F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M THE TRANSITION TO UNIVERSAL HEALTH COVERAGE IN BARMM Delivering and Financing Health Services in the Bangsamoro Autonomous Region in Muslim Mindanao 1 © 2020 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. 2 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE OF CONTENTS Acknowledgements 11 Abbreviations and Acronyms 13 A note on the geographic focus of this report 14 Executive Summary 16 Chapter One: Introduction 23 Chapter Two: The Philippines National Context 26 Summary 26 The Health Sector 31 Overview 31 Health service delivery 33 Health governance and regulation 34 PhilHealth 35 Philippines National Health Plans and Legislation 36 Health Financing 37 Health Sector Performance and Status 39 Focus – Contrasting Stories in the Philippines and China 43 Fuure Directions 44 Chapter Three: The Historical, Political and Health-Specific Context of the BARMM Region 45 Summary 45 Historical and Political Context 45 The GPH-MILF Comprehensive Agreement on the Bangsamoro 47 BARMM and the BOL 48 The Bangsamoro Transition Authority: Challenges and Opportunities for Health 49 Regional Poverty and Inequity 51 Focus – Immunization in BARMM illustrates the challenge to address poverty and inequity in sub-national regions 54 59 The BARMM Health System Future Directions 60 Chapter Four: Financing Health in BARMM 61 Summary 61 Introduction 62 63 Findings and Results Funding Streams 63 Health Funding Allocated for ARMM, 2013-2017 64 3 TABLE OF CONTENTS Locus of Control 66 Flow of Funds 68 Use of Funds 69 Discussion 74 Chapter Five: Access to Basic Health Services in BARMM – Results and Analysis of a Household Survey 81 Summary 81 Rationale 82 Methodology 82 Findings 85 The Population of the BARMM Sample 85 Household economic conditions 87 Health 95 Immunization Coverage 105 Nutrition, Breastfeeding and Perceptions on Stunting 117 Conclusions 125 Chapter Six: Supply-Side Readiness of Primary Health Care in BARMM 127 Summary 127 Analytic Approach 127 Overview 127 Data Overview 128 The SARA Framework 128 Findings 130 General Service Availability 130 General Service Readiness 122 Specific Service Readiness Overview 137 Conclusions 147 General Trends 147 BARMM in the National Context 149 FIndings and Recommendations 152 Chapter Seven: Immunization Program in the Philippines and Immunization Coverage in BARMM 154 Summary 154 Overview 155 Immunization Financing 157 Immunization Service Delivery 160 4 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE OF CONTENTS Program Management and Service Provision 160 Vaccine Inventory Management Distribution and Supply 163 Cold Chain/Stock Management 165 Discussion 166 Chapter Eight: Preparing for Effective and Robust Governance of Health in BARMM - Financial Management 168 Summary 168 Introduction 169 Context 169 Legal and regulatory arrangements for Public Financial Management 169 Institutional arrangements for Public Financial Management 170 Fiscal planning, budget preparation and allocation 171 Fiscal and fiscal risks 171 Budget preparation 172 Budget allocation 173 Revenue Collection and Management 174 ARMM/BARMM Revenue 174 LGU Revenue 175 Fiscal and budgetary trends 176 Budget execution 177 Cash management 177 Operational and program expenditure 177 Health and Social Services 178 Procurement 179 Controls on budget execution 180 Internal Audit 180 Accounting and financial reporting 181 External audit and oversight 181 Cross-cutting Issues 182 Cohesion and integration within and across tiers of government 182 Capacity and capability 182 Transparency 183 Autonomy and accountability 183 Health service delivery impact 184 Conclusions and Recommendations 185 5 TABLE OF CONTENTS Chapter Nine: Preparing for Effective and Robust Governance of Health in BARMM - Organizational Development 187 Summary 187 Background & Rationale 187 A Functional Structure for the MOH 188 Considerations for Further Strengthening of BARMM-MOH Functional Structure 191 Structure refinements: Options for the Future 192 Discussion and Policy Options 195 Summary 195 References 205 ANNEXES Annex A. Discussion of BARMM Health Financing Streams Annex B. Health Funding Allocations: Source, Allocating Authority, and Disbursing Authority by Level of Government Annex C. Assumptions on Expense Class Categories Annex D. Assumptions on Type of Health Care Function Annex E. BARMM Appropriations for Ministry of Health Annex F. Details about Sampling of Barangays, 2019 BARMM Household Survey Annex G. Immunization Findings, Children Age 0–11 Months, 2019 BARMM Household Survey Annex H. Immunization Findings, Children Age 12–23 Months, 2019 BARMM Household Survey Annex I. Nutrition and Anthropometric Results and Discussion, 2019 BARMM Household Survey Annex J. Additional Figures and Tables from 2017 BARMM Supply Side Readiness Assessment Annex K. Rationale for Proposed Changes in the BARMM Ministry of Health Functional Structure Annex L. Cross-Functional Groups for Decision Making and Coordination in the BARMM MOH Annex M. Number of Positions in the Proposed BARMM MOH Structure http://bit.ly/BARMMHFSAAnnexes 6 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURES Figure 1.1. BARMM Health Financing System Assessment Components 25 Figure 2.1. Philippine Population Age Pyramid, 2015 28 Figure 2.2. Philippines GDP Growth, 1980-2015 29 Figure 2.3. Average Yearly Growth in the Philippines of Various Economic Measures, 2006–2015 29 Figure 2.4. Income Inequality: Philippines versus Select East Asian Countries, 2006 – 2015 30 Figure 2.5. Leading Causes of Death, Philippines, 2018 31 Figure 2.6. Changing Burden of Disease in the Philippines, 1990 versus 2017 32 Figure 2.7. Current Health Expenditures by Financing Agent, Philippines, 2018 37 Figure 2.8. Out-of-Pocket Spending as Percentage of Current Health Expenditure, 2014-2017 39 Figure 2.9. Domestic General Government Health Expenditure as Percentage of Current Health Expenditure, 2014-2017 39 Figure 2.10. Under-5 Mortality Rates (per 1,000 live births), Philippines, 2008-2018 40 Figure 2.11. Under-5 Mortality Rates, by Region, Ten-Year Period Preceding 2017 NDHS (Per 1,000 Live Births) 41 Figure 2.12. Prevalence of Underweight, Select East Asian countries, 2010-2018 41 Figure 2.13. Maternal Mortality Ratio per 100,000 Live Births, Philippines versus Select East Asian Countries, 2005-2015 42 Figure 3.1. Poverty Incidence among BARMM Families over time 52 Figure 3.2. PhilHealth coverage by Region, 2017 52 Figure 3.3, Panel A: Infant and Child Mortality (per 1,000 population), Philippines versus BARMM, 2017 53 Figure 3.3, Panel B: Under-5 Stunting Prevalence (per 100 population), Philippines versus BARMM, 2019 53 Figure 3.4. Maternal Health Indicators, Philippines versus BARMM, 2017 53 Figure 3.5: Socioeconomic indicators, BARMM, Mindanao and Philippines overall, 2017 54 Figure 3.6. All Basic Vaccination Coverage by Region in the Philippines 55 Figure 3.7. All Basic Vaccination Coverage by Selected Southeast Asian Countries and Region Therein 55 Figure 3.8. Percentage of Children with No Vaccination by Selected Southeast Asian Countries 56 Figure 3.9. Polio vaccination coverage in Philippine Regions Source: DHS 2008, 2013 and 2017 56 Figure 3.10. Polio3 Vaccination Coverage by Selected Southeast Asian Countries 57 Figure 4.1a. Health Funding Allocations for ARMM, by Funding Source, 2016 to 2017 65 Figure 4.1b. Health Funding Allocations for ARMM, by Funding Stream, 2016 to 2017 65 Figure 4.2. Locus of Source, Allocation, and Disbursement of ARMM Health Funds, 2016–2017 (PhP13.3 billion) 67 Figure 4.3. Flow of Funds of Health Resources for ARMM 69 Figure 4.4. Health Expenditures by Health Care Function, ARMM, 2016-2017 71 Figure 4.5. Type of Health Spending by Funding Stream and Health Care Function, 2016-2017 72 Figure 4.6. Locus of Allocation of Health Funds, Variation 75 7 FIGURES Figure 4.7. Shift in Allocation Authority under Three Scenarios 79 Figure 5.1. Distribution of households per income quartile, BARMM provinces, 2019 87 Figure 5.2. Monthly Expenditures versus Average Monthly Income, BARMM, 2019 90 Figure 5.3. Proportional Breakdown of Medical Expenditure by Category, BARMM, 2019 91 Figure 5.4. Home and Land Ownership, BARMM, 2019 92 Figure 5.5. Matrix of Access Category by Indicator, BARMM 2019 95 Figure 5.6. Vaccine coverage, BARMM and Philippines, 2017 and 2019 106 Figure 5.7. Provincial Variation in Vaccine Coverage, BARMM, 2019 107 Figure 5.8. Vaccine coverage and timeliness, BARMM, 2019 108 Figure 5.9. Messages about Vaccination, BARMM, 2019 114 Figure 6.1. Analysis Overview 129 Figure 6.2. The Location of RHUs across BARMM 131 Figure 6.3. RHU and BHS Density 131 Figure 6.4. General Service Readiness, by Province 134 Figure 6.5. Facility-Based Delivery 2013–2016 139 Figure 6.6. Immunization Service Readiness 140 Figure 6.7. Stock-outs of NIP Vaccines 141 Figure 6.8. Child Health Service Readiness 143 Figure 6.9. Cervical Cancer Screening Service Readiness 146 Figure 7.1. Children Age 12-23 Months Receiving All Basic Vaccinations and with No Vaccination Coverage, 1998, 2008, 2017. 156 Figure 7.2. National Immunization Program funding, 2013 – 2019 158 Figure 7.3. Percent of RHUs staffed by Personnel with Training Related to Immunization Delivery 162 Figure 7.4. Vaccine Flow from RITM to RHUs in Each of the Five Provinces and Two City Health Offices, BARMM 164 Figure 7.5. Main Source of Electricity by Province, BARMM 165 Figure 9.1. The MOH proposed functional structure organogram 190 Figure 9.2. Alternative functional structure for MOH 194 MAPS Map 2.1. Population Density of the Philippines 27 Map 3.1. Bangsamoro Autonomous Region in Muslim Mindanao 46 Map 3.2. Poverty Incidence and Human Capital Index, Philippines 51 8 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLES Table 2.1. Number of Health Facilities by Region, 2016 34 Table 2.2. Health Expenditure in the Philippines, 2018 37 Table 3.1. Descriptive Overview of the BARMM Provinces 50 Table 3.2. Health Infrastructure in BARMM and Nationwide, 2016 59 Table 3.3. PhilHealth Accreditation Status of RHUs in BARMM, 2017 60 Table 4.1. Funding Streams for ARMM Health Sector 63 Table 4.2. Health Funding Allocated for ARMM Health Services, by Funding Stream, 2013-2017 (in million PhP) 64 Table 4.3. Locus of Control of Health Funding in BARMM, by Funding Stream, 2016-2017 66 Table 4.4. ARMM Health Funding Allocations by Expense Class (in million PhP), 2016-2017 70 Table 4.5. National Appropriations for ARMM Health Services and for ARMM (Total), 2016-2019; and BARMM Appropriations for Ministry of Health, 2020, in million PhP 74 Table 4.6. Potential for Mobilizing Additional Resources for Health from Various Funding Streams 76 Table 4.7. Health Expenditure as a Percentage of Total Current Expenditure, 2016 and 2017 77 Table 5.1. Distribution of Barangays and Sample Size by BARMM Provinces/City 83 Table 5.2. Distribution of Sample Households Visited, by BARMM province and classification, BARMM, 2019 84 Table 5.3. Distribution of Sample Population by Socio-Demographic and Economic Variables, BARMM, 2019 85 Table 5.4. Percent Distribution of Households by Province/City and Socio-Demographic Attributes, BARMM, 2019 86 Table 5.5. Average Household income per month, by province, BARMM, 2019 87 Table 5.6. Per Capita Income Distribution by Province (in Philippine Pesos), BARMM, 2019 88 Table 5.7. Household Additional Sources of Income, BARMM, 2019 89 Table 5.8. Average Estimated Monthly Household Expenditures in the Past Month (in PhP), BARMM, 2019 89 Table 5.9. Average Medical Expenditures by Category of Medical/Health Care Expenses (in PhP), BARMM, 2019 90 Table 5.10. Sources of Drinking Water, BARMM, 2019 93 Table 5.11. Treatment of Drinking Water Prior to Consumption, BARMM, 2019 93 Table 5.12. Prevalence and Type of Toilet Facilities, BARMM, 2019 94 Table 5.13. Distribution of Households by Province/City and by Health Service Consulted and Accessed/Availed, First 1,000 Days for Mother and Child, BARMM, 2019 97 Table 5.14. Percent Distribution of Households by Province/City and by Service for Child/Adolescent Health, BARMM, 2019 99 Table 5.15. Health Care Service Preferences, BARMM, 2019 101 Table 5.16. Distribution of Households by Provinces/City and by Type of PhilHealth Membership, BARMM, 2019 102 Table 5.17. Cost of medical services and mode of payment for most recent illness, BARMM, 2019 103 Table 5.18. Physical, Economic and Cultural Access Indexes, BARMM, 2019 105 Table 5.19. Crude coverage for children age 12-23 months, by gender, BARMM, 2019 109 9 TABLES Table 5.20. Intra-dose Interval Timeliness, Children Ages 12-23m, BARMM, 2019 111 Table 5.21. Missed Opportunities for Vaccination, by Visit, Children Ages 12-23m, BARMM, 2019 112 Table 5.22. Most Common Reasons Child is Not Fully Vaccinated 113 Table 5.23. Prevalence of Underweight, Stunting and Wasting of Children Ages 0-59m by Province/City, BARMM, 2019 118 Table 5.24. Prevalence of Underweight, Stunting, Wasting and Co-Existing Nutritional Problems of Children Ages 0-24m by Age Group and Gender, BARMM, 2019 120 Table 5.25. Breastfeeding Initiation and Exclusive Breastfeeding Practices, BARMM, 2019 121 Table 6.1. Data Collection by Province 128 Table 6.2. Health Facility Density 130 Table 6.3. Health Workforce Density 132 Table 6.4. Proportion of RHUs Meeting PhilHealth Accreditation Requirements 132 Table 6.5. Availability of Basic Amenities 135 Table 6.6. ANC Utilization Rates (Percent of Eligible Population) 138 Table 6.7. Immunization Service Readiness 142 Table 6.8. CVD Service Readiness 144 Table 6.9. Specific Service Readiness: Overall Performance 148 Table 6.10. General Service Readiness: Comparison to the National Context - a Condensed Set of Tracer Indicators 150 Table 6.11. Specific Service Readiness Comparison to the National Context - a Condensed Set of Tracer Indicators 151 Table 7.1. Philippines National Immunization Schedule. 155 Table 7.2. Vaccine Antigens Delivered from RITM to BARMM, 2014 to 2017, No. of Doses and Equivalent in PhP 159 Table 8.1. ARMM Proposed and Approved Budget (in Pesos Millions) – Net of RLIP 172 Table 8.2. GAA Allocations per ARMM Regional Line Agency (in Pesos, Millions) – Net of RLIP 173 Table 8.3. GAA Allocations per General Expense Class, 2015-2019 (in Pesos Millions) – Net of RLIP 173 Table 8.4. 2016 LGU IRA Dependency (in Pesos Millions) 176 Table 8.5. 2016 LGU External Revenue (in Pesos Millions) 176 Table 8.6. Infrastructure Development Indicators by Region 184 10 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M ACKNOWLEDGEMENTS This report was prepared by the World Bank’s Philippines This report is the result of continuing interaction and Health, Nutrition, and Population (HNP) team led by feedback between the World Bank team and a steering Robert Oelrichs and consisting of Netsanet Workie, Tomo and working group of core offices of the regional Morimoto, Ann Jillian Adona, Nelia Agbon, Sylvia Delosa, government, spanning the period of both the current Joyce Encluna, Maria Carmen (Ica) Fernandez, Vida Bangsamoro Autonomous Region in Muslim Mindanao Gomez, Sharon Faye Piza, Melissa Poot, Roberto Rosadia, (BARMM) and the former Autonomous Region in Muslim Angelo Santos, and Erin Sowers. Ed Alvinez, Jeramie Mindanao (ARMM). The working group was led by Chief Caballes, Regina Calzado, and Veronica de Leon provided Minister Hon. Ahod Ebrahim and Executive Secretary administrative and logistical support for the team. Abdulraof Macacua, Minister of Health Saffrullah Several chapters resulted from the work of consultants Dipatuan and OIC-Minister of Health Amirel S.Usman, and consulting firms, specifically: The Research Institute and Minister of Interior and Local Government Naguib for Mindanao Culture (RIMCU) led by Sharon Linog for Sinarimbo for BARMM; and Governor Hon. Mujiv Hataman the chapter on the 2019 BARMM Household Survey and Executive Secretary Laisa Alamia, Department on Healthcare Access, Biostat Global Consulting, led of Health-ARMM Secretary Kadil Sinolinding Jr., and by Dale Rhoda, for the immunization section therein, Department of Interior and Local Government-ARMM and Cecilia Acuin for the nutrition section; and Meraki Secretary Noor Hafizullah Abdullah for ARMM. Focal Consulting, Inc., led by Ruth Gerochi and Human Capital persons of the working group were, from the MOH- Asia, Inc., for the chapter on Governance - Organizational BARMM and DOH-ARMM: Deputy Minister Abdulhalik Development. Several chapters draw substantially Kasim, Deputy Minister Zul Qarneyn Abas, Tato Usman, from reports previously published by the World Bank, Sadaila Raki-in, Ibrahim Disomangcop, Laxaman specifically the World Bank Philippines HNP team led by Bangcola, Anisa Matuan, Erlyn Hampac, Eloisa Usman, Tomo Morimoto for the chapter on Supply-Side Readiness RC Harvy Gene Aquino, and Bai Almirah Raguia; and from Assessment, and the World Bank Philippines Governance the DILG-BARMM and DILG-ARMM: Luzminda Halud and team led by Lewis Hawke for the chapter on Governance Fredelino Gorospe. - Financial Management. The BARMM Household Survey was conducted in collaboration with the United Nations The working group also included the following offices: Children’s Fund (UNICEF); data collection was carried out Bangsamoro Planning and Development Authority led by RIMCU. The cover and report layout were designed by Director-General Mohajirin Ali, and the Ministry of by Christopher Carlos. The authors would like to thank Finance, and Budget and Management led by Minister Caryn Bredenkamp, Mickey Chopra, and Maude Ruest Eduard Guerra and Chief Minister Ahod Ebrahim during Archambault for their valuable comments as peer BARMM; and the Regional Planning Development Office reviewers; and Clarissa Crisostomo and David Llorito led by Executive Director Baintan Amputan, Finance also for their review. The team is