to the world (Aiken, 2004) and the second major exporter of physicians (Bach, 2003). Although the country is producing a surplus of health workers for overseas market since the 1960s, the large exodus of nurses in the last four years has been unparalleled in the migration history of the country. While Filipino physicians have been migrating to the United States since the 1960s and to the Middle East countries in the 1970s in steady outflows, the recent outflows are disturbing because they are no longer migrating as medical doctors but as nurses (NOH, 2005-2010). 13 STRATEGIES (1) Eradicate extreme poverty and hunger (2) Reduce child mortality (3) Improve maternal health (4) Combat HIV and AIDS, Malaria and other diseases (5) Ensure environmental sustainability (6) Develop a global partnership for development EXPECTED OUTCOMES (1) Halve, between 1990 and 2015, the proportion of people who suffer from hunger (2) Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate (3) Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio (4) Have halted by 2015 and begun to reverse the spread of HIV/AIDS (5) Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
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(6) Halve, by 2015, the proportion of people without sustainable access to safe drinking water (7) In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries Based on the baseline survey of nursing-medics in the Philippines, more than 3,500 Filipino doctors have left as nurses since the year 2000 (Galves-Tan, Sanchez, Balanon, 2004). A little more than 1,500 doctors have passed the national nurse licensure examination in 2003 and 2004 (PRC, 2002). An estimated 4,000 doctors are enrolled in nursing schools all over the country (Galves-Tan, Sanchez, Balanon, 2004). The Philippine socioeconomic and political situations have not helped munch in retaining licensed and skilled nurses and other health professionals in the country. (NOH, 2005-2010).

2 SOCIO ECONOMIC GEOPOLITICAL MAPPING 2.1 Socio-cultural Factors Table 2-1 Socio-cultural indicators Indicators Human Development Index: Literacy Total: Female Literacy: Women % of Workforce Primary School enrollment (gross) % Female Primary school pupils %Urban Population

1990 0.673 80.3 26.7 120.33 83.17

1995 0.732 28.2 109.35 84.99

2000 0.752 86.5 29.6 102.46 48.44 86.64

2002 0.758 30.1 87.19

Source: Human Development Report 2004: http://hdr.undp.org/statistics/data/cty/cty_fLBN.html 2.2 Economy Table 2-2 Economic Indicators Indicators 2004 GNI per Capita (Atlas method) current US$ GNI per capita (PPP) Current International GDP per Capita (constant 95$) GDP annual growth % Unemployment % Public Debt as % GDP* External Debt as % of GDP External balance on goods and services (% of GDP)
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1995

2000

2002

2003

2,650 3,940 2,776 4.51 26.68 -53.60

4,000 4,450 2,876 -1.81 18 (97) 153.7 59.78 -24.79

3,900 4,690 2,922 0.95 181.5 93.51 -25.55

184.6 -

184.1 -

Sources: Banque Audi, Quarterly Economic Bulletin, First Quarter 2005. CIA factbook: http://www.cia.gov/cia/publications/factbook/geos/le.htm UNDP, Human Development Reports http://www.hdr.undp.org

Table 2-3 Major Imports and Exports Major Machinery and electrical equipment, base metals and Exports: precious stones, chemical products, prepared foodstuffs, Textiles and vegetable products. Major Metal and metal products, machinery and electrical Imports: equipment, transportation equipments, chemical products, pearls and precious and semi-precious stones, works of art and antiques Source: Banque du Liban, Quarterly Bulletin, second Quarter 2004. Key economic trends, policies and reforms The 1975-91 civil war seriously damaged Lebanon's economic infrastructure, cut national Output by half, and all but ended Lebanon's position as a Middle Eastern port of entry and banking hub. Peace enabled the central government to restore control in Beirut, Begin collecting taxes, and regain access to key port and government facilities. A Financially sound banking system and resilient small- and medium-scale manufacturers Helped economic recovery. Family remittances, banking services, manufactured and farm Exports and international aid provided the main sources of foreign exchange. Lebanon's Economy made impressive gains since the launch in 1993 of "Horizon 2000," the Governments $20 billion reconstruction program. Real GDP grew 8% in 1994, 7% in 1995, 4% in 1996 and in 1997, but slowed to 1.2% in 1998, -1.6% in 1999, -0.6% in 2000, 0.8% in 2001, 1.5% in 2002, and 3% in 2003. During the 1990s, annual inflation Fell to almost 0% from more than 100%. Lebanon has rebuilt much of its war-torn Physical and financial infrastructure. The government nonetheless faces serious Challenges in the economic arena. It has funded reconstruction by borrowing heavily - Mostly from domestic banks. The very large majority of external assistance originated from bilateral donors (55%) and non-UN system multilateral donors (32%). In order to reduce the ballooning national debt, the re-installed Hariri government began an Economic austerity program to rein in government expenditures, increase revenue Collection, and privatize state enterprises. The Hariri government met with international Donors at the Paris II conference in November 2002 to seek bilateral assistance restructuring its domestic debt at lower rates of interest. While privatization of state owned enterprises had not occurred by the end of 2003, massive receipts from donor nations stabilized government finances in 2002-04. After the assassination of PM Hariri, and despite the reassuring factor of the Lebanese will to emerge from the crisis, the concern remains over the possibilities of further incoming donations and investments.

2.3 Geography and Climate

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Lebanon is a small country of only 10,452 sq km; from north to south it extends 217 km And from east to west it spans 80 km at its widest point. The country is bounded by Syria on both the north and east and by Israel (the Palestinian Occupied territories) on the south. Lebanon's landforms fall into four parallel belts that run from northeast to Southwest: a narrow coastal plain along the Mediterranean shore. Most of Lebanon has a Mediterranean climate, with warm, dry summers, and cool, wet winters, although the Climate varies somewhat across the landform belts. The coastal plain is subtropical, with 900 mm (35 in) of annual rainfall and a mean temperature in Beirut of 27 C (80 F) in summer and 14 C (57 F) in winter.

2.4 Political/ Administrative Structure Lebanons constitution, written in 1926, declares the country a secular Arab state, Parliamentary democracy and free economy. It recognizes the rights of each religious Community, but calls for the ultimate abolition of political confessionals. The president Is elected by the National Assembly (parliament) and, in theory, serves for one six-year Term, although the term of Mr. Hrawi and now Mr. LaHood were extended to nine years because of regional political conditions. The president appoints the Prime Minister, after conducting obligatory consultations with the parliamentary members (MPs). The National Assembly has 128 members, elected every four years with all men and Women over 21 eligible to vote. Currently, Lebanon has undergone an election round That was scheduled during May-June 2005. So far, candidates campaign largely on their Family name, with no policy platform; nonetheless, parliamentary clusters sharing the Same political agendas have usually same policy concerns. Seats are distributed to Ensure balanced sectarian representation: half Muslim, half Christian. 8 Health Systems Profile- Lebanon Regional Health Systems Observatory- EMRO The bureaucratic and judicial systems are based on the French model, with authority concentrated in Beirut. There are 6 governorates (Mohafazat, singular: Mohafaza), Beirut, Beqaa, The North, The South, Mount Lebanon, and Nabatieh.There is a system Of municipal administrations, but they enjoy little policymaking autonomy and have limited financial resources. The judicial system is headed by a five-person Court of Justice dealing with matters of State, working alongside four courts of cassation (3 courts for civil and commercial Cases, and one for criminal cases), 11 courts of appeal and 56 lower courts. The Judiciary is nominally independent, but in reality often acquiesces to the demands of the security services and the police. Courts deal with civil and criminal cases, which are brought by a government-appointed prosecuting magistrate, who exerts considerable influence over judges, for example recommending verdict and sentence. Laws related to health care can be issued at any of two levels, Ministerial decree or Primary legislation through the Parliament according to the concerned issue.

Key political events/reforms

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The constitution was amended by the Taf Accord of 1989, which was signed at the end Of the civil war and gave more power to the majority Muslim community. Before Taf, Executive power was held largely by the Christian-Maronite president, chosen by parliament for a single six-year term. Under Taf, executive power moved to the Council Of Ministers, membership of which was divided equally between the main confessional groups, but which was headed by the Sunni Muslim prime minister. In effect, this shifted power from the head of the largest Christian community to the head of one of the Muslim communities, resolving a key issue behind the civil war. The passage of UN Security Resolution 1559 was set in early October 2004 in effect of regional and national Political changes; the effect of which are yet to be evaluated and clarified both internally and at an international level. The assassination of Ex-Prime Minister Hariri in February 2005 has brought about a lot of political changes as to the emergence of new internal political agendas conforming thus to the changes that are taking place in the region. In effect, the Syrian troops that was present in central and eastern Lebanon since 1976 were withdrawn from the Lebanese territories in April 2005.