equally grateful to and Budget Management Service and Regional Budget Gabriel Demombynes, Toomas Palu, Enis Baris, Aparnaa and Management Office led by Director Mimbalawag Somanathan, Mara Warwick, and Ndiame Diop for overall Mangutara Jr, and Technical Management Service led by technical guidance and direction. Director Ramil L. Masukat during ARMM. 11 ACKNOWLEDGEMENTS The report also benefited from numerous inputs received was substantially supported by the Government of from local chief executives and their staff, authorities of Australia through the regional Multi-donor Trust Fund health programs and facilities of DOH-ARMM and MOH- for Integrated Donor Financing for Health Programs. BARMM and national DOH, civil society organizations, The team thanks the representatives of the Australian and other development partners through a series of Department of Foreign Affairs and Trade for useful health summits, consultative workshops, and meetings. discussions and advice during the course of program National government agencies, namely the Department implementation. The team also acknowledges the of Health through Undersecretary Abdullah Dumama, the generous contribution by the State and Peacebuilding Department of Budget Management and the Department Fund (SPF). The SPF is a global fund to finance critical of Interior and Local Government also participated and development operations and analysis in situations of gave valuable guidance during these discussions. fragility, conflict, and violence. The SPF is supported by the Governments of Australia, Denmark, Germany, The This report was prepared as part of the programmatic Netherlands, Norway, Sweden, the United Kingdom, as advisory services and analytics delivered by the World well as IBRD. Bank to the Government of the Philippines. The program 12 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M ABBREVIATIONS AND ACRONYMS ANC Antenatal Care DOF Department of Finance AO Administrative Order DOH Department of Health AOL ARMM Organic Law DPWH Department of Public Works and Highways ARG ARMM Regional Government DSWD Department of Social Welfare and Development ARMM Autonomous Region in Muslim Mindanao DTTB Doctors to the Barrios BAC Bids and Awards Committee EMR Electronic Medical Record BARMM Bangsamoro Autonomous Region in EVMA Effective Vaccine Management Assessment Muslim Mindanao FAB Framework Agreement on the Bangsamoro BBO Bangsamoro Budget Office FBMS Finance and Budget Management Service BEmONC Basic Emergency Obstetric and Newborn Care FDA Food and Drug Administration BG Bangsamoro Government FP Family Planning BHS Barangay Health Stations GAA General Appropriations Act BIR Bureau of Internal Revenue GIDA Geographically Isolated and BOL Bangsamoro Organic Law Disadvantaged Areas BONC Basic Obstetric and Neonatal Care GPH Government of the Philippines BP Bangsamoro Parliament HBR Home-Based Vaccination Record BTA Bangsamoro Transition Authority HELPS Health, Education, Livelihood, Peace and BTr Bureau of Treasury Governance, and Synergy CAB Comprehensive Agreement on the Bangsamoro HEMS Health Emergency Management Service CAPI Computer-assisted personal interview HFEP Health Facilities Enhancement Program CAR Cordillera Administrative Region HFSRB Health Facilities and Service CCS Cervical Cancer Screening Regulatory Bureau CHD Centers for Health Development HHDRB Health Human Resource Development Bureau CHO City Health Office HFSA Health Financing System Assessment CLGU City Local Government Unit HRH Human Resources for Health CO Capital Outlay IDF International Diabetes Federation COA Commission on Audit IC Insurance Commission COPD Chronic Obstructive Pulmonary Disease ICCMN Inter-Cabinet Cluster Mechanism CRD Chronic Respiratory Disease on Normalization CSC Civil Service Commission IMCI Integrated Management of Childhood Illness CVD Cardiovascular Disease IPHO Integrated Provincial Health Office DBM Department of Budget and Management IPV Inactivated Poliovirus Vaccine DBMRO Department of Budget and Management IPT Intermittent Preventive Treatment Regional Office IRA Internal Revenue Allotment DepED Department of Education IRR Implementing Rules and Regulations DHD Demographic and Health Survey ITN Insecticide-treated Net DILG Department of the Interior and Local LGC Local Government Code Government LGU Local Government Unit DM Diabetes Mellitus MAM Moderate Acute Malnutrition 13 A B B R E V I AT I O N S A N D A C R O N Y M S ABBREVIATIONS AND ACRONYMS MCH Maternal and Child Health PhilGEPS Philippine Government Electronic MCP Maternity Care Package Procurement System MDG Millennium Development Goals PhilPEN Philippine Package of Essential M&E Monitoring and Evaluation NCD interventions MECA Midwives in Every Community in ARMM PIB Performance Informed Budgeting MILF Moro Islamic Liberation Front PNHA Philippines National Health Accounts MLGU Municipal Local Government Unit PS Personnel Services MNLF Moro National Liberation Front PSA Philippine Statistics Authority MOA Memorandum of Agreement RBMO Regional Budget and Management Office MOOE Maintenance and Other Operating Expenses (of ARMM) MOV Missed Opportunity for RDP Regional Development Plan simultaneous Vaccination REDPB Regional Economic and Development NCD Non-Communicable Disease Planning Board NCR National Capital Region RG Regional Government NDHS National Demographic and Health Survey RHU Rural Health Units 
 NDP Nurse Deployment Program RHMPP Rural Health Midwives Placement Program NEDA National Economic and Development Authority RITM Research Institute for Tropical Medicine NEP National Expenditure Plan RLA Regional Legislative Assembly NG National Government RLIP Retirement and Life Insurance Premiums NGA National Government Agency SAAOB Statement of Appropriations, Allotments NIP National Immunization Program and Obligations NNC National Nutrition Council SAM Severe Acute Malnutrition NHTS National Household Targeting System SARA Supply-side Availability and NOH National Objectives for Health Readiness Assessment NTPS National Tuberculosis Prevalence Surveys SDG Sustainable Development Goal OPAPP Office of the Presidential Adviser on the SDN Service Delivery Networks Peace Process SHA System of Health Accounts OD Organizational Development SHF Special Health Fund ODA Official Development Assistance SSRA Supply Side Readiness Assessment ORG Office of the Regional Governor TB-DOTS Tuberculosis–Directly Observed Treatment, (or Government) Short Course OPV Oral Polio Vaccine TFR Total Fertility Rate ORS Oral Rehydration Solution UHC Universal Health Care PCB Primary Care Benefit VSSM Vaccination Supplies Stock Management PDP Philippine Development Plan WaST Wasting and Stunting PFM Public Financial Management PHIC Philippines Health Insurance Corporation 14 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M A NOTE ON THE GEOGRAPHIC FOCUS OF THIS REPORT This report was developed with the aim of informing health policy during the political transition from the Autonomous Region in Muslim Mindanao (ARMM) to the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM). This transition began with the ratification of the Bangsamoro Organic Law (BOL) in January 2019. Some data collection under this study, and by other referenced sources, took place over the two years prior to passage of the BOL, when the area was governed under the ARMM political entity. However, as this transition is a very recent one, the findings in this report continue to reflect the current status of the new region. An exception is made for any reference to programs that were specific to the region’s prior government and legal framework. In those cases, reference is made to the policies, legal frameworks, or institutions that were specific to ARMM. Historically, health outcomes have been far worse in BARMM than elsewhere in the country. While health outcomes are complex and multi-dimensional, weaknesses in health governance have exacerbated the geographic and socio-cultural challenges associated with health care delivery. While the authors recognize that the transition is likely to introduce some challenges, it is hoped that the findings documented in this report can guide health policy, including investments towards high-impact priorities, and in this way help lay the foundation for better health care – and better health – for the people of BARMM. 15 EXECUTIVE SUMMARY EXECUTIVE SUMMARY This report is a subnational assessment of the health The Philippines has a mixed public-private healthcare financing and delivery system of an autonomous region system in which the private sector serves fewer people in the Philippines. This region, now known as the but holds a greater share of resources; however, the Bangsamoro Autonomous Region of Muslim Mindanao distribution of private hospitals is not equitable (BARMM), is in a period of transition, having recently throughout the country, with most being in major shifted to a new political organization and relationship metropolitan areas like the National Capital Region. Rural with the Philippines national government (NG) as the areas further from Metro Manila are served more often result of the ratification of the Bangsamoro Organic Law by public facilities, like government hospitals and rural (BOL) in early 2019. This assessment was initiated prior health units (RHUs). A hospital-based model of care to the formation of BARMM, when the region was known that emphasizes curative care services has resulted in as the Autonomous Region of Muslim Mindanao (ARMM). the underutilization of preventive and public health This was fortuitous timing, as the evidence and analysis services, driving up the cost of care and worsening of the health financing system under ARMM and the outcomes. A highly devolved system of health service corresponding policy recommendations for improvement delivery, in place since 1991, gives local government units can be made available to BARMM leadership when the (LGUs) responsibility for delivering primary and secondary region is already in a natural period of transition health services to consumers and implementing public and planning. health programs at the subnational level. To an extent, service delivery relies on local funding for staff and Although the region is autonomous in its governance, facilities, among other functions, which has resulted in it is subject to national-level program and policy disparate health outcomes depending on the funding initiatives, and the Philippines has taken key steps priorities of each LGU. In BARMM, the regional government recently towards the goal of ensuring universal health acts in some ways similarly to a single LGU, and as such, coverage for its citizens. In early 2019, it passed the the region is responsible for ensuring health care service Universal Health Care (UHC) Law, which aims to expand delivery, with provincial and municipal LGU support. the coverage of PhilHealth, the national health insurance program, to all Filipinos. The UHC Law also proposes The Philippines is currently one of Asia’s fastest growing to consolidate the majority of public health financing economies. Since 2010, the country has seen a period of around PhilHealth, with a view to reducing fragmentation accelerated growth, which has contributed to an overall of the public health financing system, and strengthening reduction in the national poverty rate, from 26.6 percent PhilHealth as the key strategic purchaser in the public in 2006 to 21.6 percent in 2015. Growth during this period health sector. was fastest among the poor: average per capita income among households in the bottom 40 percent of the Even before this law was passed, the Philippines population rose by 2.9 percent, compared to 1.6 percent was working to expand PhilHealth eligibility by fully for the country as a whole. Nevertheless, the Philippines subsidizing the premiums of poor families, and to expand faces numerous challenges to its development vision, benefits by making its primary care benefit package in particular in the areas of income inequality and high more widely available. Despite these efforts, in 2017 subnational poverty rates. families in the lowest income quintile reported the lowest PhilHealth coverage among all income groups As a lower middle-income country poised to transition to (59 percent versus 79 percent in the highest upper middle-income status, the Philippines exemplifies income quintile). the challenges of a health system in transition, having 16 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M yet to develop integrated, sustainably financed systems was highly fragmented, characterized by parallel to deliver a full range of services with equity and but uncoordinated funding streams with their own efficiency. Coverage of basic health programs lags well planning, reporting, and accounting burdens. National behind what would be expected of a country of the government appropriations provided up to 65 percent of Philippines’ level of economic development. Government the resources, channeled through health allocations in expenditure on health is low (as a share of GDP), while the appropriations for ARMM, cash and in-kind transfers out-of-pocket spending is very high, constituting two- from the national Department of Health (DOH), and thirds of total health spending. Immunization coverage funding for national DOH hospitals providing services is the lowest it has been in 20 years, maternal mortality to ARMM constituents. PhilHealth payments to health rates are high compared with other countries in the facilities also constituted a substantial 26 percent of total region, and many children continue to face malnutrition, health funding. Two-thirds of ARMM health expenditure resulting in high rates of underweight, stunting went towards curative care provided in hospitals; just and wasting. 35 percent of funds supported preventive and curative care provided at primary care facilities, public health, The poverty rate in BARMM is among the highest in the and administration of health programs. The regional nation: in 2018, at least 50 percent of the population government held limited allocation authority for health lived below the national poverty line. Results from the funding in ARMM. The new regional government in household survey conducted in BARMM in 2019 (Chapter BARMM stands to gain allocation authority, especially 5) produced similar results, finding the average monthly now that NG appropriations will be made via block grant. income for the five BARMM provinces to be below the However, under several future funding scenarios, the national poverty line and one-third of households living national government and possibly LGUs will maintain a on less than PhP 5,000 per month (approximately USD substantial degree of allocation authority. $100); in one province, over 50 percent of households reported this level of income. Low PhilHealth coverage Results from a 2017 supply side readiness assessment compounds the effect of low income on health care (Chapter 6) conducted by the World Bank show the access, and less than half of BARMM households reported effects of this poor investment in and funding of primary PhilHealth membership (in some provinces fewer than 40 care facilities, specifically rural health units (RHUs) percent). Unsurprisingly, health outcomes in BARMM are and barangay health stations (BHSs). The study found some of the worst in the nation, where child mortality is an overall shortage and uneven distribution of RHUs four to five times higher than it is in the National Capital throughout the region, such that some communities Region (NCR) and basic vaccine coverage for young had very little access to primary care services, or none children hovers around 30 percent by one estimate, at all. A lack of adequate human resources for health, compared to nearly 80 percent in the NCR. including doctors, nurses and midwives, compounded this shortage. Many facilities lacked basic amenities Since it is an autonomous region, the structure of health needed to support health service provision, including service delivery in BARMM differs from other parts of the electricity, communications equipment, and internet- Philippines in that the regional Ministry of Health holds enabled computers, though they did tend to have basic administrative control over facilities and the provision diagnostic equipment. In addition, there were substantial of health programs and services. However, BARMM LGUs gaps in essential medicines needed to prevent and treat are still required to ensure effective access to health care health conditions, and in vaccine antigens, which were under the 1991 mandate. This ambiguity in the sharing altogether unavailable or improperly stored at many of responsibility between MOH and LGUs has resulted in facilities. Provincial variation was observed, such that confusion in the accountability structure in health service fairly low average scores on readiness measures overall delivery and, at best, modest levels of LGU financial belied exceptionally poor availability in some facilities support for health programs and services. and correspondingly poor health care access for the communities served by them. A detailed analysis of Health Financing in BARMM (Chapter 4) found that the funding of the health system 17 EXECUTIVE SUMMARY A 2019 BARMM Household Survey (Chapter 5) provides immunization coverage to a convergence of multiple important insights into health care access among factors. Important amongst these was the lack of BARMM residents from the consumer perspective. Survey continuity in the supply of vaccines. Weaknesses in the respondents reported the highest utilization of services cold chain threaten the efficacy and availability of vaccine during pregnancy and a child’s early life, with more than antigens and other essential medicines. The high rates of 70 percent of respondents reportedly accessing child drop-out between first and third doses of routine infant immunization services, antenatal care (synonymous with vaccines indicate barriers to health service access, as well prenatal care) and infant vitamin supplementation. Health as gaps in service delivery readiness at the local facility care utilization declined among older children and was level. The report makes recommendations to address very low among adults, such that fewer than 10 percent these challenges in BARMM, however the findings are of respondents reported accessing any of the surveyed also most relevant to national efforts to integrate primary services for adult communicable and noncommunicable health service delivery and focus health financing through diseases, probably due to high cost or low service pooled funding mechanisms. availability. Specific to cost, respondents reported spending nearly PhP 1,000 on their most recent health Anthropometric data collected as part of the BARMM care visit (comprising professional fee plus the cost of Household Survey revealed a high prevalence of any medication). As described above, considering the underweight, stunting and wasting among children in the very low monthly incomes reported by respondents, it is region. Overall, 25 percent of children 0–5 years old were not surprising that primary care and preventive services found to be moderately or severely underweight, nearly were underutilized. 40 percent stunted, and 10 percent wasted. Moreover, the prevalence of coexisting wasting and stunting, a condition The effectiveness of routine immunization service delivery termed WaSt, was quite high at 3.2 percent. serves as can be viewed as an indicator of health system function. Every element of system capacity – including Improved governance in the region—as well as a financing, management, infrastructure, public demand more efficient functional organization of key agencies, creation and trained human resources – must be in place especially MOH—would help to address many of these for high rates of vaccine coverage to be achieved. That challenges. A 2019 study of BARMM governance and coverage may then be rigorously quantified through financial management (Chapter 8) underscores the a population-based survey, and the dimensions of challenges and opportunities facing the Bangsamoro deficiency and inequity informatively assessed. For this Transition Authority (BTA) during this period of reason, immunization was a focus of the HFSA (Chapter transition. The BTA faces the important task of 7) and serious failures of this basic health function are establishing improved systems and policies for BARMM described. Despite more than 70 percent of respondents and developing plans for supporting key priority areas in reporting accessing immunization services, just 34 the future while maintaining key functions of government percent of children aged 12–23 months received basic during the transition period. The time delineation of vaccine coverage, and just over 10 percent were fully these efforts adds an extra challenge and threatens to vaccinated. On the other hand, nearly one-quarter had undermine comprehensiveness and implementability no vaccine history at all. Within these broader measures, in favor of speed; COVID-19 adds another, much larger a more complex picture emerges: one-third of children challenge as it has forced the quick realignment of funds had evidence of receiving a first dose in a vaccine series to address the devastating health and economic impact but not subsequent doses, and more than 50 percent of of the pandemic. The regional Ministry of Health (MOH) children received a subsequent dose 56 days or more will play an essential role in COVID-19 recovery efforts, after a prior dose, both of which indicate but an assessment of its organizational structure incomplete protection. under ARMM (Chapter 9) found it to be inefficient, with offices and programs inappropriately positioned in the By examining the BARMM health system from multiple organizational structure and minimal institutionalized perspectives – covering inputs, capacities and outputs mechanisms for cross-collaboration. – the report was able to ascribe the low rates of 18 EXECUTIVE SUMMARY F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M SUMMARY OF POLICY OPTIONS AND RECOMMENDATIONS PRIORITY ACTION ITEMS FOR BARMM MOH Immediate 1. Begin a comprehensive strategic planning process with LGU participation. • Prioritize funding building blocks of service delivery as a way to target supply- side limitations and more effectively address immunization and nutrition program weaknesses and primary care access constraints. • Build (or strengthen) regional oversight mechanisms towards a goal of improving efficiency and equity in service delivery throughout BARMM provinces. • Ensure regional funding priorities are aligned with national funding priorities, as a substantial proportion of health funding in BARMM still flows from the National Government. • Work to increase regional resources for health by leveraging additional resources from existing funding streams, and spending more efficiently in order to gain value for money. • Engage local executives and health boards as well as hospitals as important stakeholders in service delivery. • Build monitoring and evaluation (M&E) into planning process by defining quantitative measures and assigning responsibility for ongoing plan implementation and refinement to a high-level office within MOH. Consider linking a portion of LGU health budgets to performance in key areas. 2. Develop a health financing strategy that integrates all current health-related funding streams in BARMM within MOH in order to increase the resource pool for addressing priority health needs, with a goal of reducing out of pocket expenditure for health among the population. 3. Initiate planning to address recommendations within the BARMM Regional Action Plan for Nutrition as well as the Effective Vaccine Management Assessment, recently conducted by UNICEF. Couch both of these efforts within the broader MOH regional planning initiative. 4. During transition period, maintain key staff, systems and resources from the ARMM administration in order to ensure government functioning. Major changes in these areas must be carefully managed in order to avoid disrupting continuity of services. Medium-term following plan development Make use of findings from the 2019 BARMM Household Survey to develop targeted interventions to address the most pressing access issues, especially for immunization and nutrition services. Utilize local talent to develop and implement creative public education campaigns on a variety of health-promotion messages, including accessing PhilHealth benefits and entitlements. Specifically gear messages to women as primary caregivers. 19 EXECUTIVE SUMMARY Ongoing 1. (with special attention before 2022) Make a targeted effort to engage LGUs in increasing local funding for health service delivery, for example through focused education efforts and incentive mechanisms. Consider (and build support for) the future possibility of a regional Special Health Fund that includes LGU contributions and supports services throughout BARMM with an aim to ensure geographic and socioeconomic equity. 2. Build BARMM data collection and analysis capacity in order to better track and measure health outcomes. Prioritize staff development in this area, or prioritize hiring for this skill set. MATTERS OF STRATEGIC ATTENTION FOR BTA AND MOH Medium-term Consider forming a management unit with dedicated technical staff to develop and implement a Special Health Fund and Regional Service Delivery Network. Action items for this unit would include: • Preparing partnership agreements that include definitions of roles and responsibilities of the different levels of health facilities, funding contributions, and payment mechanisms. • Preparing and implementing operational guidelines for referral systems, gatekeeping, and care management. • Designing and implementing unified records systems, care registries, and data collection and analysis systems. • Designing and implementing continuous quality improvement programs. Long-term Consider the possibility of regional purchasing of vaccine antigens, pending the following: • Supply-side limitations in vaccine service delivery have been adequately addressed throughout the provinces. • MOH has strong oversight mechanisms in place around inventory management, staff training and other vaccine delivery requirements. • Staff turnover rates are low or dropping, which would suggest the skill and experience levels of staff are improving. • MOH has strong data collection and analysis capacity to monitor immunization rates and target interventions to provinces, LGUs, and/or barangays with poor vaccine coverage. 20 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Policy Options and Recommendations There is no question that this period of change within BARMM will be deeply affected by the global emergence The transition from ARMM to BARMM heralds an of COVID-19, which will test the capacity of governments opportunity to re-envision a governance structure that both large and small to battle an ongoing pandemic is more efficient and better organized. Currently, the while facilitating the return to health and the economic BTA prioritizes maintenance of essential services for recovery of their populations. The COVID-19 pandemic has the BARMM population while simultaneously planning already highlighted the weaknesses in the Philippines and implementing changes in how those same services health system and the immediate and devastating will be provided once the transition period concludes situation that can emerge when public health and in 2022, all within the constraints of the BOL and other primary care services are persistently underfunded. A national regulations that guide how an autonomous new World Bank Group project was urgently mobilized region can function. At the same time, a coherent strategy in 2020 to address some of these elements, but recovery for sustainable health financing—including resource will be a prolonged effort. BARMM is in a fragile period mobilization and increased purchasing efficiency—is of transition, and expectations are high for improved under development. With all that is at stake in terms of conditions for all its citizens; the global pandemic will history and hopes for the future, it is essential the BTA challenge—yet hopefully inspire—the transition process succeeds in this effort. Specific to health, considering and the structures and systems that emerge. the poor health access and outcomes already described, the BTA should strongly consider creating a governance As of 2020, government appropriations to BARMM structure for health that reduces fragmentation and are made in the form of a block grant, giving the simplifies management of programs, attempts to BARMM regional government more authority over engage local-level players in supporting specific high how appropriations are spent. In addition, in 2020 the impact functions, and strategically utilizes existing and block grant appropriation was twice as large as the 2019 additional funds for maximum impact and appropriation, as was the amount allocated to the MOH. minimal duplication. The main question facing the BARMM-MOH leadership now is how best to use this increased funding to fill Although focused on BARMM, the current HFSA analysis gaps in service provision, and enhance the infrastructure may also serve as a case study of the challenges faced that supports service delivery. MOH should initiate a by subnational regions of the Philippines as the nation comprehensive strategic planning process to delineate moves towards unified financing for UHC and more its goals in the short- and medium-term, involving all integrated health service delivery. As mandated in the relevant stakeholders to ensure buy-in. This plan should UHC Law, the institution of collectively financed Service be accompanied by a five- to ten-year financing strategy Delivery Networks will do much to increase the efficiency that lays out detailed plans for mobilizing, utilizing, and of service delivery. This HFSA draws out details of the increasing resources as well as strengthening strategic BARMM experience that exemplify common challenges purchasing and payment arrangements. to instituting this mandate. In particular, the effective pooling and management of public financial resources Strengthening the building blocks of service delivery for health may not be straightforward – and will depend should be a major priority for MOH planning efforts and heavily on local, provinicial and regional governance initiatives. There is an urgent need to increase capacity capacities. A focus on delivering integrated services in a and infrastructure in RHUs specifically in the areas of coherent, person-centered framework must not lead to staffing, training, logistics, IT and equipment, in order de-emphasis of priority services previously supported by more effectively to deliver services as identified in the vertical programs, such as immunization. The scale of the 2018 Supply Side Readiness Assessment. investment needed to raise the health system’s readiness to deliver services should not be underestimated, and a In addition to the funding already appropriated, BARMM- rigorous assessment of local capacities is required. MOH should work to leverage additional resources from existing funding streams to further support service delivery. The focus for this effort should be on 21 EXECUTIVE SUMMARY NG appropriations and LGU funding, which are the two The impact of gender on access to health services funding streams that could offer the greatest increase was explicitly considered throughout this Health in resources and over which the regional government Financing System Assessment (HFSA). Both the supply has the greatest potential influence. Specifically, MOH side readiness assessment and the household survey should lobby the BARMM regional government to allocate suggest that accessibility and readiness of gender-specific a higher percentage of its block grant appropriation to services such as for maternal and child health, albeit still support health services, for although the total amount subject to considerable constraints in BARMM, are better of funding for BARMM and MOH doubled under the block than services for communicable and noncommunicable grant, the percentage of total BARMM funding dedicated diseases. Nutrition indices were also better for female to health services remained the same (4.7 percent) as for children than male children, while immunization 2019. Aside from mobilizing additional funds, the BARMM coverage rates are similar between female and male government can also make more resources available children. Female-headed households were enumerated for health by spending more efficiently, in order to gain in the household survey, but no evidence of any gender value for money. One way is for BARMM-MOH to ensure specific barriers to service delivery was found at that that additional funding streams that relate to health but level. While encouraging, caution should be exercised in are not directly appropriated to MOH be incorporated into drawing too strong a conclusion from this limited and the MOH budget and integrated into the overall health non-representative sample of services and households. plan for the region. Consolidating all existing health- Further research into gender-specific access to and related funding streams within MOH will give it a greater satisfaction with health services—particularly including pool from which to allocate resources to meet identified qualitative research—is recommended. needs. Formalizing a pooling mechanism during this time of regional transition will also make it easier for future Mothers made up over 90 percent of primary caregivers funding streams to be seamlessly integrated. in the BARMM household survey, indicating that interventions to improve child health outcomes should BARMM LGUs spend considerably less than non-BARMM target mothers. One area where women could be targeted LGUs on health services. MOH should devise ways to for interventions is childhood nutrition and breastfeeding encourage LGUs to take more responsibility for their practices. A “Women First” approach makes sense constituents’ health by providing more local funding. considering the role of women in child feeding; it would A regional health sector plan that clearly delineates also help with addressing the misconceptions regarding responsibilities, including funding roles of different the causes and consequences of stunting that were stakeholders, will make it easier for LGUs to see what elicited in the household survey. their support would go towards. Engaging LGU support for the health sector over the next few years is essential in BARMM is in a period of change and opportunity. It is light of the 2018 Mandanas v. Ochoa legal decision, which poised to address the challenges it faces through a new will significantly increase internal revenue allotments for structure of government and an improved organization of LGUs beginning in 2022. MOH to better manage and direct health programs. This report highlights many areas where improvements are Beyond these funding goals, MOH should take an active needed, and offers solutions and recommendations for role in ensuring integrated, comprehensive and high- accomplishing them. Poor health outcomes are influenced quality care at the service delivery level by providing by many factors: insufficient and untargeted funding; stronger regional oversight. Initiatives to increase access inadequate staffing and supply of medicines (including to care, for example by educating constituents about vaccines); poor economic conditions that make paying their PhilHealth benefits and ensuring adequate staffing for care nearly impossible for some families; and a lack at local facilities, should be spearheaded by MOH and of knowledge that prevents health seeking. Effective monitored and evaluated. A strong working relationship planning, coordination, monitoring and oversight are with the BARMM provinces will ensure that provincial essential to achieving the region’s goals for health for variation in geography, economics, ethnicity of citizens, its citizens. health care access and outcomes is addressed. 