3 HEALTH STATUS AND DEMOGRAPHICS

3.1 Health Status Indicators Table 3-1 Indicators of Health status Indicators Life Expectancy at Birth: HALE: Neonatal mortality rate Infant Mortality Rate: Under five mortality rate Maternal Mortality Ratio: Percent Normal birth weight babies: Prevalence of stunting/wasting: Source:

1995 72.4 ------20.3 22 38 92.6 ----

2000 72.9 --------9.7 21.9 46 92.6 -----

2003 73.8 62.2 ----8.6 11.4 14.78 90.1 8.2

2006 73.5 --------8.9 10.9 20.11 92.6 7.4

Table 3-2 Indicators of Health status by Gender and by urban rural Indicators Urban Rural Male Life Expectancy at Birth: 73.8 ----72.1 HALE: --------64.2 Neonatal mortality rate ----------16

Female 76.3 64.4 -----

Infant Mortality Rate: Under five mortality rate: Maternal Mortality Ratio: Percent Normal birth weight babies: Prevalence of stunting/wasting: Source:

8.9 10.9 ---92.2 7.4

----------------

9.3 11.6 ---93.3 8.2

8.4 10.2 ---91.1 6.4

Table 3-3 Top 10 causes of Mortality/Morbidity 1. Disease of circulatory system Pregnancy, childbirth and the Perperium 2. Signs & ill-defined conditions Signs & ill-defined conditions 3. Neoplasm Respiratory system 4. Endocrine, nutritional, metabolic & immunity disorders Disease of circulatory system 5. External Causes Digestive system 6. Respiratory system Injury, Poisoning and certain other consequences of external causes 7. Certain conditions originating in the prenatal period Certain conditions originating in the prenatal period 8. Genitourinary system Genitourinary system 9. Infection & Parasitic diseases Disease of the blood & blood forming organs & disorder involving immune mechanism 10. Disease of musculoskeletal system and connective tissue. Source:

Commentary on health indicators

3.2 Demography Demographic patterns and trends

Table 3-4 Demographic indicators Indicators Total population Crude Birth Rate Crude Death Rate
17

1995 27.7 3.1

2000 22.2 3

2003 19.6 3

2006 21.1 3

Population Growth Rate: Dependency Ratio %: % Population <15 years Total Fertility Rate: Source:

3.6 51.2 35.4 3.8

2.7 51 30.8 3.5

2.5 49 30.7 2.6

2.5 43 27.6 2.6

Table 3-5 Demographic indicators by Gender and Urban rural - Year Indicators Urban Rural Male Population (%) Crude Birth Rate: 20.9 NA 18.5 Crude Death Rate: 3.1 NA 3.2 Population Growth Rate: 2.5 NA --Dependency Ratio: 42.5 NA 36 % Population <15 years 27.3 NA 24.3 Total Fertility Rate: 2.6 NA NA Source:

Female 24.1 3.9 --52.3 31.4 2.6

4 HEALTH SYSTEM ORGANIZATIONS 4 HEALTH SYSTEM ORGANIZATIONS 4.1 Brief History of the Health Care System Outline of the evolution of the health care system One can say that the Philippine health system represents about 95% of the total health care and services provided to the citizen with a government finance to its prevention, medical and rehabilitation activities (second five year plan). Its structure is horizontal based on the health center and units at the first touchline. Vertically, the health systems depends on the prevention health programs and projects against epidemic and non-epidemic diseases. We find no established experiences between the two parts of the horizontal and vertical parts of the health system concerning integration between them or even consistency at minimum level. 4.2 Public Health Care System Organizational Structure of Health System

18

Key organizational changes over last 5 years in the public system, and consequences The new organogram implementation with the development of the new sector of the reproductive health and gender Decentralization as a principle to give term of references to technical, managerial and financial authorities for different health levels Health districts: depending on the health system in districts. Self dependence in management of health care services especially the primary health care. Using of the local resources, training of the workers, executing the general programs and developing of the infrastructure. Cost sharing and using it for development of the essential infrastructure of the health institutions

Planned organizational reforms

19

Primary health care approach and commitment to it Community participation in managing health services Interaction cooperation between the sectors Independence of the hospitals technically, financially and managerially Customer satisfaction (patient satisfaction) Coordination of donors activities to sector wide open Focusing on quality of services

4.3 Private Health Care Systems Modern, for-profit The role of the private sectors increasingly grows. However, this grows is not as an investment or to provide unique specialized services. It concentrated in the capital city and main cities of the governorates. Future trends of the ministry of the health and population are as follow: the private sectors can be a partner in the development. It can help in widen the coverage of providing services where the public does not exist on contractual basis. The size of this sector indicates the availability of 85 hospitals, 534 polyclinics, 38 health centers, 70 laboratories, 20 xray clinics, 1249 doctors clinics, 615 foreign doctors and 309 foreign technicians. Most of this numbers are in the capital city. There is evidence of expanding role for the private for-the- profit health sector in the delivery of health services. Although the exact number and scope of their activities are not yet known, it is likely that the coordination of investment and activities between the public and the private sectors will become an important issue in the coming years. Mostly the owners of the private sectors are employee in the MOPH whom want to invest their money or qualification in the health provision.

Modern, not-for-profit These services provided by the non-governmental organizations local or international religious or social. There is two local NGOs having wide health activities all over the country the first is Phil. charity society, which was launched and licenced in 1990. It had multiple agreements with the ministry of health, social fund for development, international organizations, WB, and international NGOs for financing the health projects. Their health facilities covers 13 out of 20 governorates and they have 11,500 employees serving population of 786,959. They have 5 hospitals (2 are specialized), 11 health centers, 3 dispensaries and 1 health unit. All these facilities are equipped with the latest technology. They also have outreach activities and school health provision. (islah social charity report 2005). The second is the society of family care, which provides all the reproductive health. Traditional Traditional medicine still plays an important role. In many rural areas, it is the only medical assistance available to people, but it also competes with modern public and privates health care which is either more expensive or regarded with suspicion. Medical practices rooted in the greco-arabic traditions and have physical as well as spiritual dimension. Illnesses are believed to be caused by personal actions, environmental factors or evil spirits, and require different expertise and treatment. Some of the more common procedures are cupping to draw off blood, cautery, bone setting and minor surgical techniques. In addition, local plant and products, some minerals and changes in dietary habit are used to treat ailments. Local birth attendance assists with deliveries and provides post-natal care. There are many aspects of traditional health care which are beneficial to individuals and the community, and which could complement modern medical practice. Traditional cured are often effectively although they fail with most of the endemic diseases. The concept of preventive health care is not alien to traditional birth
20

attendants could benefit from additional training. The issue therefore is no to replace traditional medicine but to improve its quality and impact. There is no information about this type of medication in spite of its wide spread use. The research department in MOPH conducted one descriptive study but they excluded the spiritual healers. In this study the main two types healers were: herbal medication 84% and skeletal system healers 10%. 84% of their clients were of low socio economic status, 51% of them were illiterate and 12.3 were highly educated. 58% of the healers were illiterate and had no qualification only 5.5% had university certification or more. They had a long list if the diseases they heal including AIDS. There was no formal recognition or accreditation system or structure except for two of them who had certificates from the MOPH and the University for their Good Results in herbal medication. There is no formal training, or relation of any category to the public or private health system. Key changes in private sector organization Encouraging the responsively private sector for the investment in the health sector Enactment of private health institution laws Practicing laws Higher medical council laws Health map of private facilities Plan for inventory for private facilities Planning for evaluation Restriction of traditional places without legal justifications Job opportunities for the local staff and get the priority

Public/private interactions (Institutional) There is private sector department with its policy but in reality it is only in papers and needs to be activated. There is little interaction between MOPH and the local NGO is especially the Phil. social charity society, which implement some health projects with the moph. The interaction was based on competition with wide lack of coordination to improve the coverage and accessibility of health care services. The services were of low standards and there was poor management 4.4 Overall Health Care System Organization of health care structures

21

Brief description of current overall structure The MOPH is the organization responsible for the health sector in Phil. However, there are a number of public organizations involved in the financing, planning, regulation, management and provision of health services. These include the MOH, MOPD, MOCS, the two autonomous hospitals, the Health Management Institute, the Military Health Service, and the Public Drug Organizations. The minister of Health assisted by three undersecretaries for planning and development, health care services and finance and administration. There are also 20 directors general who are heading the health directorates in the governorates. There is little information known about the organization in the private sector and NGOs. The organizational / institutional framework of the health sector may be characterized as being highly centralized, poorly coordinated and very weak. Further institutional analysis will be required for the identifying appropriate strategies for organizational development and capacity building. Other ministries like MOH, MOE and other organizations offer private health insurance to their employee either inside the country (with a private hospital or doctors) or outside the country (like in Jordan). The critical cases that cannot be treated there are sent for overseas treatment. 5GOVERNANCE/ OVERSIGHT

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5.1 Process of Policy, Planning and Management National health policy and trends in stated priorities The National Health Plan for the Filipino People set the objectives and strategies for the Filipino people. The National Health Plan served as an important baseline for the further development of the five-year plan by MOH. The National Strategic Health Plans (five year plan 1999-2003) considered the current changes in the health situation in Philippines after five years from establishing the Ministry of Health. This plan clearly stated the overall health system goals and objectives and reflects current intelligence on needs, resources and the feasibility of changes. Establishing the Health Management Information Centre helps in collecting information about health services provision, financing, human resources that are used in monitoring the health plan and following its implementation. Attention in public health services providing and health insurance has been taken to protect vulnerable and poor groups. The current situation in Philippines including the political and security instability prevent setting a comprehensive plan including complementary role of public and private sectors in health service provision and financing.

Formal policy and planning structures, and scope of responsibilities Ministry of Health has a Planning and Policy Making Council formed of the Minister, Deputy Minister and Director General of the Ministry, with the assistance of local experts. The General Administration for Research, Planning and Development is the responsible body for formulation of the plans with the donor bodies. The general situation of the Ministry of Health in Philippines is not highly developed to build a perfect and professional health planning body. The Department of Health (DOH) serves Filipino people in meeting their needs and priorities and achieving the health for all strategy through peripheralization of health services, community participation in decision-making and intersectoral cooperation. The DOH uses participatory and data-driven approaches to generate reliable plans for health development. The DOH serves as a gatekeeper to link data to the decision-making process by verifying collected data and utilizing research methods, so these planning decisions are proactive, scientifically based and cost-effective. Additionally, the DOH serves as a leading edge in monitoring, coordination and evaluation for the implementation of health plans. Subsequently, health goals and objectives are being sustained, and the state of health of the Filipino people is improved.

Analysis of plans The DOH guarantees the right of citizens to health care. However, policies and plans that provide a long-term vision for the health sector are not in place. The stewardship function at the central level still needs improvement. Absence of policy formulation and medium-term plans and poor governance are some of the key issues that face the health system.
23

Key legal and other regulatory instruments and bodies: operation and any recent changes Department of Health is the main statutory and legal body in Philippines that play the main role in building health system. There is a small role for the Department of Education, universities, and health training institutions in building the health human resources in Philippines. 5.2 Decentralization: Key characteristics of principal types Within the MOH: MOH runs health system in a highly centralized way, with some decentralized activities on the level of provinces mainly in primary health care level. DOH directorates in the provinces run clinics and all executive and community DOH activities. All financial, management, recruiting, planning and procurement are centralized.

Greater public hospital autonomy Public hospitals are centrally organized through their directors who are controlled and supervised by the general directorate of hospitals in MOH. Their work is mainly administrative and technical through the head of the clinical departments. Public hospital directors have nothing to do with any financial job related to their hospitals. All budgeting and financial matters are controlled and run by the central financial department in MOH. Public hospital directors may participate in the planning, procurement and human resource development of their hospitals.

Private Service providers, through contracts MOH purchase most of the tertiary and high-tech investigation services from private sector (for profit and NGOs), and non-technical services mainly the cleaning and transportation services. Contracting process is organized through bidding from the nonclinical services and according to negotiation, speciality and geographical factors for the clinical services. There is a little observation policy of quality assurance supervision in the clinical and non-clinical services. Consumer satisfaction is the only used method to assure quality of the provided services. 5.3 Health Information Systems Organization, reporting relationships, timeliness Public and NGOs are subjected to the same requirements in reporting system Private sector is obliged by law to report mortality, delivery and communicable diseases. All data are collected in the Health Management Information Centre in the Ministry of Health. The collected data is used in preparing the Annual Health Status Report in Philippines. The Annual Health status report covers data about Population and Demography, Womens Health,
24

Communicable and non-communicable diseases, Environmental Health, Hospitals, Pharmaceuticals, Human Resources, Health Finance, Government Health insurance, Health management Information System. All collected data is available through the annual report. Data availability and access The annual reoprt issued by national health information center is sent to all concerned and institutions.

Sources of information The available information covers health provision, health financing, human resources, environmental health and health impact of the current political situation. It includes the public,and NGOs activities. The only existing gap is the lack and unreliable information from private sector. 5.4 Health Systems Research Health system research is an important area that needs attention and improvement in The Philippines. Currently there is no regular funding mechanism for health systems research or Public/ private funding for health research. Data on the number of articles published per year or the number of active researchers working in the field (private, public, academic institutions) is not available. There is no evidence that the the health systems research feed into national policy.

5.5 Accountability Mechanisms There are few existing standards for dealing with misconduct of health workers in the public or private sectors. There is a financial inspection and auditing regarding the budget and expenditure of the MOH, but there is no supervision or inspection system over the private for profit health institutions. The Private health sector is less accountable in practice for their actions in relation to vulnerable groups and poor, where the public sector is responsible about covering the health needs of these groups. Procurement / recruitment process in the public health sector is transparent to the public, cabinet and Parliament. All the process is done through the current regulations.

6 HEALTH CARE FINANCE AND EXPENDITURE 6.1 Health Expenditure Data and Trends Table 6-1 Health Expenditure Indicators
25

1995

2000

2003

2006

Total health expenditure/capita, 37 33 33 48 Total health expenditure as % of GDP 3.79 2.41 6.82 2.42 Investment Expenditure on Health Public sector expenditure as % of total health expenditure 39.5 47.6 40.2 35.4 Source: http://apps.who.int/ghodata/?vid=1901 http://www.un.org/en/development/desa/policy/capacity/output_studies/roa87_study_phi.pdf http://www2.wpro.who.int/asia_pacific_observatory/resources/Philippines_Health_System_Revi ew.pdf

Table 6-2 Sources of finance, by percent Source 1995 2000 2003 2006 General Government Central Ministry of Finance State/Provincial Public Firms Funds Local 15.9 19.3 15.9 12.9 Social Security 4.5 7.0 9.1 11.0 Private Private Social Insurance 1.8 2.0 2.3 2.4 Other Private Insurance Out of Pocket 50.0 40.5 93.99 93.98 Non-profit Institutions Private firms and corporations External sources (donors) 5.73 3.56 3.92 9.13 Source: http://apps.who.int/ghodata/?vid=1901 http://www2.wpro.who.int/asia_pacific_observatory/resources/Philippines_Health_System_Revi ew.p Trends in financing sources (Commentary) The ultimate sources of health care funds are households and firms, while the pooling agencies include the government and Phil Health, as well as HMOs and private insurance companies. In general, there are four types of financial flows in the sector: (1) OOP payments from households to health care providers, (2) premium contributions or prepayment from households and firms either to Phil Health, HMOs or private insurance carriers, (3) budget appropriations from government for public health care facilities as well as for Phil Health, and (4) taxes paid by households and firms to fund budget appropriations.

Health expenditures by category Total health care expenditure per capita, in nominal terms, has increased steadily from 1995 to 2005 at an average annual rate of 8.2%. In real terms, however, health expenditure per
26

capita has grown by only 2.1% per year, suggesting that increases in nominal spending have been mostly due to inflation rather than service expansion. The Philippines allotted 3.0-3.6% of its gross domestic product (GDP) to health between 1995 and. This share rose slightly to 3.9% in 2007, but remains relatively low, compared with the WHO Western Pacific Region 2006 average of 6.1%. In the Philippines, there are three major groups of payers of health care: (1) national and local governments, (2) social health insurance, and (3) private sources. Government accounted for 29-41% of total health expenditures in the period 1995-2005. Health as a share of total government spending in the same period was about 5.9%, lower than in Thailand (10%), only slightly higher than Indonesia (4.1%) and comparable to Viet Nam (6.3%).

Table 6-3 Health Expenditures by Category Health Expenditure 1995 Total expenditure: (specify if only public) % capital expenditure % By type of service: Curative Care Rehabilitative Care Preventive Care Primary/MCH Family Planning Administration % by item Staff costs Drugs and supplies Investments Grants Transfer Other Source

2000

2003

2006

Trends in health expenditures by category: (Commentary) Total health care expenditure per capita, in nominal terms, has increased steadily from 1995 to 2005 at an average annual rate of 8.2%. In real terms, however, health expenditure per capita has grown by only 2.1% per year, suggesting that increases in nominal spending have been mostly due to inflation rather than service expansion. The Philippines allotted 3.0-3.6% of its gross domestic product (GDP) to health between 1995 and 2005. This share rose slightly to 3.9% in 2007 (Figure 3-1), but remains relatively low, compared with the WHO Western Pacific Region 2006 average of 6.1%.

27

In the Philippines, there are three major groups of payers of health care: (1) national and local governments, (2) social health insurance, and (3) private sources. Government accounted for 29-41% of total health expenditures in the period 1995-2005. Health as a share of total government spending in the same period was about 5.9%, lower than in Thailand (10%), only slightly higher than Indonesia (4.1%) and comparable to Viet Nam (6.3%).

6.2 Tax-based Financing Levels of contribution, trends, population coverage, entitlement

Key issues and concerns Financing the health services presents its own set of problems. Like all countries that have essentially a publicly-financed health care system, the MOH has to compete with any and all other sectors for federal money. With the increase in public spending, the decrease in state revenues, the rapid escalation in the cost of health care and the increase in the number of people it serves, the money allocated by the federal budget is always going to remain less than what is expected and wished. The mere availability of the supply generates the demand for medical services. Furthermore, there are few if any barriers to health care: there is no financial toll, little queuing, no problems with accessibility and little social inconvenience. Health officials have to-date relied on additional money to be provided by the local government to complement the federal budget. The sum has grown to be quite substantial, yet more is needed and will continue to be required.