22 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M CHAPTER ONE: INTRODUCTION Before the current pandemic crisis, the Philippines was The country saw another major change in early 2019 with one of Asia’s fastest growing economies, having grown by the ratification of the Bangsamoro Organic Law (BOL), an average of 6.3 percent per year from 2010 to 2018. It is which disbanded the Autonomous Region of Muslim poised to cross the threshold from lower-middle income Mindanao (ARMM) and created a new Bangsamoro country (LMIC) status to upper-MIC status within the next Autonomous Region of Muslim Mindanao (BARMM). three years. Rapid growth has contributed to poverty BARMM is in a period of transition until it holds its first reduction, with poverty falling from 26.6 percent in election in 2022. The Bangsamoro Transition Authority 2006 to 16.6 percent percent in 2018. Growth during this (BTA) is working to determine the organization of the period was fastest among the poor. However, the effects government and its agencies as well as program priorities of the Covid-19 global pandemic on efforts to reduce and funding allocations in order to best meet the needs poverty throughout the world—and in the Philippines in of the people of the region, many of whom have faced particular—are likely to be severe, given the significant and continue to face substantial economic hardship. impact the pandemic has had on poor populations. The BARMM is a fragile region: a history of conflict and World Bank Group estimates that, worldwide, “up to 60 exposure to climate change and extreme weather events million people will be pushed into extreme poverty—that has led to economic vulnerability, high poverty rates, erases all the progress made in poverty alleviation in the and poor health outcomes compared to other regions past three years.” In the Philippines, efforts to contain 1 in the Philippines. The government of BARMM as well as the spread of Covid-19 have been particularly hard on the LGUs within BARMM have an opportunity to address poor families, who often rely on day wages earned in the some of these issues through strong organization and informal economy, which has been severely constrained. governance, and an allocation of resources that aims to The full extent of the hardships these families face is not address these inequalities. yet understood. The focus of this HFSA—the first subnational HFSA Under the current administration, the Philippines has undertaken by the World Bank Group—is to identify undertaken an ambitious medium-term reform agenda the unique constraints and opportunities facing the with a focus on equitable tax reforms, boosting market BARMM health financing system as situated within the competition, and improving ease of doing business, as broader legislative and health system context of the well as scaling up public investments for infrastructure Philippines as a whole. The broader aim underlying that and social services. One strategic area of this plan is to focus is to support the inclusive and overall growth “promote a long and healthy life [through] quality and and development of the Philippines by addressing affordable universal health care and social protection” intra-national inequities. Health financing refers to (NEDA 2017, 10). To meet this goal, the government passed the “function of a health system concerned with the a Universal Health Care (UHC) Law in early 2019, which mobilization, accumulation and allocation of money to aims to expand coverage of PhilHealth, the national cover the health needs of the people, individually and health insurance program, to all Filipinos, among other collectively, in the health system [...] The purpose of goals for the integration and comprehensiveness of health financing is to make funding available, as well health service delivery overall. as to set the right financial incentives to providers, 1 World Bank Group President David Malpass, media call transcript, May 2020. https://www.worldbank.org/en/news/speech/2020/05/19/remarks-by-world- bank-group-president-david-malpass-during-press-call-on-100-countries-milestone-for-covid-19-coronavirus-emergency-health-support 23 CHAPTER ONE: INTRODUCTION to ensure that all individuals have access to effective including the factors that led to the 2019 plebiscite and public health and personal health care” (WHO 2000). the ways in which the BOL and BTA aim to address them; Health financing is intrinsic to achieving universal health a special focus on the BARMM health system provides coverage, which can be conceptualized as consisting additional regional context. Then, taking sustainable of three key dimensions: population coverage, service health financing for UHC as the focus, this HFSA examines coverage, and cost coverage (WHO 2010b). In other words, health system inputs (financing) in BARMM, thoroughly universal health coverage must aim to meet the following analyzing the complex sources of funding as well as how three objectives (Teo and Cain 2018): they are disbursed—by whom and for what purposes. Options for a more effective and sustainable allocation of 1. There should be equity in access to health services— resources are presented and discussed, paying attention everyone who needs services should receive them, to the new opportunities available to the region in its not only those who can pay for them. current period of transition. 2. Quality of health services should be good enough to The results of a BARMM household survey conducted improve the health of those receiving services. in 2019 by the World Bank Group and development partners provide context on economic conditions and 3. People should be protected against financial risk, access to health care services among households within ensuring that the cost of using services does not put the five former-ARMM provinces as well as the BARMM them at risk of financial harm. expansion areas. The results of a 2017 supply side readiness assessment conducted by the World Bank With the passage of the UHC Law in the Philippines, the Group in the BARMM region provide a detailed accounting government has already demonstrated its commitment of the supply shortages faced by BARMM RHUs and the to achieving these goals, though implementation has challenges these shortages pose to delivering health faced challenges from the beginning. As an autonomous services. region, BARMM has a unique degree of independence in making decisions about health financing and health In order to look more closely at the interplay between system organization. The current period of transition supply and demand as it relates to a specific health is an opportune time to conduct a thorough and outcome, an in-depth study of vaccine coverage is comprehensive assessment of the current service gaps, presented. How can the low rates of immunization among barriers to access and utilization, and health financing children in the BARMM region be explained? Are they mechanisms. This will enable the region to make due to vaccine stockouts or staffing shortages in RHUs, considered decisions about how to better organize itself or does lack of time or money to visit a health care for maximum impact. Considering the WHO “building facility offer a better explanation—or is it something else blocks” framework (Figure 1.1), how can BARMM invest entirely? How might the UHC Law improve this situation, in and improve health system inputs now while it has and what else could be done to increase utilization of the opportunity to reconsider priorities, align fund this essential service? allocations, and make structural and organizational changes, in order to bring about the required outputs, Finally, results from a recent assessment of BARMM impact and health outcomes for its citizens? governance and financial management are presented, followed by recommendations for the efficient and To assist the BTA through this process, the following effective organization of the new BARMM Ministry of chapters present the findings of a broad review of the Health (MOH). The HFSA ends with a discussion of policy BARMM health system conducted by the World Bank options and recommendations for how the new BARMM Group and partners over the 2018 to 2019 calendar years. government might use the current transition period to It begins by providing context on the Philippines health put systems in place to improve health service delivery system, followed by a history of ARMM (now BARMM), and health outcomes in the region. 24 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 1.1: BARMM HEALTH FINANCING SYSTEM ASSESSMENT COMPONENTS FUNDING FROM REGIONAL BUDGET HEALTH PFM ASSESSMENT FUNDING ANALYSIS INPUTS PHILHEALTH REIMBURSEMENT FUNDING FROM NATIONAL APPROPRIATIONS FUNDING AND IN-KIND RESOURCES FROM SERVICE DELIVERY HUMAN RESOURCES CAPACITY SUPPLY-SIDE ORGANIZATIONAL INFRASTRUCTURE READINESS DEVELOPMENT ASSESSMENT LOGISTICS SERVICED ACCESS TO SERVICES HOUSEHOLD SURVEY POPULATION IMMUNIZATION COVERAGE This report was undertaken prior to the emergence the health sector—will impact the BARMM people and of the COVID-19 pandemic, but the findings and communities. The difficulty for the BARMM population lies recommendations must now be interpreted within that in the extreme fragility of its circumstances immediately context. The extent to which the pandemic will affect prior to the pandemic: recovery here will proceed from a vulnerable populations like those in the Philippines is much lower starting point than elsewhere in the country. still unknown, as is the effect it will have on the BARMM To address the massive impact of the pandemic, and region specifically in this important period of transition. mobilize effective curative and preventative interventions The BARMM region is indeed autonomous, but it is at scale, it will be critical for BARMM, and for the still very much affected by policies implemented at Philippines as a whole, to ensure the health system is the national level. The entire country’s efforts to move strengthened at the level of primary care and the lower- towards economic recovery from COVID-19—not least in level hospitals. 25 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T CHAPTER TWO: THE PHILIPPINES NATIONAL CONTEXT SUMMARY • The Philippines is one of Asia’s fastest growing economies, but growth has not been equitably distributed throughout the country. Several geographic areas lag behind—including the newly- organized BARMM region—on a number of economic and health indicators. • The Philippines model of health care service delivery places a strong emphasis on hospital-based curative care; meanwhile, the primary care system remains weak and underfinanced. PhilHealth, the national health insurance program, has an effective coverage children aged 12–23 months receiving basic coverage rate of 66 percent; however, fewer poor families in 2017—a drop in coverage of nearly 10 percent since are covered by PhilHealth than wealthier families 2008. In 2019, just over 30 percent of BARMM children despite recent efforts to increase enrollment among aged 12–23 months received the required basic the lower income quintiles. High out-of-pocket vaccines, according to one estimate. costs for health care, especially pharmaceuticals, disproportionately affect poor families, leaving many • The Philippines passed a Universal Health Care (UHC) exposed to severe financial hardship. Government Law in 2019, in an attempt to streamline and simplify spending on health care is low as a share of GDP. health financing, and to expand coverage of services and populations. However, implementation of the • The Philippines has a devolved system of health law faces financial and administrative challenges. care, with the national government (NG) setting policies and Local Government Units (LGUs) The Philippines is the 13th most populated country in implementing programs and ensuring access to the world, and the fourth in the East Asia region, with services. However, LGUs vary in how effectively they a total population in 2018 of 107 million spread across design and implement their policies, leading to wide more than 7,000 islands. These diverse tropical islands variation in the quality and comprehensiveness of are grouped into three geographic areas: Luzon, the service delivery. Visayas, and the large southern island of Mindanao. The population growth rate, though showing steady declines • Health outcomes in the Philippines are poor, since 2012, was still a robust 1.4 percent in 2018, with especially in economically disadvantaged 47 percent of the population living in urban areas. The regions. Though some health indicators are population is relatively young: in 2015, the median age showing improvements, many, including of citizens was 24.3 years, and in 2018 just five percent of childhood immunization, maternal mortality and the population was 65 or older. Adult literacy is high (98 undernutrition, lag behind those for regional percent in 2015), and average life expectancy in 2018 was counterparts abroad. Vaccination is particularly weak, estimated at 71 years. and geographically patchy, with just 70 percent of 26 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M MAP 2.1. POPULATION DENSITY OF THE PHILIPPINES I Ilocos Region VIII Eastern Visayas 120°E 1 2 Ilocos Norte Ilocos Sur 49 50 Biliran Eastern Samar PHILIPPINES 3 4 La Union Pangasinan 51 52 53 Leyte Northern Samar 11 POPULATION DENSITY Samar CAR Cordillera Admin. Reg. 54 Southern Leyte 20°N 5 Abra 6 Apayao IX Zamboanga Peninsula Lu zo n S tra it POPULATION DENSITY SELECTED CITIES 7 Benguet 55 Zamboanga del Norte PEOPLE PER KM2 8 Ifugao 56 Zamboanga del Sur 42,500 NATIONAL CAPITAL 9 Kalinga 57 Zamboanga Sibugay 10 Mountain Province 58 City of Isabela 3,500 PROVINCE BOUNDARIES II Cagayan Valley X Northern Mindanao 1,000 REGION BOUNDARIES 11 Batanes 59 Bukidnon Ba b u nel 500 12 Cagayan 60 Camiguin ya n Cha n 13 Isabela 61 Lanao del Norte 250 14 Nueva Vizcaya 62 Misamis Occidental 1 100 15 Quirino 63 Misamis Oriental 6 20 III Central Luzon XI Davao Region 12 16 Aurora 64 Davao de Oro Tuguegarao 17 Bataan 65 Davao del Norte 5 18 Bulacan 66 Davao del Sur 9 125°E 19 Nueva Ecija 67 Davao Oriental CAR II 20 Pampanga 68 Davao Occidental 2 21 Tarlac I 10 13 22 Zambales XII SOCCSKSARGEN 8 69 San Fernando 3 Cotabato NCR National Capital Reg. 70 Sarangani 7 71 South Cotabato Baguio IV-A CALABARZON 72 Sultan Kudarat 14 PHILIPPINES 15 23 Batangas 24 Cavite XIII Caraga 4 25 Laguna 73 Agusan del Norte 26 Quezon 74 Agusan del Sur 16 27 Rizal 75 Dinagat Islands 19 III 76 Surigao del Norte 22 21 IV-B MIMAROPA 77 Surigao del Sur San IV-A 28 Marinduque Fernando 18 29 Mindoro Occidental Bangsamoro 20 30 Mindoro Oriental Autonomous Reg. in 17 31 Palawan BARMM Muslim Mindanao NCR 27 32 Romblon 78 Basilan V Bicol 79 80 Lanao del Sur Maguindanao MANILA 24 Calamba V 33 Albay 25 26 34 81 Sulu 34 Camarines Norte 82 Tawi-Tawi 23 35 Camarines Sur 36 36 Catanduanes 37 Masbate 35 Calapan 38 Sorsogon 28 30 33 Legaspi VI Western Visayas 39 Aklan 29 Sibuyan 40 Antique Mi Sea 38 41 Capiz nd or 42 Guimaras o 52 43 Iloilo 32 37 Str 44 Negros Occidental ait 53 VIII VII Central Visayas Visayan 45 Bohol 46 Cebu IV-B Sea 49 50 47 Negros Oriental 39 48 Siquijor 41 Tacloban 40 43 51 Leyte Iloilo Gulf Philippine IBRD 45378 | OCTOBER 2020 46 Cebu This map was produced by the 42 54 Sea Cartography Unit of the World Bank Group. The boundaries, VI 75 colors, denominations and any 10°N other information shown on this 44 45 map do not imply, on the part of 76 the World Bank Group, any 31 47 judgment on the legal status of any Mindanao XIII territory, or any endorsement or 60 73 acceptance of such boundaries. 48 Sea VII 77 X Butuan IX Cagayan de Oro 63 74 Sulu Sea 62 55 Pagadian 61 59 56 79 57 65 64 56 69 66 67 Cotabato Davao City 80 XI Moro 58 Gulf Davao 78 BARMM Gulf 72 Koronadal 71 68 MAL AYSIA XII 70 81 0 50 100 Miles 82 Celebes Sea 5°N 0 50 10 Kilometers 120°E 125°E 27 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T FIGURE 2.1. PHILIPPINE POPULATION AGE PYRAMID, 2015 MALE AGE GROUP FEMALE 80 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 UNDER 5 6 4 2 0 2 4 6 Source: Philippines Statistics Authority, 2017b (within National Objectives for Health, 2017-2022, p. 6). The national population is young—with children aged 0–4 and 5–9 comprising the largest age groups. The median age of the total population is 24.3 years. Males outnumber females in the age groups 0 to 54 but the situation is reversed in older age groups. The dependency ratio remains relatively high, despite a slight decrease from 60 to 58 dependents for every 100 persons in the working age group (over the period 2010 to 2015). The Philippines was until recently one of Asia’s fastest the Philippines was poised to cross the threshold from growing economies, showing sustained economic growth lower-middle income country (LMIC) status to upper-MIC since the end of the 1990s (Figure 2.2). Categorized as status within the next three years.2 Rapid growth has a newly industrialized country, it is transitioning from seen the incidence of poverty fall from 26.6 percent in an economy based on agriculture to one geared more 2006 to 21.6 percent in 2015. Growth during this period toward manufacturing and services. Since 2010, the was fastest among the poor: average per capita income Philippines has experienced accelerated growth, with among households in the bottom 40 percent of the annual average growth of 6.3 percent in 2010–18, second population rose by 2.9 percent, compared to 1.6 percent only to China among large economies in the East Asia for the country as a whole (Figure 2.3). and Pacific region. Prior to the COVID-19 global pandemic, 2 GNI per capita of the Philippines was $3830 in 2018 (Atlas Method, Current US$). 28 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 2.2. PHILIPPINES GDP GROWTH, 1980–2015 EXTERNAL DEBT COUP ASIAN FINANCIAL GLOBAL FINANCIAL CRISIS ATTEMPTS CRISIS CRISIS GDP GROWTH RATE $3.20 POVERTY RATE 8% 70% 60% 6% 50% 40% 4% 30% 2% 20% 10% 0% 0% -2% -4% -6% -8% 1980 1985 1990 1995 2000 2005 2010 2015 CRISIS PERIOD GDP GROWTH RATE $3.20/DAY POVERTY RATE Source: World Bank 2018 FIGURE 2.3. AVERAGE GROWTH RATE OF VARIOUS ECONOMIC MEASURES, 2006-2015 9.1% 3.6% 2.9% 2.2% 1.6% 0.4% Average wage Average income Median income Income of the GDP per capita Wealth of the richest 15 bottom 40% (2006-2018) Source: World Development Indicators, World Bank staff estimates using the Family Income and Expenditure Survey, the Labor Force Survey, and Forbes wealth estimates. The Philippines elects a new President every six years and as such elects its own regional government. Each to serve as head of government and of the State. A of the constituent units at the provincial and city or tripartite system of governance distributes the powers of municipal level is governed by a Local Government government among three branches: Executive, Legislative Unit (LGU) headed by a Local Chief Executive. In 1991, and Judiciary. The nation consists of 17 regions; the enactment of the Local Government Code (LGC) within these, there are 81 provinces, 145 cities, 1,489 transferred some national government (NG) powers municipalities and 42,036 barangays (the Filipino term for and functions to LGUs, including the delivery of basic the smallest administrative unit, equivalent to a village, social and health services. Each LGU enjoys a certain district or ward). The regions are administrative divisions level of autonomy and is legally entitled to an annual and do not have elected officials; the exception to this is share of national wealth called the Internal Revenue BARMM, and its precursor ARMM, which is autonomous Allotment (IRA) (DOH 2018). This amount is set to increase 29 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T dramatically in 2022 as a result of the Mandanas v. Ochoa Despite recent advances, the Philippines faces challenges legal decision, which expands the revenue base from to this development vision. Income inequality, although which IRAs will be drawn. 3 declining, remains stubbornly high and is one of the highest in the East Asia region (Figure 2.4). Average real The Philippine Development Plan 2017–2022 outlines an wages have been stagnant since 2000, partly driven by a ambitious reform agenda with a focus on equitable tax lack of market competition. Despite recent improvements, reforms, boosting market competition, and improving the quality of basic education remains low, and not all ease of doing business, as well as scaling up public children complete compulsory schooling, particularly in investment in infrastructure and social services. This areas affected by conflict. Plan has four strategic aims: (a) building a prosperous, predominantly middle-class society where no one is Just under five percent of the population of Metro Manila poor; (b) promoting a long and healthy life through social lives below the national poverty line. Meanwhile, outside protection, with affordable universal health care of a the nation’s capital, the poverty rate is much higher. This high quality; (c) becoming smarter and more innovative can be partly explained by the link between poverty and through expansion of skill sets in order to adapt to physical vulnerability in the form of conflict and natural rapidly changing technology and work requirements; disasters. The highest poverty rates in the country, where and (d) building a high-trust society, through people- more than 50 percent of the population is poor, are in centered, effective, and accountable government (NEDA two areas: conflict-affected areas of western Mindanao 2017). This medium-term plan is anchored in Ambisyon (plus islands of BARMM), and provinces in the eastern Natin 2040, a 25-year long-term vision adopted by the Visayas region, which are particularly vulnerable to current administration. Approved in October 2016 by typhoons and other extreme weather events. Mindanao, President Rodrigo Roa Duterte, the Ambisyon Natin though home to one-quarter of the population of the envisages a three-fold increase in per capita income by Philippines, is where nearly 40 percent of the nation’s 2040 and an eventual end to poverty in the Philippines. poor reside. FIGURE 2.4. INCOME INEQUALITY: PHILIPPINES VERSUS SELECT EAST ASIAN COUNTRIES, 2006 – 2015 50 48 PHILIPPINES 46 INDONESIA 42 THAILAND GINI INDEX 40 VIETNAM 38 MALAYSIA 36 CHINA 34 32 30 2006 2009 2012 2015 Source: World Bank, Development Research Group 3 Mandanas v. Ochoa, Jr, GR Nos. 199802 & 208488, May 22, 2019 30 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M The Philippine population is expected to reach nearly 140 efficiently to deliver a full range of services. High million by 2040, with those of working age (15–64 years) levels of out-of-pocket payments for health care and set to increase to 66 percent of the population, with incomplete or inefficient health financing mechanisms eight percent over the age of 65. However, current trends mean that expenditure on health remains a significant strongly suggest mixed human capital outcomes that cause of poverty. In the Philippines, although external undermine the well-being and productivity of current sources account for at most two percent of total health and future generations. In 2018, the Philippines ranked expenditure since 2005,5 they remain an important 84th out of 157 countries in the WBG Human Capital Index source of financing and technical assistance for priority (HCI), which captures the impact of human capital on disease programs. future growth prospects. The national HCI rating (0.55) indicates that the future productivity of a child born The Philippines faces additional challenges as it in the Philippines today will be 45 percent below what transitions from a burden of disease that was primarily could have been achieved if that child had completed communicable and infectious to one of chronic, their education and achieved full health. In 2017, the HCI 4 noncommunicable disease and malnutrition (Figure for the Philippines was lower than the average for other 2.5). Furthermore, as described in the Philippines countries in the East Asia and Pacific region (0.61). Health Agenda 2016–2022, it also faces a third or triple burden of disease resulting from rapid urbanization and industrialization.6 Increasingly, diseases of affluence THE HEALTH SECTOR and urbanization (such as diabetes and cardiovascular disease) present a drain on national resources. The Overview current health system, with its emphasis on curative services at the expense of primary health care, is ill- As a lower middle-income country, the Philippines equipped to either prevent or manage these chronic exemplifies the challenges of a health system in conditions. At the same time, long understood and transition. These are the challenges faced by rapidly relatively tractable threats—such as vaccine preventable developing countries that have yet to develop integrated, diseases—continue to threaten the health of Filipinos. sustainably financed systems, able equitably and FIGURE 2.5. LEADING CAUSES OF DEATH, PHILIPPINES, 2018 Ischaemic heart diseases 88 Neoplasms 67 Cerebrovascular diseases 62 Pneumonia 57 Diabetes Mellitus 32 Hypertensive diseases 27 Chronic lower respiratory infections 25 Respiratory tubercolosis 22 Other heart diseases 20 Other genitourinary diseases 16 0 10 20 30 40 50 60 70 80 90 100 Deaths (in thousands) Source: Philippines Statistics Authority 2018b 4 “Ranging between 0 and 1, the Human Capital Index takes the value 1 only if a child born today can expect to achieve full health (defined as no stunting and survival up to at least age 60) and complete her education potential (defined as 14 years of high-quality school by age 18). Source: World Bank, The Human Capital Project. 5 Philippine Statistics Authority, Philippine National Health Accounts. 6 The Philippines defines the triple burden of disease as: communicable diseases (i.e. HIV/AIDS, tuberculosis, malaria; mosquito-borne diseases), non-com- municable diseases (i.e. diabetes, cancer, heart disease and their risk factors, including obesity and smoking), and diseases of rapid urbanization and indus- trialization (i.e. mental illness, substance abuse, and injuries) 31 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T FIGURE 2.6. CHANGING BURDEN OF DISEASE IN THE PHILIPPINES, 1990 VERSUS 2017 Source: Institute for Health Metrics and Evaluation, University of Washington. Changes in lifestyle and the increasing prevalence of risk factors related to diet, tobacco smoke and high systolic blood pressure contribute to a rising incidence of diseases of the cardiovascular system, malignant neoplasms, diabetes and road traffic accidents, which are cases of non-communicable diseases in the country. Despite advances in the management and treatment of infectious diseases, many Filipinos continue to suffer from diseases for which effective interventions are available. These include human immunodeficiency virus infection, TB and vaccine-preventable diseases such as measles and diphtheria. Blue: Non-communicable Diseases, Red: Communicable, Maternal, Neonatal and Nutritional Diseases, Green: Injuries and Violence 32 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M In general, the Philippines has sound, comprehensive health strategies and policies developed at the national level, but these have not been effectively mirrored in local-level program implementation. Coverage of basic health programs lags well behind what would be expected of any country at a comparable phase of economic development, with immunization coverage at its lowest point in twenty years, poor (albeit improving) maternal health outcomes, and high levels of malnutrition for a middle-income country. Government expenditure on health is low (as a share of GDP) by global (but not by regional) standards. Out-of- pocket spending on health is high (predominantly for pharmaceuticals, constituting two-thirds of total health spending), and shows no sign of declining. However, there is reason for optimism. In 2012, the Philippines passed Republic Act (RA) No. 10351, known as the Sin Tax Reform Law, in order to finance its governments manage district and provincial hospitals. growing investment in human capital through an excise Meanwhile, municipal governments provide primary care, tax on tobacco and alcohol products. The law was including preventive and promotive health services and successful in generating new income: in its first year of other public health programs through RHUs and BHSs. implementation, excise tax collections on these products The health system is organized differently in the BARMM increased from 0.5 percent of GDP in 2012 to 0.9 percent region due to its special autonomous status; specifics of in 2013, and to 1.2 percent in 2017.7 The Philippines used this system will be discussed in later chapters. In general, this revenue to further health care goals, specifically RHUs and BHSs are intended to be the first point of by increasing enrollment of poor families in PhilHealth, contact for government health services. However, many the government health insurance program, from 5.2 patients lack knowledge of PhilHealth benefits, and million to 14.7 million by the end of 2014. An additional consequently access care at hospitals instead, where the half million Filipinos were enrolled by the end of 2015 focus is more on cure and less on prevention and (Kaiser, Bredenkamp and Iglesias 2016). This expansion early intervention. in PhilHealth enrollment promises to bring much- needed financial protection for vulnerable families—if The Philippines has a mixed public-private healthcare accompanied by efforts to ensure awareness of both system that operates within a fragmented environment. enrollment and benefits, to expand the benefit package, The private sector caters to only about 30 percent of and to increase the efficiency of health the population but is larger than the public system in service purchasing. terms of financial resources and staff (Oxford Business Group 2017). It provides health care that is generally paid Health service delivery through user fees at point of service. Sixty-five percent A hospital-based model of care in the Philippines of the 1,224 hospitals in the country in 2016 were private, has resulted in the underutilization of preventive and though they are not evenly distributed throughout the public health services, driving up the cost of care and regions: the majority are located in Metro Manila and worsening outcomes. Throughout the country, provincial surrounding areas in Central Luzon (Dayrit et al. 2018). 7 Broken down as follows: Tobacco excise taxes (0.3 percent of GDP) and alcohol excise taxes (0.2 percent of GDP) in 2012; tobacco excise taxes (0.6 percent of GDP) and alcohol excise taxes (0.3 percent of GDP) in 2013; tobacco excise taxes (0.8 percent of GDP) and alcohol excise taxes (0.4 percent of GDP) in 2017. 33 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T TABLE 2.1. NUMBER OF HEALTH FACILITIES BY REGION, 2016 Group of Regions Barangay Rural Health Government Government Private Private Total Total Average islands Health Stations Units Hospitals Beds Hospitals Beds Hospitals Beds Beds per Hospital NCR NCR 20 492 48 17,221 115 12,502 163 29,723 182.3 The rest of CAR 796 97 14 1,340 11 622 25 1,962 78.5 Luzon Ilocos (I) 1,176 150 36 2,093 50 2,044 86 4,137 48.1 Cagayan Valley (II) 1,356 96 25 1,898 32 1,427 57 3,325 58.3 Central Luzon (III) 1,934 293 50 4,064 116 5,866 166 9,930 59.8 CALABARZON (IV-A) 2,424 225 58 3,342 159 9,086 217 12,428 57.3 Mimaropa (IV-B) 1,104 82 13 920 12 487 25 1,407 56.3 Bicol (V) 1,146 134 21 1,916 30 1,571 51 3,487 68.4 Visayas Western Visayas (VI) 1,897 147 34 2,862 27 2,936 61 5,798 95.0 Central Visayas (VII) 2,035 163 23 2,060 37 4,376 60 6,436 107.3 Eastern Visayas (VIII) 883 161 23 1,835 23 1,127 46 2,962 64.4 Mindanao Zamboanga Peninsula 757 92 13 1,580 31 1,424 44 3,004 68.3 (IX) Northern Mindanao (X) 1,307 121 23 2,182 45 3,185 68 5,367 78.9 Davao Region (XI) 1,119 68 13 1,388 42 3,519 55 4,907 89.2 SOCCKSARGEN (XII) 1,100 53 12 1,230 45 3,381 57 4,611 80.9 CARAGA (XIII) 698 82 10 725 8 564 18 1,289 71.6 BARMM 464 131 18* 715 7 200 25 915 36.6 Philippines 20,216 2,587 434 47,371 790 54,317 1,224 101,688 83.1 Source: DOH-HFSRB 2016 Health governance and regulation regional hospitals, and it is in charge of licensing hospitals, laboratories and other health facilities through The Philippines has a devolved system of health service the Health Facilities and Service Regulatory Bureau delivery; this was put into place with the enactment of (HFSRB), and health products through the Food and the Local Government Code (LGC) in 1991. In this system, Drug Administration (FDA). Meanwhile, the Insurance both the NG and LGUs play important roles in managing Commission (IC) regulates and supervises the operations the delivery of promotive, preventive, curative and of private insurance companies, and since 2015, of rehabilitative health services. health maintenance organizations as well, except for the government health insurance program, PhilHealth. At the national level, the Department of Health (DOH) The national DOH manages and funds large-scale public serves as the overall steward and technical authority on health programs, such as immunization and tuberculosis health, being the national health policy and regulatory treatment, while also coordinating government, private institution. It is mandated to develop national plans, sector and development partner assistance on health, technical standards, and guidelines on health. It and leveraging funds for improved health performance. supervises government hospitals and specialty and 34 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M The LGUs, on the other hand, are responsible for delivery short course) and an outpatient package. It also has a of primary and secondary health services as well as primary care benefit (PCB) package, which was previously the implementation of public health programs at the only available to indigent beneficiaries, but in 2018 was subnational level. LGUs prepare plans, ensure financing, expanded to include a portion of the formal economy, and implement local health programs and services. lifetime and senior citizen beneficiaries.8 The PCB The local health board, which consists of selected and package includes general consultations as well as some appointed members, exercises advisory powers, planning outpatient diagnostic services and medicines; members authority and responsibility for health services (Keleker must access these services at a PhilHealth-approved and Llanto 2013). This allows for localities to be more facility, usually their local RHU or BHS. The government responsive to the unique needs of the citizens who entity that owns the RHU or BHS is paid a fixed, yearly fee live there; however, it also means variation in program per enrolled family. coverage across provinces and municipalities, and unpredictability of financing from year to year at the Despite its primary care packages, PhilHealth spending local level, resulting in disparate health outcomes. In has historically been heavily biased towards