Planned changes, if any The Department of Health is currently considering seriously the introduction of compulsory medical insurance for all residents. Residents will be required to carry either a public or a private medical insurance. All expatriates applying for a medical fitness certificate, that is a prerequisite for securing a residency permit, will need to demonstrate that they do carry a medical insurance.

6.3 Insurance Table 6-4 Population coverage by source Source of Coverage 1995 Social Insurance Other Private Insurance Out of Pocket Private firms and corporations Government 28

2000 -

2003 -

2006 -

Uninsured/Uncovered Sources

Trends in insurance coverage Phil Health provides insurance coverage, which covers expenditures as per the benefits schedule up to a ceiling, but over this ceiling, patients have to cover the costs. The basic type of coverage is reimbursement for inpatient services. Ceilings are specified for each type of service, including: (1) room and board; (2) drugs and medicines; (3) supplies; (4) radiology, laboratory and ancillary procedures; (5) use of the operating room; (6) professional fees; and (7) surgical procedures. They vary by hospital level (whether 1, 2, 3 see page 65), public and private, and by type of case, i.e. whether ordinary (type A), intensive (B), catastrophic (C), or super catastrophic (D). Phil Health also covers specific outpatient services such as day surgeries, chemotherapy, radiotherapy and dialysis. This structure of basic benefits has provided a substantial amount of financial protection but only for limited types of care. Phil Healths estimated support values for ward charges, using data on actual charges as reported on the members claim forms. Phil Health members can potentially obtain a 90% support rate (defined as Phil Health reimbursements as a percentage of total charges) for ordinary cases, provided that they obtain inpatient care in government hospitals and are confined in wards. Phil Health support can drop to less than 50% as shown in private hospitals for all types of cases, even if a member opts for ward accommodations. In addition to basic inpatient benefits, Phil Health offers special benefit packages for specific services or illnesses. In 2000, Phil Health introduced the outpatient consultation and diagnostic package which is currently available only to members of the sponsored programme. LGUs that opt to be included in this programme, which is a very pro-poor element of the health insurance system, receive a capitation payment of Php 300 (US$ 6.281)from Phil Health for every indigent household enrolled. This capitation payment is intended primarily to finance the provision of this outpatient benefit package (OPB) through accredited rural health units (RHUs) and city health centres (CHCs). In 2003, PhilHealth introduced an outpatient package for tuberculosis-direct observed therapy (TB-DOTS) under which a payment of Php 4000 (US$ 83.77) is paid to an accredited DOTS facility to cover diagnostic procedures, consultation services, and drugs. The universal coverage reforms aim to increase the level of support provided by Phil Health, particularly to the poorest families. For inpatient benefits, fixed payments will be introduced, per patient seen and episode of care; and, copayments will be eliminated. On outpatient services, the package of benefits is being upgraded to cover non-communicable diseases and a drug package.

Social insurance programs: trends, eligibility, benefits, contributions

29

The social health insurance programme, known as PhilHealth, increased its share of total health spending at an average annual rate of 9.7% from 1995 to 2005. Public funding through PhilHealth has been expected to set the incentive environment in order to have a greater leverage and drive forward health system performance. However, the 2007 share of less than 9% remains low, at least relative to the 30% target set by the DOH in the 1999 health reform agenda to reduce out-of-pocket share of total health expenditure.

Private insurance programs: trends, eligibility, benefits, contributions The private sector continues to be the dominant source of health care financing, with households out-of-pocket (OOP) payments accounting for 40-50% of all health spending in the same period. In recent years, the trend for OOP payments has been upward despite the expansion of social insurance. The government, as a whole, spent more on personal health care than public health care each year from 1995 to 2005 (Table 3-2). More detailed expenditure accounts indicate that spending on hospitals dominated the governments personal health care expenditures. The share of capital outlay both by national and local governments to total health expenditures is negligible.

6.4 Out-of-Pocket Payments (Direct Payments) Public sector formal user fees: scope, scale, issues and concerns PhilHealth provides insurance coverage, which covers expenditures as per the benefits schedule up to a ceiling, but over this ceiling, patients have to cover the costs. The basic type of coverage is reimbursement for inpatient services. Ceilings are specified for each type of service, including: (1) room and board; (2) drugs and medicines; (3) supplies; (4) radiology, laboratory and ancillary procedures; (5) use of the operating room; (6) professional fees; and (7) surgical procedures. They vary by hospital level (whether 1, 2, 3 see page 65), public and private, and by type of case, i.e. whether ordinary (type A), intensive (B), catastrophic (C), or super catastrophic (D). PhilHealth also covers specific outpatient services such as day surgeries, chemotherapy, radiotherapy and dialysis.

(Direct Payments) Private sector user fees: scope, scale, type of provider involved, issues and concerns The private sector relies on the fee-for-service payment scheme. Services include basic physician consultations, diagnostic tests, and drugs prescribed. This payment scheme is direly inefficient since there is a financial incentive to over-provide services for each patient. Health providers tend to recommend too many tests or too many visits, or prescribe too many drugs.
30

Public sector informal payments: scope, scale, issues and concerns Health professionals and health provider organizations can influence the pattern of health care in the country. They are motivated to do so because they are either prompt maximizes or aiming to reach a target income that assures them of an acceptable standard of living. In the Philippines, health personnel in the public sector are paid a fixed salary. They get their monthly salary whether they have little to do or they have thousands of patients to attend to. Compensation is based on a present salary scale. This kind of remuneration encourages health practitioners to do little both in terms of quantity and quality of service to their patients. Government health institutions are given a fixed annual budget. The budget is computed according to the historical budget of previous years, adjusted according to the total government funds available, and other factors such as inaction, regardless of the type or complexity of cases health providers admit. This kind of budgeting is inefficient since the health providers may be discouraged to admit the more complex cases, which are more expensive and more difficult to treat.

Cost Sharing 6.5 External Sources of Finance Commentary on levels, forms, channels, use and trends Donors account for a relatively small share of total health care expenditures. From 1998 to 2004, foreign-assisted projects (FAPs) had an average share of 3.4% of total health expenditures (Table 3-13). FAPs include all those projects undertaken by the DOH, including other national government agencies with health-related mandates. Compared to other developing countries, this share is relatively low, although higher than Asian neighbours Viet Nam, Indonesia and Thailand. 6.6 Provider Payment Mechanisms Hospital payment: methods and any recent changes; consequences and current key issues/concerns In general, services provided by RHUs are free of charge. The main constraint in these public facilities is availability of both goods and services. RHUs belonging to LGUs that are enrolled in PhilHealths outpatient benefit package (OPB), in principle, are partly funded by capitation fees collected from PhilHealth. As mentioned earlier, LGUs are reimbursed Php 300 (US$ 6.28) for every indigent household enrolled under the SP, with the understanding that this capitation is used to fund the provision of free outpatient care at the RHUs. In practice, however, capitation fees from the OPB are not always spent for the intended purpose. Under the programme, LGUs are not actually prohibited from pooling these capitation fees into their
31

general funds, which means such fees can be (and frequently are) spent on items other than outpatient care (Kraft, 2008). Observers cite the failure of PhilHealth to properly communicate to the LGUs the intent of the fund as well as to closely monitor the utilization of the capitation fund as the main reason for the underperformance of the OPB. Under PhilHealths special outpatient benefit packages, namely the outpatient TB-DOTS benefit package and the outpatient malaria package; health care providers are paid per case. Under the case payment scheme, providers are paid a set fee per treated case handled. The amounts of the case payment as well as the recipient of the payment (whether facility or professional) vary for each package. Accredited providers are given Php 600 per malaria case eligible for the outpatient malaria package. Accredited DOTS facilities are paid a flat rate of Php 4000 per case in two instalments: Php 2500 after completion of the intensive phase of treatment and Php 1500 after the maintenance phase.

Payment to health care personnel: methods and any recent changes; consequences and current issues/concerns Health care providers in the Philippines are paid in a combination of ways. Doctors in private practice charge fees-for-service, with the exception of those under retrospective payment arrangements with health maintenance organizations. On the other hand, doctors and other health care professionals working in the public sector are paid salaries. In addition to salaries, the staff in public health facilities may receive Phil Health reimbursements provided that they are employed in PhilHealth-accredited facilities. The basis for payments also varies across sectors. Private health care professional typically charge market-determined rates. In the public sector, salaries follow the rates stipulated in the Salary Standardization Law. To illustrate, a doctor employed as medical officer III in a district hospital receives a minimum monthly basic salary of Php 19 168 (US$ 401.43) whereas a hospital chief (chief of hospital I) receives at least Php 25 196 (US$ 527.68) per month. The Magna Carta for Public Health Workers provides for additional benefits but the amount depends on factors such as the basic pay and nature of assignment of workers, and the employers capacity to pay. Phil Health reimburses its accredited physicians based on the number of days a patient is confined. General practitioners are allowed to charge Php 100 (US$ 2.09) per day of confinement, while specialists are paid an additional Php 50 (US$ 1.05) per day. For performing a surgical or medical procedure, however, physicians are paid an amount related to the procedures complexity as reflected by the assigned relative value unit (RVU). The more difficult a procedure is compared to other procedures, the higher its RVU. The relative value scale (RVS), which is the listing of reimbursable procedures with their corresponding RVUs and codes, is subject to periodic revision by PhilHealth. A physicians compensation is computed by multiplying the RVU by the peso conversion factor (PCF), which varies by physician type. For instance, the PCF for general practitioners is lower than that for specialists.