hospital- addition, decentralization also challenges the ability of based services: in 2018, more than 80 percent of the DOH to mandate reforms, as LGUs have the executive PhilHealth benefit payments were to finance hospital- and financial authority to decide their own approach to based care (both public and private). Nevertheless, health service delivery. despite such substantial spending, PhilHealth covered just 14 percent of hospital care, while households paid The health governance and health service delivery for nearly half (41 percent) of total hospital care expenses system in the BARMM region differ from this national (PSA-PNHA 2014). model. The BARMM regional government plays a significant role in health financing and oversight, though PhilHealth eligibility has grown rapidly in the past decade LGUs still play an important role in local service delivery since the NG began fully subsidizing the premiums and ensuring access to care. of poor families identified through the National Household Targeting System for Poverty Reduction PhilHealth (NHTS, known locally as Listahanan). PhilHealth itself estimated population enrollment at around 90 percent PhilHealth, the Philippines national health insurance in 2016. However, effective coverage lags behind: the program, purchases health services from public and 2017 National Demographic and Health Survey (NDHS) private providers on behalf of its members. PhilHealth estimates that 66 percent of the total population was is a tax-exempt government corporation connected to covered by PhilHealth in 2017, up from 38 percent the Department of Health for policy coordination and in 2008. However, the coverage rate for the bottom guidance. A Board of Directors, which is chaired by the quintile increased to just 59 percent, as poor families Philippines Secretary of Health, leads the organization; a may lack awareness of their eligibility or their benefits board member is appointed each year by the Philippines (Bredenkamp, Gomez and Bales 2017). President to serve a one-year term as PhilHealth President/CEO. PhilHealth has four specific packages that PhilHealth plays an essential role in establishing it offers to beneficiaries, including an inpatient benefit quality standards for facilities. Conversely, unlike the package, a Millennium Development Goal (MDG)-related regulation of hospitals, which are licensed by DOH and package that includes maternal and child health care automatically accredited by PhilHealth, there are no and TB-DOTS (tuberculosis: directly observed treatment, licensing requirements for RHUs in the Philippines. While 8 PhilHealth defines formal economy beneficiaries as those in the government and private sectors with established employer-employee relations (compared to those in the informal economy such as migrant workers and self-employed individuals). Lifetime beneficiaries are individuals aged 60 years and older, uniformed personnel aged 56 years and older, and SSS underground miner-retirees aged 55 years and older who have paid at least 120 monthly contributions to PhilHealth and the former Medicare programs, as well as Medicare pensioners prior to March 4, 1995. 35 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T individual health programs supported by the national financing, service delivery, regulation, governance and DOH establish basic requirements of care, they exist as performance accountability. unfunded mandates and lack enforcement mechanisms. By contrast, PhilHealth circulars often provide a detailed Finally, RA No. 11223,9 known as the Universal Health Care accounting of the infrastructure and service standards Law, was passed by the Duterte administration in 2019. required for accreditation. Facilities must be accredited The reforms mandated in the UHC Law aim to ensure to be included in PhilHealth’s provider network, which health services are integrated, comprehensive and local. puts PhilHealth in the position to build and ensure local It seeks to enroll every Filipino in PhilHealth, thereby capacity to provide high quality services. In order to providing access for all citizens to the entire spectrum increase access to care, however, PhilHealth has taken of health care services, including preventive, promotive, the approach of accrediting facilities for specific services curative, rehabilitative, and palliative care for medical, rather than overall. This lowers the bar for accreditation dental, mental health, and emergency care services. The and helps expand the number of accredited facilities. The UHC Law also proposes to consolidate the majority of underlying rationale is that facilities can be authorized public health financing around PhilHealth with a goal of to deliver services for which they already have sufficient reducing fragmentation of the public health financing capacity, while building up readiness to provide more system and strengthening PhilHealth as a key strategic complex care. purchaser in the health sector. Philippines National Health Plans and Legislation The stated objectives of the UHC Law are to a) progressively realize universal health care in the country The Philippines has been proactive in developing through a systemic approach and clear delineation plans and strategies and implementing initiatives to of the roles of key agencies and stakeholders tasked improve the current and future health of its citizens. with improving performance in the health system, and The Philippine Health Agenda (2016-2022) lays out the b) ensure that all Filipinos are guaranteed equitable country’s vision of “all for health towards health for access to excellent and affordable health care goods and all.” The Agenda focuses on guaranteeing all Filipinos services and protected against financial risk. Key features equitable geographical and financial access to a of the law encompass financing, service delivery, the local comprehensive range of quality health services across health system, regulation, governance and accountability. different levels of care (upon first contact with the health For example, the UHC Law calls for the organization of care system). The Agenda is built around three pillars: integrated province- and city-wide health systems and (a) guarantee care at all life stages and reduce the triple the creation of Special Health Funds (SHFs), into which burden of disease; (b) ensure access to a functional multiple streams of funding for health services will be service delivery network; and (c) ensure universal pooled. The creation of SHFs could help streamline and health insurance through expansion of health insurance simplify funding, at least at the service delivery level. coverage and improvement of benefit packages. The UHC Law, and the earlier health plans on which it was built, give priority to health financing to guarantee While the Philippine Health Agenda lays out a strategic universal access to comprehensive care at the primary vision, FOURmula One plus for Health (or F1 Plus for care level and continuity of care through referral. The Health) describes an ambitious reform plan that targets health financing direction takes into account population universal health coverage (UHC) with financial risk coverage, service delivery package, role clarification (of protection and good health outcomes for the population; various departments, agencies and administrative levels), the National Objectives for Health 2017–2022 (NOH) revenue generation, pooling, resource allocation and go further by providing a medium-term roadmap for strategic purchasing, procurement, remuneration, and achieving UHC (DOH 2018). F1 Plus for Health outlines health facilities. reforms and interventions in the following areas: 9 Otherwise known as An Act of Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating Funds Therefor. 36 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Health Financing PhilHealth coverage, households bear a substantial burden of health care, with out-of-pocket health The current health funding scheme in the Philippines expenses amounting to more than 50 percent of current is complex and fragmented, with funding streams health expenditure (Table 2.2), making catastrophic originating from various government and private sources, expenditure on health a significant cause of poverty and traversing or terminating at a variety of different for many families. In order to address these issues, the disbursing entities. The highly devolved nature of health UHC Law includes several key priorities related to health service delivery in the Philippines means that LGUs exert reform: (a) addressing persistent issues with balance substantial control over the use of funds, and has led billing10 and co-payments; (b) expanding the national to uncertain resource allocations for the sector as a health insurance benefits package to include outpatient whole. Historically, national DOH has had a low budget care and drugs that would add value for money; (c) execution rate, exacerbated by ineffective procurement contracting arrangements with service delivery networks; processes. This challenge has been aggravated by the and (d) enrolling the formal sector through payroll taxes recent increase in the department’s budget due to the and the informal sector through Government subsidies. significant surge in Sin Tax revenues (from tobacco and alcohol sales). It will take time for these objectives to be achieved, and currently inadequate funding and staffing will slow the Public expenditure on health rose from 0.5 percent of process further. In its first year of implementation of UHC, GDP in 2013 to 0.9 percent of GDP in 2018, a significant the government estimates a funding gap of Php62 billion, increase, but still well below the five percent threshold which could increase to Php109 billion by its fifth year recommended by the World Health Organization. Despite of implementation. TABLE 2.2. HEALTH EXPENDITURE IN THE PHILIPPINES, FIGURE 2.7. CURRENT HEALTH EXPENDITURES BY 54+12+81727D 2018 FINANCING AGENT, PHILIPPINES, 2018 Commercial Corporations Total Health expenditure (% of GDP) 4.6% Insurance (other than Companies insurance Percent private* 64% 7.6 companies) Percent out-of-pocket (OOP)* 2.1 54% Philippine Source: Philippines Statistics Authority, Philippine National Health 16.6 Insurance Health Accounts 2018 Corporation 53.9 *Note: Percent of Current Health expenditure, which is 96 percent of THE. Percent private includes out-of-pocket payments as well as payments by corporations and commercial 7.5 Households insurance companies. (out-of-pocket) State/ 12.3 Regional/ Local government Central government Source: Philippines Statistics Authority, Philippine National Health Accounts 2018 10 The no balance billing policy was put in place in 2010 to enhance financial protection, especially among indigent and sponsored members. According to this policy, no other fees shall be charged or paid for by PhilHealth indigent and sponsored patients availing of services paid on a case rate basis. For non-in- digent patients, facilities can bill patients for the balance that is left after payments from PhilHealth are subtracted from their charges. For indigent patients, hospitals must cover any balance between charges and PhilHealth case rate payments from other revenue sources, e.g., DOH and LGU medical assistance funds. This policy was applied to public hospitals; slowly, and with intense enforcement, their compliance is expected to improve. 37 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T THE UHC LAW 2019– KEY FEATURES Financing Local Health System a. Membership a. Integration of health systems into province-wide • Automatic inclusion into the National Health and city-wide health systems Insurance Program • Simplification of PhilHealth membership b. Pooling and management of all resources intended for health into a “Special Health Fund” in b. Financing Source a province-wide or city-wide health system • Pooling of funds from Sin Tax, PAGCOR, PCSO, premium, DOH annual appropriations, and national Regulation government subsidy to DOH and PhilHealth • Population-based health services financed by a. Establishment of performance-based incentive the DOH scheme for health facilities • Individual-based health services financed by PhilHealth b. Licensing and regulatory system for stand-alone health facilities c. Entitlement to Benefits • Free of charge at point of service for population- c. Formulation of standards for clinical care in based health services cooperation of DOH with professional societies • Immediate eligibility for health benefit package and academia • No PhilHealth Identification Card required • No co-payment for services in d. Institutionalization of Health Technology basic/ward accommodation Assessment for development of policies and programs, regulation, and determination of range Service delivery of entitlements a. Delivery of Health Services Governance and Accountability • Contracting of province-wide and city-wide health systems for population-based health services by a. Submission of health and health-related data to the DOH with minimum operating requirements PhilHealth as a requirement for all financed entities • Contracting of public, private or mix of health care provider networks for individual-based health b. Health Impact Assessment as requisite for services by PhilHealth policies, programs and projects b. Human Resources for Health c. Health Information System as requisite for all • Implementation of a National Health Human health service providers and insurers Resource Master Plan • National Health Workforce Support System to assist LGUs • Expansion of allied and health-related degree and training programs • Return Service Agreement for all allied and health-related government-funded scholars 38 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Health Sector Performance and Status system is generally under-resourced and there is considerable geographical variation in access to care. The Philippines’ health sector has in general performed Although these issues are similar to those faced by poorly when compared regionally and with similar other countries in the region, the Philippines is an economies. Health care is predominantly centered outlier because of its low public health expenditure and around hospitals; it is volume driven and of variable consistently high rates of out-of-pocket payment for institutional quality and efficiency. The primary care health services (Figures 2.8 and 2.9). FIGURE 2.8. OUT-OF-POCKET SPENDING AS PERCENTAGE OF CURRENT HEALTH EXPENDITURE, 2014-2017 100 90 80 70 60 56 55 54 53 50 40 30 20 10 0 2014 2015 2016 2017 Indonesia Thailand China Malaysia Philippines Vietnam Source: WHO Global Health Expenditure database 11 FIGURE 2.9. DOMESTIC GENERAL GOVERNMENT HEALTH EXPENDITURE AS PERCENTAGE OF CURRENT HEALTH EXPENDITURE, 2014-2017 100 90 80 70 60 50 40 31 32 32 30 28 20 10 0 2014 2015 2016 2017 Indonesia Thailand China Malaysia Philippines Vietnam Source: WHO Global Health Expenditure database 11 World Health Organization Global Health Expenditure Database. Data retrieved online at: https://apps.who.int/nha/database. 39 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T Strong political support and wider fiscal space do new opportunities for coordination in the financing and not automatically engender improved health system delivery of health services, such as with maternal and performance, as there is insufficient institutional capacity child health care and TB management. to translate policy into effective program implementation, with monitoring and evaluation (M&E). For instance, For some health indicators, the Philippines has seen while PhilHealth’s membership coverage has expanded in improvements. The country was able to meet MDGs recent years and its payment mechanism has improved, for child mortality and for reducing the incidence of limitations in strategic purchasing have yet to assure communicable diseases like malaria. In 2018, under-5 its members of affordable, comprehensive and high- child mortality fell to 28 deaths per 1000 live births, quality health care. Meanwhile, despite the DOH’s approaching the 2030 SDG target of 25 (Figure 2.10). commitment to construct and upgrade local health However, there is significant geographic variation: for facilities and deploy critical health staff, access remains example, child mortality in the Mindanao region is four highly inequitable due to the maldistribution of health to five times higher than in the National Capital Region facilities, health personnel and specialists. However, (Figure 2.11). with increased financial resources for health, there are FIGURE 2.10. UNDER-5 MORTALITY RATES (PER 1,000 LIVE BIRTHS), PHILIPPINES, 2008-2018 32.8 32.4 32.0 31.6 31.2 30.9 30.5 30.1 29.7 29.1 28.4 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Source: UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA Population Division) 40 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 2.11. UNDER-5 MORTALITY RATES, BY REGION, TEN-YEAR PERIOD PRECEDING 2017 NDHS (PER 1,000 LIVE BIRTHS) National Capital Region 11 Cordillera Admin. Region 11 Region III - Central Luzon 19 IVA - CALABARZON 21 Region II - Cagayan Valley 24 XI - Davao 24 IX - Zamboanga Peninsula 26 XIII - Caraga 28 Region I - Ilocos Region 29 VII - Central Visayas 29 VIII - Eastern Visayas 32 X - Northern Mindanao 32 MIMAROPA Region 33 V - Bicol 38 VI - Western Visayas 46 XII - SOCCSKSARGEN 48 ARMM 55 Source: PSA and ICF, 2018 The prevalence of malnutrition is also high for a country for human capital development. Compared to other of the Philippines’ level of economic development: in countries in the East Asia region, the Philippines has 2015, more than 30 percent of children under five years made the least progress in reducing the prevalence of old were stunted and 20 percent were underweight (NEDA underweight among young children (Figure 2.12). and UNICEF 2018), carrying long-term consequences FIGURE 2.12. PREVALENCE OF UNDERWEIGHT, SELECT EAST ASIAN COUNTRIES, 2010-2018 22 20 18 16 14 12 10 8 6 2010 2011 2012 2013 2014 2015 2016 2017 2018 Philippines Indonesia Malaysia Thailand Vietnam Based on available yearly data. Source: UNICEF, WHO, World Bank: Joint child malnutrition estimates (JME). 41 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T The downward trend in immunization coverage among to achieve some maternal coverage targets, such as children in the Philippines is clearly of concern not only antenatal care (94 percent) and facility-based delivery at the individual level but also at the population level. (from 61 percent in 2013 to 78 percent in 2017). However, Just 70 percent of children were fully immunized in 2017, as with child health outcomes, vast geographic and down from 79 percent in 1998. High immunization rates in economic variations persist: for example, in 2017, while Metro Manila skew this figure and belie a troublingly low 78 percent of births nationwide took place in a health rate of immunization in poorer areas with comparatively facility, just 28 percent of births in ARMM did so (PSA and patchy access to health care. As a result, the Strategic ICF 2018). Stubbornly poor maternal health outcomes Advisory Group of Experts on Immunization of the World reflect the continued challenges in both access to and Health Organization has listed the Philippines among the quality of care. 10 countries where most unvaccinated children live, as well as one of the countries where coverage has While total fertility rate (TFR) in the Philippines is about declined considerably. 2.7 children per woman, total wanted fertility rate is estimated to be 2.0 children per woman, or 26 percent The Philippines faced similar challenges in meeting MDG lower than the actual TFR (PSA and ICF 2018). Women in goals for maternal mortality and access to reproductive the lowest quintile have a much higher TFR than women health services. Although there have been improvements, in the highest quintile: after remaining stable for five maternal health outcomes have long been identified as years, the TFR among the lowest quintile decreased from one of the weakest areas of program coverage in the 5.2 in 2008 and 2013 to 4.3 in 2017, but was still 2.5 times Philippines: the maternal mortality ratio in 2015 was 127 higher than the wealthiest quintile. Seventeen percent per 100,000 live births, nearly double the regional rate of currently married women reported having an unmet of 73 (Figure 2.13). New policies and the introduction of need for family planning services in 2017, while nearly 50 maternal care packages under PhilHealth have helped percent of unmarried women reported this need. FIGURE 2.13. MATERNAL MORTALITY RATIO PER 100,000 LIVE BIRTHS, PHILIPPINES VERSUS SELECT EAST ASIAN COUNTRIES, 2005-2015 200 175 150 125 100 75 50 25 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Philippines East Asia & Pacific Source: UNICEF State of the World’s Children, Childinfo, and Demographic and Health Surveys. Note: Excluding high-income countries in the EAP region. 42 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FOCUS – CONTRASTING STORIES IN THE PHILIPPINES AND CHINA These data illustrate the differing development similar challenges of health system inefficiency, trajectories of China and the Philippines over China has adopted a model of Patient-centered the last two decades. In China, a trend towards integrated care, which the World Bank-supported Universal Health Coverage is reflected in increasing reforms in China have helped to advance. investment in health overall and a marked increase By contrast, in the Philippines, public health in public investment—with a corresponding expenditure and out-of-pocket expenditure decrease in out-of-pocket expenditure. Facing have stagnated. Source: World Health Organization Global Health Expenditure database12 12 WHO Global Health Expenditure Database. Data retrieved online at: https://apps.who.int/nha/database. 43 C H A P T E R T WO : T H E P H I L I P P I N E S N AT I O N A L C O N T E X T FUTURE DIRECTIONS The UHC Law more fully consolidates health care funding around PhilHealth, which plays an essential role in Inequity in health status and access to services are guaranteeing access to comprehensive, affordable care considered the most important health sector problems for all Filipinos. The NG must ensure that PhilHealth’s in the Philippines, arising from structural defects in the support value is 100 percent, with zero co-payment basic building blocks of the national health system. for the poor admitted in basic accommodation, and a These governance-associated challenges are a key predictable (fixed) co-payment for the non-poor and impetus for recent health reform efforts, including the those admitted in non-basic accommodation. The NG passage and initial implementation of the UHC Law. The must prioritize PhilHealth enrollment, especially of Philippines government has prioritized the development geographically isolated and economically vulnerable and broad implementation of interventions at the people, many of whom may not know or understand individual and population levels to promote health, their benefits. It must correct misconceptions about prevent and treat the triple burden of disease, preclude PhilHealth benefits and billing practices, and work to or delay health complications, facilitate rehabilitation increase knowledge about immunizations and the value and provide palliative care. It aims to ensure that all of preventive care. Much of this work will happen at the Filipinos have access to appropriate health services local level through concentrated outreach and education through functional Service Delivery Networks (SDNs). campaigns, which the NG must support. These are important actions, but the impact of such efforts is not entirely under NG control. In its effort to make health care integrated, comprehensive and localized, it will be essential to Instead, the implementation of national health policies ensure the continuation of programs that are currently and agendas rests primarily with LGUs. The devolved vertically-funded and managed (such as immunization nature of health care delivery in the Philippines means and TB). This could entail either appropriate inclusion that the national government, in order to meet its goals in the PhilHealth benefit packages, or alternative ways for universal health coverage, must work with LGUs to to incentivize and track service delivery. As mentioned, ensure adequate allocation of funds and strengthen the Philippines has a long way to go towards ensuring service quality and access, and it must develop full immunization coverage of children. This issue is far monitoring tools and instruments to hold provinces and too important in both human as well as economic terms LGUs accountable as the SDN reforms are implemented. to be left in the hands of local funding decision-making The NG must ensure that all LGUs embrace the national processes. Efforts to improve vaccination rates and goals of eliminating regional inequities and ensuring other health outcomes will require a commitment at the health care access for all people as a means to elevate national, regional, provincial and local levels to build a the country as a whole. This may be facilitated by sustainably financed and correspondingly valued primary National DOH and PhilHealth engaging the private care system. sector in planning supply side investments, helping to form SDNs, and expanding PhilHealth accreditation and related structural and workforce requirements for all benefit packages. 44 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M CHAPTER THREE: THE HISTORICAL, POLITICAL AND HEALTH-SPECIFIC CONTEXT OF BARMM SUMMARY • The vaccination rate in particular lags well behind the national average, and is comparable to rates • The newly-designated BARMM region has long faced among poor subgroups in other South East Asian persecution and conflict, resulting in poor health countries. As elsewhere, this weakness threatens and economic outcomes for residents. It is now in children in terms of health, families in economic a period of profound transition in its governance terms, and, by consequence, the entire country. and fiscal and regulatory relationship with the Philippines national government, following the passage of the Bangsamoro Organic Law (BOL). HISTORICAL AND POLITICAL CONTEXT • This period of transition presents an opportunity At the time of the 2015 national census, the population for the BARMM government to set priorities and of ARMM was over 3.78 million, and it was the fastest reorganize its systems to better serve constituents. growing region in the country, with an average annual In addition, several key components of the BOL— population growth rate of 2.89 percent (PSA 2017a). namely block grant appropriations and an increased Since the passage of the BOL, that population has share in revenue—will provide BARMM with more increased somewhat owing to the changed administrative resources and greater independence in determining boundaries of the region, which now include Cotabato how resources are allocated and used. City and 63 barangays in North Cotabato. As a result, BARMM now includes approximately 4.64 million • The health system in BARMM has more autonomy residents (based on PSA 2015 data) in the five provinces, than other regions of the Philippines, though a lack three cities, and 116 towns spanning 2,590 barangays that of clarity about the role of the regional government are included in the final territorial jurisdiction as a result versus that of provincial and municipal Local of the 2019 plebiscite. Government Units (LGUs) has tended to complicate service delivery and funding. Health facilities are Principal cities in BARMM now include Cotabato City mostly public institutions rather than private ones. (population 299,438), Marawi City (201,785 prior to the 2017 Many residents are unaware that they have health crisis), and Lamitan City (74,782). Despite not having city coverage through PhilHealth. In 2017, just 50 percent status, the municipalities of Jolo (population 125,564) and of ARMM residents reported having any health Bongao (100,527) are major provincial hubs.13 insurance at all, the lowest in the country. The region now encompassed by BARMM has a long • Health service delivery in BARMM has faced a history with a unique social, political and development significant challenge due to high poverty rates and trajectory. The history of Mindanao and its pursuit of the fragile political and security context. As a result, self-determination and self-rule has been a matter of health outcomes in BARMM are significantly worse record since the 13th century. The spread of Islam in the than in the rest of the country. Philippines began in the 14th century in this region: the first mosque in the Philippines was built in the mid-14th century in the town of Simunul, Tawi-Tawi. By the 16th 13 Isabela City in the province of Basilan remains a major hub in the island provinces, although it is not administratively part of BARMM, having chosen not to join the region in the last two plebiscites. 45 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M MAP 3.1. BANGSAMORO AUTONOMOUS REGION IN MUSLIM MINDANAO 125°E PHILIPPINES MINDINAO ISLAND PHILIPPINES Philippine MANILA Sea 10°N BARMM REGION PROVINCE BOUNDARIES IN BARMM REGION Mindinao Mindanao REGION BOUNDARIES Island Sea XIII MALAYSIA Caraga 120°E X IX Northern Zamboanga Mindanao Peninsula Sulu Lanao del Sur XI Davao Region Sea Cotabato Cotabato City (some barangays Moro (added) added) Gulf Maguindanao Davao BARMM Gulf Bangsamoro XII Basilan Autonomous Region Soccsksargen in Muslim Mindanao Sulu Celebes Sea MAL AYSIA 5°N 5°N Tawi-Tawi IBRD 45379 | DECEMBER 2020 This map was produced by the Cartography Unit of the World Bank Group. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of the World Bank Group, 0 50 100 Kilometers any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 120°E century, Muslim sultanates had been established in Sulu, In 1972, the Moro National Liberation Front (MNLF) was Lanao and Maguindanao (from which the name Mindanao formed, aiming for a fully independent Bangsamoro is derived). state through armed struggle. Throughout the 1970s, the MNLF and the Philippine Government were engaged The term “Bangsamoro” translates as “Moro Nation” and in fierce conflict, with sporadic ceasefires parallel to encompasses at least thirteen Islamized ethnolinguistic peace negotiations. In 1984, a splinter group named groups in Mindanao, the four largest of which are the the Moro Islamic Liberation Front (MILF) was formed, Tausug, the Samal, the Magindanaon and the Maranao also seeking a fully independent Bangsamoro state in (Kapahi and Tañada 2018). The collective identity of the Mindanao through armed revolution, but with a more Bangsamoro is unique, and shaped by a shared historical explicitly Muslim identity. ARMM was created on August experience of increasing external influence throughout 1, 1989 under RA No. 6734 (known as the Organic Act for the preceding five centuries. It has also been the site of the ARMM) and consisted of five predominantly Muslim intermittent waves of armed conflict since the late 1960s, provinces: Basilan (excluding Isabela City), Lanao del Sur, directed both vertically, between the state and various Maguindanao, Sulu and Tawi-Tawi. The Organic Act was Moro groups fighting for self-determination, as well as later strengthened in 2001 through RA No. 9054 after the horizontally among political dynasties, communities, MNLF and the Philippine Government signed the 1996 and clans. In addition, international criminal groups and Final Peace Agreement. terrorist organizations have been able to gain a foothold in the area, including those involved in the five-month However, the MILF was not part of this peace accord, and siege of the city of Marawi in 2017. continued advocating for full Bangsamoro independence, including through armed action, until the recent 46 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M conclusion of negotiations in 2014. Conflict and violence, included the Framework Agreement on the Bangsamoro between Bangsamoro actors and against the national (FAB), signed in 2012, and the Comprehensive Agreement government, have until recently persisted with varying on the Bangsamoro (CAB) in 2014. degrees of intensity. Between 1970 and 2005, some 120,000 people died, most of them civilians, and up to The 2014 CAB is the final political settlement between 3.5 million were displaced by armed conflict between the the two parties, concluding 17 years of negotiations government and Moro insurgents, plus countless more and decades of conflict. It consists of 12 documents, by horizontal conflict. The “all-out war” in 2000 displaced including the FAB and several annexes on transitional 930,000 people. The number fell to 411,000 in 2003 arrangements, normalization, wealth, power-sharing, and during the ceasefire, but jumped to 700,000 after the water territories. It also paves the way for the drafting of Memorandum of Agreement on Ancestral Domain (MOA- the Organic Law for the Bangsamoro Autonomous Region AD), negotiated between the government and the MILF, in Muslim Mindanao (RA No. 11054), popularly known as was ruled unconstitutional and terminated in 2008. the BBL (Bangsamoro Basic Law), and its final iteration, the above-mentioned BOL. The BOL abolishes the ARMM While the core conflict in Mindanao has been between and creates the Bangsamoro Autonomous Region in Muslim armed groups and the government, it is not Muslim Mindanao (BARMM). exclusively a religious conflict. Endemic drivers of violence in the region include: 1) social injustice and The CAB also provides for a so-called normalization alienation, involving exclusion of Muslim and indigenous process, which serves as a guide to ensure security peoples, 2) suppression of Muslim and indigenous in the region. It defines this process as one ‘whereby traditions, customs and institutions, 3) inter-ethnic communities can achieve their desired quality of life, conflict, d) “rido” clan war and revenge killing, 4) land which includes the pursuit of sustainable livelihood tenure and ownership disputes, 5) competition for scarce and political participation within a peaceful deliberative natural and mineral resources, 6) local election disputes, society’. The Annex on Normalization spells out 7) ineffective governance in the absence of the rule of four phases of activities to be conducted alongside law or service delivery, and 8) widespread poverty and a other elements of the peace agreement, including lack of job opportunities. One estimate puts the financial the decommissioning of approximately 40,000 MILF cost of conflict in Mindanao from 2010–2016 alone at US$ combatants and their families, allowing them to 850 million, 14 while the cost of reconstruction as a result transition into productive civilian life. Following of the 2017 Marawi siege could reach PhP 62 billion, or ratification of the BOL, Phase 2 was initiated, which over US$ 1 billion. Beyond financial costs, the human refers to, among other things, the decommissioning of costs have been incalculable, including displacement and 30 percent of total combatants of the MILF’s Bangsamoro the disruption of lives and livelihoods, loss of cultural Islamic Armed Forces. In exchange, each decommissioned identity and social cohesion, increased polarization of combatant is to receive a package estimated at around issues and affiliations, aggravating ethnic and social PhP 1 million, with P100,000 in cash and in-kind support tensions, and increased kidnapping, trafficking, and other in the form of health, social, and housing benefits. The illegal activities. CAB also commits to the accelerated socio-economic development of their camps and communities, with The GPH-MILF Comprehensive Agreement on specific packages for vulnerable sectors, including the Bangsamoro people with disabilities, widows, orphans, and detainees and their families, as well as extensive measures Peace talks between the MILF and the NG resumed towards security sector reform, confidence building, and in 2010, leading to the signing of agreements aimed transitional justice and reconciliation. at establishing permanent peace in Mindanao. These 14 Project Ploughshares, 2015. 