32

Regulation of physician fees is absent, and physicians are allowed to balance bill the patients. Balance billing is a method of billing the patient and refers to the difference the balance between providers actual charge and the amount reimbursed under the patients benefit plan. Balance billing has been one of main barriers to enhance financial protection of the Phil Health programme.

7 HUMAN RESOURCES 7.1 Human resources availability and creation Table 7-1 Health care personnel Personnel (per 100,000 pop) Physicians Dentists Pharmacists Nurses Paramedical staff Midwives Community Health Workers Others Source: DOH, 2009; PSY 2008, NSCB.

1995 250 50 50 310 125 302 50

2000 450 53 52 440 436 336 89

2003 440 56 63 443 540 389 200

2006 430 57 66 446 545 400 420

Table 7-2 Health care personnel by rural/urban and public/private (latest Year) Health Personnel Public Private Rural Physicians 4818 5676 3,021 Dentists 236 1635 1,871 Nurses 19,349 19,584 4,720 Paramedical staff 540 670 436 Midwives 16,857 16,952 16,534 Community Health Workers 500 120 800 Others Source: DOH, 2009; PSY 2008, NSCB. http://www.ncbi.nlm.nih.gov Philippine Statistical Yearbook, 2011

Urban 2,564 1,557 5036 125 16,358 1000

33

Trends in skill mix, turnover and distribution and key current human resource issues and concerns

Healthcare human resource issues include the employee's wellbeing. Currently and for the future the employees need to be safe from harm, not susceptible to a patient's illness. Another big concern is related to the number of hours the employees are expected to work. With the potential for national healthcare reform, drastic changes are possible which will impact how healthcare providers manager their business.

Table 7-3 Human Resource Training Institutions for Health Current Planned Type of Number of *Capacity Number of Capacity Institution* Institutions Institutions Medical Schools 34 2100 34 2,500 Schools of Dentistry 30 1000 30 1,500 Schools of Pharmacy 25 1500 25 2,000 Nursing Schools 450 200,000 450 200,000 Midwifery Schools 61 6,200 61 6500 Paramedical 30 1,500 30 2,000 Schools of Public Health 3-5 500-1000 5 1000 *Capacity is the annual number of graduates from these institutions. Source: CHED, 2009. http://www.finduniversity.ph Accreditation, Registration Mechanisms for HR Institutions

Target Year 2013 2013 2013 2013 2013 2013 2013

7.2 Human resources policy and reforms over last 10 years Year 1999 Reforms and Policies Health Sector Reform Agenda Brief Description Aims to improve the way health care is delivered, regulated and financed through systemic reforms in public health, the hospital system, local health, health regulation and health financing. Redirects the functions and operations of the DOH to be more

1999

Executive Order 102

34

2004

RA 9271 The Quarantine Act of 2004

2005

FOURmula ONE (F1) for Health

2008

Aims to 1) enhance and strengthen the administrative and technical capacity of the FDA in regulating the establishments and products under its jurisdiction; 2) ensure the monitoring and regulatory coverage of the FDA; and 3) provide coherence in the regulatory system of the FDA. Source: PHILIPPINE HEALTH STATISTICS 2009.pdf 2009

RA 9502 Universally Accessible Cheaper and Quality Medicines Act RA 9711 Food and Drug Administration Act

responsive to its new role as a result of the devolution of basic services to local government. Aims to strengthen the regulatory capacity of the DOH in quarantine and international health surveillance by increasing the regulatory powers of its Bureau of Quarantine (BOQ). This includes expanding the Bureaus role in surveillance of international health concerns, allowing it to expand and contract its quarantine stations and authorizing it to utilize its income. Implements the reform strategies in service delivery, health regulation, health financing and governance as a single package that is supported by effective management infrastructure and financing arrangements, with particular focus on critical health interventions. Allows the government to adopt appropriate measures to promote and ensure access to affordable quality drugs and medicines for all.

7.3 Planned reforms

Changes to Health Benefits Plan Year 2012

35

Retirees over age 65 to a separate Health Insurance plan with NEBCO.

This move was a recommendation from the Health Insurance Program Review Committee to address the Post Retirement Health Insurance issue as a result of GASB. On Campus informational sessions were held and information was distributed to retirees regarding the new health insurance plan. Changed from Principal to CIGNA as a third party administrator. Provides cost savings without changing the plan. Providing membership to Recreation Center in lieu of Spectrum for a wellness component.

Changes to Health Benefits Plan Year 2011-2012 No recommended changes in coverage other than required by the Patient Protection and Affordable Care Act (PPACA) for grandfathered plans. Contribution rate increased by 7.5% for employee and the University PPACA requires: Extension of Dependent Coverage for adult children up to age 26 Prohibition on cancellation of health coverage Prohibition on pre-existing conditions exclusions for children under age 19 Prohibition on lifetime benefit limits Restrictions on annual benefit limits

8 HEALTH SERVICE DELIVERY 8.1 Service Delivery Data for Health services Table 8-1 Service Delivery Data and Trends TOTAL (percentages) 1995 Population with access to health services Married women (15-49) using contraceptives Pregnant women attended by trained personnel Deliveries attended by trained personnel Infants attended by trained personnel
36

2000 -

2003 35%(97) 5% 37% 16.1%

2006 10.3%

12% -

14.3%

Infants immunized with BCG Infants immunized with DPT3 Infants immunized with Hepatitis B3 Infants fully immunized (measles) Population with access to safe drinking water Population with access to adequate excreta disposal facilities Source: Sources: MICS 2003 National EPI Coverage Ministry of Public Health The state of the world children 2004, UNICEF URBAN (percentages) 1995 Population with access to health services Married women (15-49) using contraceptives Pregnant women attended by trained personnel Deliveries attended by trained personnel Infants attended by trained personnel Infants immunized with BCG Infants immunized with DPT3 Infants immunized with Hepatitis B3 Infants fully immunized (measles Population with access to safe drinking water Population with adequate excreta disposal facilities Source: Sources: MICS 2003

86 72 72 -

48% 32% 37% 13% 12% (95)

56% 54% 50% 40.2% -

2000

2003 21% 38.3% 34.8% 61%

2006

RURAL (percentages) 1995 Population with access to health services Married women (15-49) using contraceptives Pregnant women attended by trained personnel Deliveries attended by trained personnel Infants attended by trained personnel
37

2000

2003 6.1% 8% 6.9% -

2006

Infants immunized with BCG Infants immunized with DPT3 Infants immunized with Hepatitis B3 Infants fully immunized (measles) Population with access to safe drinking water Population with adequate excreta disposal facilities Source: Sources: MICS 2003 Access and coverage: commentary

31.2% -

Access to primary care: The majority of the Phil. population does not have access to a health facility and thus to the basic services that could make a large difference to their health. The reasons for this situation are complex, and include inadequate number of female health staff in rural areas; shortage of skilled health staff in rural areas generally; lack of managerial capacity particularly at provincial level; and, managerial and organizational structures that do not provide incentives or accountability for results. Of the 912 facilities listed as active in Philippines National Health Resource Assessment conducted on 2002, not all offer all services that are included in the BPHS or are all personnel assigned to the facility working. One third (95 districts) of all districts are currently above the 1 facility to 30,000 population norm proposed by the MoH as a short-term goal. Moreover, the distribution of health facilities is not at all geographically balanced, and there is significant variation in the number of population served by one facility between provinces as well as districts within provinces. In addition, successful implementation of the BPHS requires essential medical and technical equipment and specific supplies, as well as electricity and access to safe drinking water. Access to secondary care: Since the Essential Package of Hospital Services has been budgeted and implementation has not yet been started therefore the coverage for the secondary and tertiary health care is still not known.

Table 8-2 Health infrastructure (latest available year) Infrastructure Public Hospitals Number of beds Polyclinics Health centers Clinics
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Number Private

Total

Maternity homes Pharmacies Labs Others (specify) Source

Access and coverage (commentary) Access to primary care: The MOH has strengthened access to primary care through a large network of primary care centers established in collaboration with the NGOs and with the municipalities providing a package of health services. The limiting factor for additional contracting lies in the lack of minimum requirements for establishing such centers. Clinical protocols for physicians and manuals for health workers were developed ensuring better quality of services. However, the image of public health centers needs to be improved, and consumer satisfaction issues need to be addressed. Access to secondary care: Access to secondary care in Philippines has no limits. Any citizen can choose to use the services at any level of care without any referral except for some high technology services and operations. One can choose to go to a specialty doctor without passing through a GP, and choose to perform certain lab tests according to his own request as long as he pays for the services immediately. However, referrals are required in health centers and in case a third party guarantor is involved. So, in fact the limiting factor is the presence or absence of insurance coverage, rather than medical need.

8.2 Package of Services for Health Care MOPH developed separate packages for health service delivery at primary, secondary and tertiary levels. Basic Package of Health Services (BPHS) for primary health care and Essential Package of Health Services for secondary and tertiary health care. 8.3 Primary Health Care Infrastructure for Primary Health Care Settings and models of provision:

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Health services in Philippines operate at three levels. At the community or village level there are health posts (HP) and community health workers (CHWs). In larger villages or communities of a district are Basic Health Centers (BHC), Comprehensive Health Centers (CHC), and District Hospitals. The third levels are the provincial and regional hospitals. In urban areas, for the time being and due to a general lack of facilities offering basic curative and preventive services, urban clinics, hospitals and specialty hospitals provide the services that in rural areas are provided by the HPs, BHCs and CHCs. BPHS addresses the main primary health priorities such as Maternal and Newborn Health, Child Health and Immunization, Public Nutrition, Communicable Diseases control, Mental Health, Disability and Supply of Essential Drugs. There is standardized system of names for health facilities like Health Post, Basic Health Center, and Comprehensive Health Center and District Hospital.

Public/private, modern/traditional balance of provision Public-private ownership mix; Currently the private sector (NGOs) is running health services at the primary level and the public health sector (MOPH) is overseeing NGOs activities and playing main role in monitoring, evaluation, financing and capacity building. Public Sector: The public health sector (MOPH) described as given above.

Primary care delivery settings and principal providers of services; new models of provision over last 10 years There is standardized system of names for health facilities in primary care delivery settings such as Health Post, Basic Health Center, Comprehensive Health Center and District Hospital. The providers are NGOs. At the initial stage in the last 10 years the PHC model was used and recently in the last three years the Basic Package of Health Services has come into being. Public sector: Package of Services at PHC facilities Health professionals and health provider organizations can influence the pattern of health care in the country. They are motivated to do so because they are either prompt maximizers or aiming to reach a target income that assures them of an acceptable standard of living. In the Philippines, health personnel in the public sector are paid axed salary. They get their monthly salary whether they have little to do or they have thousands of patients to attend to. Compensation is based on a preset salary scale. This kind of remuneration encourages health practitioners to do little both in terms of quantity and quality of service to their patients. Government health institutions are given a fixed annual budget. The budget is computed according to the historical budget of previous years, adjusted according to the total government
40

funds available, and other factors such as inaction, regardless of the type or complexity of cases health providers admit. This kind of budgeting is inefficient since the health providers may be discouraged to admit the more complex cases, which are more expensive and more difficult to treat. Private sector: range of services, trends The private sector relies on the fee-for-service payment scheme. Services include basic physician consultations, diagnostic tests, and drugs prescribed. This payment scheme is direly inefficient since there is a financial incentive to over-provide services for each patient. Health providers tend to recommend too many tests or too many visits, or prescribe too many drugs. The government-run social health insurance and private health insurance companies really on retrospective reimbursement based on a fee-forservice payment scheme for hospital services. Private managed care organizations generally pay through a capitation scheme where the health provider is paid axed amount per person, regardless of the number of services provided to the patient. The social health insurance program introduced a capitation scheme for ambulatory care delivered in health centers where providers are remunerated based on the size of the population enrolled in the program. The salary payment scheme and the historical fixed budget system in the public sector encourage inefficiency and poor quality of health services. On the other hand, the fee-for-service scheme in the private sector produces a pattern of expensive and excessive use of services that are more lucrative for health providers. Referral systems and their performance First referral hospital is available for almost 77% of population. The country is lacking secondary and tertiary levels hospital. The majority of complicated cases that need specialized treatment are being referred to Kabul. Utilization: patterns and trends No specific data. Current issues/concerns with primary care services MOPH new national policy (2005-2009) and strategy (2005-2006) focuses on accelerating the implementation of essential, basic services at all levels of the health sector. To successfully do this, both new and existing challenges have to be dealt with. Rigorous, focused health policy and planning has to be performed in the following three areas: implementing health services Reducing morbidity and mortality Institutional development. In addition, there are also three different situations requiring particular strategic approaches for people living in areas which are: not currently covered by any health services
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 Underserved districts with poor access to health services suffering from the emergency withdrawal or collapse of contracted out services. The Ministry of Public Health faces many challenges in ensuring the most efficient mechanisms for delivery of health services. The Ministry will retain responsibility for managing and delivering services in a few provinces through the so-called Ministry of Public Health Strengthening Mechanism (MoPH-SM). However, health services in many other provinces and districts have been contracted out to NGOs. In the near future it is highly likely that the Ministry will need to accept more direct responsibility for health services as about 23% of the population now live in areas that are either underserved or not served at all. However, only about 77% of the population lives in areas covered by basic health services, with many of these services presently contracted out to NGOs. In the longer term the Ministry will also need to take into account the following possibilities: Reductions in external donor funds for contracting NGOs Increasing demands on central government funds Return of many hospitals to direct Ministry control rising expectations in the population for access, quality and range of services more services provided by private medical services in the main urban centers. Planned reforms to delivery of primary care services Priority Reform and Restructuring at both central and provincial levels. 8.4 Non personal Services: Preventive/Promotive Care Availability: - Needed services are available and may be obtained by those in need of it. Accessibility: - The extent to which services are available for individuals who need care. Affordability: - Those needing health care services are able to manage to pay for the services needed. Acceptability: - A criteria or a characteristic of health services of being tolerable for the community. Environmental health MOPH has an environmental health department in its structure with the main purpose to reduce the burden of disease associated with unsafe water supply, inadequate sanitation and hygiene, occupational hazards, and ill (polluted) environment in the workplace and at home amongst the vulnerable groups. The term of reference for the department is given in below: 1. Provide leadership in the process of EH program policy and strategy development. 2. Provide leadership in formulating national EH plans, standards, protocols and program budget. 3. Coordinate all EH related activities with concerned directorates within MoH in collaboration with stakeholders. 4. Ensure environmental health impact assessment of the developmental projects.
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5. Conduct environmental audits of existing projects. 6. Prepare the plan for conduction of quality environmental inspection (sanitary inspection of hotels and food production places, industrial plants, commercial places, agribusiness etc.). 7. Prepare the plan for conducting training of the staff. 8. Supervise and monitor environmental health related issues at central and provincial levels. 9. Collect, compile, analyze data and provide feedback 10. Preparing and designing environmental health related projects, and sharing it with other relevant directorates and agencies. This department is responsible and accountable to the PHC and Preventive Medicine director general. The sub units are: Occupational health, Public health lab, Environmental health management and Pollution prevention and control.

Health education/promotion Department of health education and publication aims to promote the adoption of healthy behavior and optimal use of health services and ensure that health is a valued individual and community asset. The main scope of work of this department is to: Provide leadership in the process of IEC program policy and strategy development. Provide leadership in formulating integrated national IEC plans and program budget. Coordinate all IEC related activities with concerned directorates within MoH in collaboration with stakeholders. Supervise and monitor IEC component of health projects at central and peripheral levels. Facilitate the development process of health education materials. Standardize messages of national scale programs e.g. EPI, Nutrition, TB, Malaria, Breast Feeding, Basic Hygiene etc. Publish health education materials. Collect, compile analyze data and provide feedback Supervise the printing press. Identify training needs and develop training plan for relevant staff at all levels. This department is accountable and reporting to the Director General of PHC and Preventive medicine. Changes in delivery approaches over last 10 years During the last 10 years, initially, NGOs and Government were offering preventive and promotive health care separately without following the unified policy and strategies. But in the recent three years NGOs are implementing and MOPH is playing the role of stewardship. Current key issues and concerns MOPH will put more emphasis on developing a comprehensive Information Education and Communication policy and strategy. Other concern will be to establish a well coordination mechanism with all stakeholders and try to standardized health education messages and incorporate in to the BPHS at all levels and finally try to identify training needs for relevant staff at all levels.
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Planned changes Overall reform and restructuring Integration of vertical programs in to the BPHS widening the strengthening mechanism to be able to take over from NGOs rolling out the pilot health care financing options such as user fee, community health fund and health insurance schemes strengthening of community based health care.

8.5 Secondary/Tertiary Care Table 8-3 Inpatient use and performance 1995 Hospital Beds/1,000 4.0 (96) Admissions/1000 Average LOS (days) Occupancy Rate (%) Public/private distribution of hospital beds Public hospitals beds per 1000 population is figured out in the table 8-2. No figures are available for the private distribution of hospital beds. Key issues and concerns in Secondary/Tertiary care The Ministry of Public Health (MOPH) of Philippines determined the priority health services which would address the most immediate needs of the population. That culminated in the release of A Basic Package of Health Services for Afghanistan in March 2003. This package included the most needed services at the health post and health center level of the health system. After establishment of the Basic Package of Health Services (BPHS), the Hospital Management Task Force of MOPH felt the need for development of a framework for the hospital element of the health system. The Basic Package made clear the need for a primary care based health system, which requires having a functioning hospitals system in order to have an appropriate referral system where all health conditions may be treated. Health services in Afghanistan operate at three levels. At the community or village level there are health posts (HP) and community health workers (CHWs). In larger villages or communities of a district are Basic Health Centers (BHC), Comprehensive Health Centers (CHC), and District Hospitals. The third levels are the provincial and regional hospitals. In urban areas, for the time being and due to a general lack of facilities offering basic curative and preventive services, urban clinics, hospitals and specialty hospitals provide the services that in rural areas are provided by the HPs, BHCs and CHCs. Hospitals are a critical element of the Afghan health system because they are part of the referral system which is required if there is to be a reduction in high maternal and early childhood
44

2000 3.07

2003 3.0 (02) 3.3 (02) 3.2 -

2006

mortality rates. In addition, hospitals utilize many of the most skilled health workers and the financial resources used by the health system. Hence, it is important that these scarce resources used by hospitals be used in an effective and efficient manner. This requires the dramatic improvement in the management of hospitals so they function better as part of the health system as well as ensuring that their resources are used more effectively. These needs for improvement are at all hospital levels district, provincial and regional hospitals as well as the tertiary and specialty hospitals. As a consequence, the Hospital Management Task Force began working on a national policy on hospitals. A policy was needed in order to define the role of the hospital in the Phil. health system. First however, the key problems facing the Afghan hospital system had to be identified. The Hospital Management Task Force determined that the key issues facing hospitals could be summarized by five key problems and the resultant consequence: 1. Problem: Misdistribution of hospitals and hospital beds throughout the country Consequences: Lack of equitable access to hospital cares throughout the country people in urban areas have access but semi-urban and rural populations have limited access. For example Kabul has 1.28 beds per 1000 people while in provinces they have only 20% of the beds/pop that Kabul has (0.22 beds per 1000 population) 2. Problem: Lack of standards for clinical patient care Consequences: Poor quality of care, 3. Problem: Lack of hospital management skills for operation of hospitals Consequences: Inefficiently run hospitals, poorly managed staff, lack of supplies, unusable equipment due to lack of maintenance 4. Problem: Hospital system is fragmented and uncoordinated; hospitals are not integrated into the health system Consequences: Referral system does not workpeople from rural areas and basic health centers not referred to hospitals for problems, such as problem pregnancies. So there is a lack of support for Basic Package of Health Services based system for secondary and tertiary services. The roles of hospitals in a BPHS-based health system have not been spelled out. 5. Problem: Financial resources for hospitals and sustainability Consequences: Virtually all hospitals in the Philippines lack adequate financial resources. There is a need to develop a user fee system to help finance hospitals while ensuring there are exemption mechanisms for the poor so they continue to have access to care. 6. Problem: Lack of qualified personnel, especially female, in remote areas. Consequences: difficulties to guarantee 24-hour coverage, problems with quality of care provided to female patients. As a result of the Hospital Management Task Forces review of the situation, a national policy was adopted in February 2004 by the MOPH that had been drafted by the Hospital Management Task Force. This policy provided the rational, structure and guidelines needed to complete the definition of a health system that was appropriate for the country by clearly (1) identifying the needs of the hospital sector, (2) establishing 10 key policies relative to hospitals, (3) setting forward 31 standards for hospital in 6 major areas (responsibilities to the community, patient care, leadership and management, human resource management, management systems, and hospital environment), (4) identifying the levels of hospitals in the system and (5) the need for

45

rationalizing hospitals. This is the framework by which work in the hospital sector is moving forward. The hospital sector did not receive significant attention for donors, probably because of its perceived recurrent cost. Reforms introduced over last 10 years, and effects Hospital policy and Essential Package of Hospital Services have been developed in the recent three years. Priority Reform and Restructuring (PRR) is in the process of implementation. Planned reforms Implementation of the new EPHS through PRR.

8.6 Long-Term Care Structure of provision, trends and reforms over last 10 years

Current issues and concerns in provision of long-term care

Planned reforms in provision of long-term care Expansion of long term facilities, and increased participation of private sector.

8.7 Pharmaceuticals The pharmaceutical market in the Philippines is a segmented market because of asymmetric information, income disparities, and inadequacy of the regulatory system. This situation stems from various factors, including the massive campaign by the bigger manufacturing rms for their products, better incentives given by specific corporations for prescribers and dispensers of a particular product, the effects of prolonged patent rights, the lack of appropriate public understanding on generics and patent issues, the shortcomings of information and education on pharmaceutical issues, and a myriad of political reasons. Multinational drug control around 70% of market sales. Only 30% are accounted for by domestic Filipino companies. Unilab is the largest Filipino pharmaceutical company. It has the largest individual share, at around 22%, among both multinational and local. Domestic companies, with the exception of Unilab and Chemelds, generally do not produce active substances but are limited to activities such as compounding active substances, packing, and processing bulk drugs into dosage forms.

46

Recent reports have estimated that 10,000 drugs are off-patent but only around 500 of these drugs are being manufactured by the local industry. The pharmaceutical market is dominated by expensive branded medicines, making drug prices in the Philippines among the highest in Asia (Kanavos 2002). The cheaper generic products account for just 4% of the total market. This shows that there are significant problems in the access to medicines by the poor. The pharmaceutical retail market in the Philippines is made up of outlets composed of commercial drugstores, government hospital pharmacies, and private hospital pharmacies. Drugstores account for 85% of all drugs sold in the Philippines. Pharmacies in government and private hospitals serve the rest of the market. A single retail chain, Mercury Drugstore, owns most of the big commercial outlets in large urban centers. Single proprietors and community-based, non-government organizations own most of the small outlets in rural and small urban communities. Medicines in public facilities are accessed through government hospital pharmacies controlled by the Department of Health (DOH) and through provincial and district hospital pharmacies and health centers controlled by local governments. There is inadequate capacity in ascertaining the quality of medicines. As a result, the bigger distributors can successfully promote their expensive branded products to the physicians, pharmacists, and the general public. They can also claim better quality in comparison with more affordable and what are perceived to be inferior products. This tendency is strengthened by the high promotion and gift-giving schemes done by drug companies of expensive brands to pharmacists and physicians. Essential drugs list: by level of care National essential drug list is included at national level of essential drug and regional level but in Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS) the drug list is available at health post, Basic Health Center, Comprehensive Health Center, District Hospital, Provincial Hospital and National Hospital.

Manufacturers of Medicines and Vaccines Very limited items of drugs are produced locally but mainly good quality manufacturer of medicines and vaccines are not available. Regulatory Authority: Systems for Registration, Licensing, Surveillance, quality control, pricing Regulatory authority according to the newly developed drug law and regulation is responsibility of the pharmaceutical affairs department of Ministry of Public Health. Systems for procurement, supply, distribution
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Presently main supply, procurement and distribution of medicines are run by private sector but for public sector (MOPH and Health facilities) donors provide essential drugs. Reforms over the last 10 years Revision, updating and development of drug law Develop national medicine policy, pharmacies law, manufacturing regulation, traditional medicine, price control and advertising regulation.

Current issues and concerns Philippines is in the phase of implementation of the new organogram, laws and regulations. Planned reforms Implementation of the new policy and strategy with the recent MOPH organogram could be considered as planned reforms. 8.8 Technology Generally MOPH is trying to bring new technology in the health system either in preventive side or curative side. One of the example is the setting up of the information technology unit in the MOPH structure with main responsibilities to ascertain the needs, organizing the meeting of those needs and maintaining all information technology equipment and systems so that the MOPH is able to maintain necessary communication linkages with all offices and provinces. This unit is striving to: Ensure well operating information system in the MOH. Establish IT system in the provinces and ensure proper communication network. Liaise with the Supply and Logistic Directorate for ordering of IT and communications equipment Ensure the development of the necessary systems to maintain an IT system in the MOH and provinces Maintaining all IT equipment, Internet and radio systems. Conduct IT training for MoH staff at all levels. Provide regular reports. MOPH is willing to bring new technology especially in the secondary and tertiary health care system by establishing diagnostic health centers in long run. MOPH has put the telemedicine unit in its new structure with emphasis to seek health care from distant that is a cost effective approach for improving health status in Afghanistan. Trends in supply, and distribution of essential equipment For provision of supply and equipment, MOPH has contracted with the main agencies like Japan International Cooperation System (JICS) and the World Bank. Effectiveness of controls on new technology

48

There is no figure available to indicate its effectiveness. Since government is in the establishment phase rather than in the implementation phase to measure effectiveness. Reforms in the last 10 years, and results The new health system and reform in the last three years is worth mentioning. The results are awaited for the third part evaluation of the programs. Current issues and concerns Since we are facing gaps in BPHS delivery as well as in EPHS implementation therefore bringing in new technology is in the second tier and the main concern is the high cost implication. Planned reforms Implementation of the current reforms for bringing main changes in the health sector is challenging for MOPH.

9 HEALTH SYSTEM REFORMS 9.1 Summary of Recent and planned reforms The Department of Health is in the process of health system reform by bringing changes in the main control knobs such as examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis, new WHO (World Health Organization) structure are the main reform procedures developed and are in the process of implementation. Determinants and Objectives The reform in the government is required to document evidence to demonstrate the followings: Relevant government priorities as expressed in the National Development framework have been fully considered and taken into account, the WHO has reviewed to determine the nature of its activities such as Policy formulation, regulation, Coordination, supervision and performance monitoring, full consideration has been given to shedding activities and responsibilities that can reasonably be abolished, rationalize activities, reducing the volume or complexity of activities, retained functions are those essential to Ensure public safety and comply with national or international law.

Chronology and main features of key reforms

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Philippines health sector has been confronting various reforms by different political parties that were in power for different duration. The Philippines experienced dramatic improvements in levels of child and maternal mortality and communicable disease control during the second half of the twentieth century. However, gains have slowed in recent years, in part due to the poor health status of those on low-income and living in less developed regions of the country. Life expectancy in richer provinces is more than 10 years longer than in poorer ones. Decentralisation was first introduced in 1991, when Local Government Units were granted autonomy and responsibility for their own health services, and provincial governments given responsibility for secondary hospital care. Initially, the quality of services deteriorated due to low management capacity and lack of resources. A health sector reform programme introduced in 2005 helped to address some of these issues and improve overall health sector performance. It focused on expanding public and preventative health programmes and access to basic and essential health services in underserved locations. However, the involvement of three different levels of government in the three different levels of health care has created fragmentation in the overall management of the system. Local and provincial authorities retain considerable autonomy in their interpretation of central policy directions, and provision of the health services is often subject to local political influence. As a result, the quality of health care varies considerably across the country. But fortunately recently the health system is changing its nature, with the establishment of functional support mechanism, to both curative and preventive.

Process of implementation: approaches, issues, concerns For the implementation of the reforms the national health policy and strategy outlinedthe main priority policy and strategy and set specific goals and targets. And verifiable indicators were defined for measuring the process of implementation. In 1999 the Philippines Department of Health took a bold step towards improving the performance of the health sector by improving the way health services are being provided and financed. This program of change, known popularly as the Health Sector Reform Agenda, are directed mainly at a) expanding effective coverage of national and local public health programs; b) increasing access, especially by the poor, to personal health services delivered by both public and private providers; and c) reducing the financial burden on individual families through universal coverage of the National Health Insurance Program (NHIP). It consists of five interrelated health reform areas: 1. Local health systems development Promote the development of local health systems where networking among municipal and provincial health facilities are functional and sustained by cooperation and cost sharing among local government units (LGUs) in the catchment area. 2. Hospital reforms Provide fiscal and managerial autonomy to government hospitals, which involves improving the way hospitals are governed and financed so that quality of
50

care is improved, hospital operations are cost efficient, revenues are enhanced and retained, and dependence on direct budget subsidies are reduced. 3. Public health program reforms Strengthen the capacity of the DOH to exercise technical leadership in disease prevention and control; enhance the effectiveness of local public health delivery systems; and sustain funding for priority public health programs over a period required to remove them as public health threats. 4. Health regulatory reforms Strengthen capacities of DOH to exercise its regulatory functions to ensure that health products (particularly pharmaceuticals), devices, and facilities are safe, affordable, and of good quality. 5. Social health insurance reforms Expand the coverage and enhance the benefit package of NHIP so as to effectively reduce the financial burden to individual families through effective risk pooling, and provide the NHIP greater leverage to ensure value for money in benefit spending

Progress with implementation The Department of Health, with USAID support, organized a workshop in October 2002 to discuss the findings of a study that assessed the progress made after three years of implementing the Philippines Health Sector Reform Agenda. The program was launched in 1999 to improve the performance of the health sector, and to address the inequities and inefficiencies in the delivery and financing of health services. The review, which was undertaken by a team led by Prof. Orville Solon of the University of the Philippines School of Economics, concluded that although most of target activities and outcomes have not been met, modest progress was achieved, mainly in social health insurance reform and in the eight LGU advance implementation or convergence sites.

Process of monitoring and evaluation of reforms The Department of health intends to hold itself and its partners accountable for achieving the goals and targets it has established. This will be done through appropriate household and health facility surveys. Future reforms We have a divided population, with 20% extremely poor, living on less than $3 a day. These are people that have been essentially neglected. We would like to focus on them for at least the first few years to make sure they are brought into our healthcare system. We intend to involve all of them in our national healthcare insurance. Based on our work over the past seven months, we
51

will be able to enroll all of them in a combination of partnerships with our local government. The national government will need to pay the premium for all this (4.7 to 5 million pesos). We need to improve our rural healthcare units, equipping them with the necessary manpower, nurses and midwives. This is also a strategy that we are working on so by 2015 some of our Millennium Development Goals can be achieved: especially four and five looking at healthcare and reducing infant mortality. We are working on all this together with our program with regard to responsible parenting and family planning issues that we have at the moment. We will be able to address these within a year or two and this is just the first phase. The future phase is to expand; not only the number of people involved, but also improve the support value. In the Philippines, health insurance does not cover everything, and we aim to increase the amount it does. This will involve considerable investment in health. It will entail a partnership with the private sector with Public Private Partnerships (PPP). So, to give you the bigger picture of the healthcare system in the Philippines, we have the local health system and the national system takes care of bigger hospitals as well as major national health issues such as Tuberculosis, Aids and Malaria. The DOH has 72 larger hospitals and around 2000 smaller hospitals. The opportunities for business here would be with regard to opening our 25 major hospitals for PPP partners. This is where we will be interested in big players partnering with us so that we can improve the 25 hospitals which are spread all over the country. These are what we call level 4 hospitals dealing with major illnesses. Let me also say something about Medical tourism. We have a very active private hospital system here with essentially half of the population going private. One of the major goals of the government, especially in partnership with the Department of Tourism is to expand our capacity for Medical tourism. We would like to have a mechanism whereby part of the funds raised by Medical tourism will be channeled to assisting the poorer people within our population. We are looking at how we can best implement this. My view would be to allocate them a certain percentage of earnings from this sector.

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DR. ENRIQUE T. ONA: I would like to tell the private sector that the Philippines is open for Public Private partnerships. I have a rough estimate that we need something like 40 to 45 billion pesos to upgrade and modernize these 25 hospitals. We are also developing and would like to expand our retirement homes and of course these homes would have to have modern and accessible medical care available. We are also targeting this section to help our country. The healthcare system in the Philippines for those with health insurance is first class. Especially for foreigners, if it can be made available here it is at least 50% cheaper if not more. It is a huge saving on the cost of healthcare.

Results/effects As measured by standard health status indicators, the health of Filipinos improved considerably during the second half of the 20th century. Infant and maternal mortalities, as well as the prevalence of communicable diseases, have been reduced to half or less, while life expectancy has increased to over 70 years. These improvements, due to improved social conditions, are also the result, at least in part, of a health system with modern technologies. Public health interventions delivered by government health services have penetrated most areas of the country. Sophisticated curative interventions are available in major metropolitan areas, especially in a dominant private health sector. Nevertheless, for many Filipinos, health services have remained less than adequate. This is evidenced by a slowing in the rate of health improvements like childrens morbidity and mortality. Maternal mortality ratios have remained unacceptably high. The prevalence of most communicable diseases continues to be high and requires continuous attention. All reforms in the different components of the health system aim at the common objective of universal health care for Filipinos. The efforts have an initial focus on improving coverage of the poor, but need to eventually cover the whole population, regardless of income, in order to avoid or reverse a two-tiered system that tends to worsen inequities.

10 REFERENCES Source documents List of referenced documents used http://www.who.int/healthmetrics/library/countries/HMN_PHL_Assess_Final_2007_07_en.pdf http://apps.who.int/ghodata/?vid=1901

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http://www.un.org/en/development/desa/policy/capacity/output_studies/roa87_study_phi.pdf http://www2.wpro.who.int/asia_pacific_observatory/resources/Philippines_Health_System_Revi ew.pdf DOH, 2009; PSY 2008, NSCB. DOH, 2009; PSY 2008, NSCB. http://www.ncbi.nlm.nih.gov Philippine Statistical Yearbook, 2011 CHED, 2009. http://www.finduniversity.ph PHILIPPINE HEALTH STATISTICS 2009.pdf HRAccomplishments2011-2012.pdf http://www2.wpro.who.int/asia_pacific_observatory/resources/Philippines_Health_System_ Review.pdf Human Development Report 2004: http://hdr.undp.org/statistics/data/cty/cty_fLBN.html http://images.endixsantos.multiply.multiplycontent.com/attachment/0/SlbCsgoKCrYAAG K4sEI1/CHD1_chapterII_health%20care%20delivery%20system.pdf?key=endixsantos:jo urnal:129&nmid=265090109 http://erc.msh.org/hsr/index.htm http://www.unitedworld-usa.com/usatoday/philippines/interviews/enrique_ona.htm

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