47 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M Geographically, both parties have committed to its adjacent islands, whether of mixed or of full blood,” the transformation—into peaceful and productive including their spouses and descendants. communities—of the six major acknowledged MILF camps, namely: By virtue of its autonomous status, BARMM has a different administrative structure than other local • Camp Abubakar as-Siddique in Maguindanao; government units (LGUs) in the country, including for • Camp Bilal in Lanao del Norte and Lanao del Sur; public financial management. Unlike the previous • Camp Omar ibn al-Khattab in Maguindanao; unitary form of government in ARMM (headed by a • Camp Rajamuda in North Cotabato and Regional Governor), BARMM has a parliamentary- Maguindanao; democratic government headed by a Chief Minister. Once • Camp Badre in Maguindanao; and the full transition is complete in 2022, an 80-member • Camp Busrah Somiorang in Lanao del Sur Bangsamoro Parliament will be elected to represent different parties, districts, and sectors, including While much effort focuses on the geographic scope of indigenous peoples. The members of the parliament will the BARMM, both the CAB and the BOL provide for the then elect a chief minister and two deputy chief ministers delivery of socioeconomic programs for Bangsamoro among themselves. The chief minister will also appoint communities outside the territorial jurisdiction members to his Cabinet. of BARMM. Much of the complex legal framework established for The Independent Decommissioning Body oversees ARMM remains in place for BARMM. Article X, Section the decommissioning of MILF forces and weapons in 20 of the 1987 Constitution enumerated the legislative coordination with the extensive institutional architecture powers of the autonomous region and required that created under the peace process. A Joint Normalization these powers be defined through a national law, which Committee composed of both government and MILF was achieved most recently through the BOL. Under appointees sets the direction for these programs. On ARMM, the legal and regulatory framework consisted of the government side, Executive Order No. 79 signed in separate national laws, executive orders, and regional 2019 created the Inter-Cabinet Cluster Mechanism on laws, which resulted in unclear and at times contentious Normalization (ICCMN) to deliver on these commitments, assignment of powers, functions and responsibilities including those in relation to health service delivery. among the national government, ARMM and the LGUs. The same situation exists for BARMM, though by nature of being a new political entity, the BTA is in a unique BARMM AND THE BOL position to establish new strategies to simplify its governance and services. The BOL establishes legislative BARMM succeeded ARMM on January 25, 2019 following powers for BARMM over: the ratification of the BOL, with three major changes: structural transformation, expanded fiscal powers, • Administrative organization; and increase in geographic scope. BARMM is currently • Creation of sources of revenues; governed by the BTA. This will continue until May 2022, • Ancestral domain and natural resources; when BARMM residents will elect members to the • Personal, family, and property relations; Bangsamoro Parliament. • Regional urban and rural planning development; • Economic, social, and tourism development; The BOL recognizes and retains the historical and • Educational policies; geographical identity of the Bangsamoro people. Section • Preservation and development of the cultural 1, Article II of the Organic Law states that Bangsamoro heritage; and People are “those who, at the advent of the Spanish • Such other matters as may be authorized by law for colonization, were considered natives or original the promotion of the general welfare of the people inhabitants of Mindanao and the Sulu archipelago and of the region. 48 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M The BOL also gives the Supreme Court the authority to BARMM will also have access to various sources of grant incumbent Shari’ah District and Court judges who donor financing, both as grants and loans, albeit subject are not regular members of the Philippine Bar a period to sovereign guarantee. The largest pots of multi- within which to qualify for membership. Tribal laws will donor support have yet to be created, including the still apply to disputes of indigenous peoples within Bangsamoro Normalization Trust Fund (BNTF), although the region. multiple streams of bilateral and multilateral financing are already active. In contrast to the planning and budgeting structure present in the rest of the country, NG appropriations to The 2019 plebiscite led to the inclusion in BARMM, BARMM will be in the form of a block grant, which will mentioned above, of new geographic areas, specifically be “automatically appropriated and released directly Cotabato City and 63 barangays within six municipalities and comprehensively to the Bangsamoro Government, in North Cotabato. In the future, contiguous areas may without need of any further action” (IAG 2019). This also be included in BARMM if there is a local government began in 2020, and is equivalent to five percent of the resolution or a petition where at least 10 percent of net national internal revenue of the Bureau of Internal registered voters seek to join the plebiscite. The BOL Revenue and the Bureau of Customs. It provides more introduces laws related to regional waters for BARMM flexibility contingent on certain conditions, including extending up to 19 kilometers from the low-water mark, the passage of an annual appropriations law by the as well as the management and preservation of inland Parliament that gives priority to education, health, and waters. However, those that are utilized for energy social services. Prior to BOL, the ARG submitted an in areas outside BARMM will be co-managed by the annual budget to the NG, which then decided on an Bangsamoro Government (BG) and the Department appropriation. The automatic appropriation of funds via of Energy. block grant will mean greater fiscal and programmatic autonomy in BARMM. The Bangsamoro Transition Authority: Challenges and Opportunities for Health The region’s share in government revenue taxes, fees, charges, and taxes imposed on natural resources will A Bangsamoro Transition Authority (BTA) was appointed increase from 70 to 75 percent. The NG will also allocate by President Duterte in February 2019, creating the to BARMM PhP 5 billion annually for a period of ten years, Bangsamoro government for the duration of the which will be used for the rehabilitation of conflict- transition until the first local elections in 2022. As implied affected areas pending the publication of a Bangsamoro above, the BTA will simply be dissolved once elected Regional Development Plan. Under the 2020 National officials assume office. Expenditure Plan (NEP), a total of PHP 70.6 billion will be allocated to BARMM, covering the following components: BARMM authorities face an array of accountabilities the annual Block Grant of PhP 63.6 billion; a Special stipulated in the BOL; expectations are also high for Development Fund of PhP 5 billion; and PhP 2 billion tangible improvements in the daily lives of citizens— as the BARMM’s share in the taxes, fees and charges notably in the provision of health and other social collected in the region. This is almost twice as high as services—and the need for effective consensus building the PhP 31.1 billion allotted in 2018 for the now-defunct in this ethnically diverse region. In the Philippines, as ARMM’s annual budget. In late 2019, the BTA approved its in many other countries, lower tiers of government face Bill No. 31, covering a total of PhP 65.9 billion, entitled greater challenges than national governments in all ‘An Act appropriating funds for the operation of the areas of budget and financial management. It is also Bangsamoro Autonomous Region in Muslim Mindanao common for lower tier governments to have difficulty (BARMM) from January 1 to December 31, 2020, and attracting and retaining sufficient qualified personnel, other purposes’. making it all the more difficult to manage finances effectively. BARMM is likely to face even more challenges 49 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M due to its recent history of conflict and weak economic decommissioning of combatants and their communities circumstances. Nevertheless, the BOL provides exciting and putting weapons ‘beyond use’, normalization also opportunities, including a stipulation that the BARMM includes issues of community security and policing, regional government develop an integrated health transitional justice and reconciliation, broad confidence- service delivery system for its constituents. The Ministry building measures, and amnesties and pardons, all of Health is also one of three priority regional agencies of which have natural links not only to the national that, as per the BOL, retained most of its workers from government-led ICCMN, but also the day-to-day the ARMM era to ensure the uninterrupted delivery of operations of various frontline service delivery ministries, services throughout the transition to the BARMM. The including the MOH. health system is less devolved in BARMM than in other regions of the Philippines, but this stipulation may drive Much of the fundamental business of autonomous the BG and the regional Ministry of Health to re-envision government remains uncertain, or under construction, its role to ensure greater coordination and equity in during the current transitional period of BARMM, and access and service delivery. will be addressed either by the BTA, the Bangsamoro Parliament, or through the Inter-governmental Relations BARMM operations, including its Transition Plan, the (IGR) Board mechanism that will resolve issues between 2020 Bangsamoro Expenditure Program and the draft the parliament and its national counterpart. Many of the Bangsamoro Regional Development Plan, are guided by day-to-day issues on fund flows, staffing, and service a 12-Point Agenda articulated by Interim Chief Minister delivery that are presently being addressed by the BTA Ahod Balawag Ebrahim. This highlights the continuity are rooted in IGR-related concerns. While the President of existing government services and the setting-up of retains general supervision over the Bangsamoro programs including those on health and sanitation. Government, ultimately the purpose of IGR lies in These tasks also interface with other elements of the transforming the relationship between NG and regional CAB, including the normalization process. Beyond actors in the Bangsamoro. TABLE 3.1. DESCRIPTIVE OVERVIEW OF THE BARMM PROVINCES Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi BARMM Philippines Population (2015) 1,045,429 1,173,933 346,579 824,731 390,715 3,781,387 100,981,437 Number of Municipalities 39 36 11 19 11 116 1,489 and Cities (2018) municipalities, municipalities municipalities, municipalities municipalities municipalities, municipalities, 1 city 1 city 2 cities 145 cities (17 regions, 81 provinces) Annual Family Income — — — — — PHP 139,000 PHP 267,000 (2015) Annual Family Expenditure — — — — — PHP 111,000 PHP 215,000 (2015) Human Development Index 0.217 0.309 0.419 0.303 0.403 — 0.644 (HDI) 2012 Life Expectancy at birth 60.7 59.5 63.5 58.0 54.4 — 73.4 (years) 2012 Mean years of Schooling 7.3 6.3 6.7 6.7 8.1 — 9.2 2012 Expected years of Schooling 11.2 11.1 10.8 12.5 10.7 — 12.2 2012 Per Capita Income 2012 19,139 23,464 30,989 22,773 31,489 — 49,903 (purchasing power parity [PPP] National Capital Region [NCR] 2012 pesos) Source: Capuno 2017 50 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M MAP 3.2. POVERTY INCIDENCE AND HUMAN CAPITAL INDEX, PHILIPPINES POVERTY INCIDENCE, 2018 HUMAN CAPITAL INDEX, 2015 50% 0.62 40% 0.58 30% 0.54 20% 0.50 10% LUZON LUZON VISAYAS VISAYAS MINDANAO MINDANAO IBRD 45389 | OCTOBER 2020 Note: Conflict-affected and disaster-prone areas account for the highest poverty rates and fare worse on most measures of development (WBG Country Partnership Framework). REGIONAL POVERTY AND INEQUITY province that has been least affected by violent conflict, is the only region to have experienced a consistent Although Mindanao is one of the riches regions of the decline in poverty over this period (Figure 3.1, Panel B) Philippines in terms of resources, the people of BARMM (Capuno 2017). have unfortunately been unable to fully benefit from these natural riches. In 2015, it was reported by the Geographic and economic variations are also evident Philippine Statistics Authority that four out of five of in terms of health coverage. In 2012, the Philippines the poorest populations in the Philippines were located government dramatically expanded the number of in Mindanao. Poverty in BARMM is correspondingly poor households receiving subsidized health insurance entrenched and pervasive. In 2006, the incidence of through PhilHealth. Considering the high poverty rate in poverty in the geographical area of the then-ARMM was the BARMM region, it seems plausible that many families twice that of the national population and, while the would have been automatically enrolled in PhilHealth national incidence of poverty has slowly declined since during this period, if they were not already included then, it has increased by nearly 20 percent in ARMM among the indigent population. However, in 2017 just 50 over the same time period. As a result, the incidence percent of BARMM residents reported receiving PhilHealth of poverty in BARMM is now nearly three times that of benefits. One explanation for this is that families were the national population (Figure 3.1, Panel A). Localized not aware of their benefits, since enrollment among poor increases in poverty in Lanao del Sur, Maguindanao, and families is done automatically rather than through action Sulu have driven much of this divergence. Tawi-Tawi, the on the family’s part (Bredenkamp 2017). 51 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M FIGURE 3.1. POVERTY INCIDENCE AMONG BARMM FAMILIES OVER TIME Panel A Panel B 100 100 90 90 80 80 70 70 60 60 Percent 50 50 40 40 30 30 20 20 10 10 0 0 2006 2009 2012 2015 Basilan Lanao del Sur Maguindanao Sulu Tawi-Tawi* Philippines ARMM 2006 2009 2012 2015 Source: Philippine Statistics Authority (PSA) 2016. Notes: Panel A shows a slow but steady decline in the national incidence of poverty between 2006 and 2015, while poverty increased in BARMM (then known as ARMM) over the same period. Panel B shows that this trend is driven by localized increases in poverty in Lanao del Sur and Sulu. Note that the 2015 data for Tawi-Tawi should be interpreted with caution due to the high variance found in the source data. FIGURE 3.2. PHILHEALTH COVERAGE BY REGION, 2017 National Capital Region 70.7 Cordillera Admin. Region 71.2 Region III - Central Luzon 65.2 IVA - CALABARZON 64.9 Region II - Cagayan Valley 65.7 XI - Davao 65.0 IX - Zamboanga Peninsula 66.9 XIII - Caraga 62.4 Region I - Ilocos Region 65.5 VII - Central Visayas 59.4 VIII - Eastern Visayas 65.9 X - Northern Mindanao 66.2 MIMAROPA Region 65.2 V - Bicol 69.2 VI - Western Visayas 71.0 XII - SOCCSKSARGEN 69.7 ARMM 50.2 Source: PSA and ICF 2018 52 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M While precise information on health outcomes in Similarly, access to essential maternal health services in BARMM has been limited (Mujer Quintos 2017), there is BARMM is much lower than the national average, though evidence that maternal and child health (MCH) outcomes, some improvements have been seen in recent years. including maternal and child mortality, are particularly For example, while 86.5 percent of pregnant women poor in the region (PSA and ICF International 2014, 2018). nationwide attended the recommended four antenatal For example, infant mortality is much higher at 37 per (ANC) visits in 2017, fewer than half of women did so in 1,000 live births compared to 21 nationally (PSA and ICF BARMM. Facility-based delivery is also low at 28 percent 2018) and under-five child mortality is twice as high in (compared to 78 percent nationally), and only 34 percent BARMM as in the nation as a whole. Malnutrition is also of all live births were attended by a skilled health a problem: a 2019 BARMM household survey found that professional (compared to 84 percent nationally). Though nearly 40 percent of BARMM children under five years these numbers are much lower than in other regions of age were stunted compared to one-third of children of the country, they reflect improvements of 14 and 16 throughout the Philippines overall (Figure 3.3). percent respectively since 2013 (Figure 3.4). FIGURE 3.3, PANEL A: INFANT AND CHILD MORTALITY (PER 1,000 POPULATION), PHILIPPINES VERSUS BARMM, 2017 PANEL B: UNDER-5 STUNTING PREVALENCE (PER 100 POPULATION), PHILIPPINES VERSUS BARMM, 2019 Panel A Panel B 60 60 50 50 40 40 30 55 30 20 37 20 39 29 29 10 23 10 0 0 Infant mortality Under-5 mortality Under-5 stunting Philippines BARMM Philippines BARMM Source: PSA and ICF 2018. Source (BARMM) 2019 BARMM Household Survey. (Philippines overall) 2019 eNNS. FIGURE 3.4. MATERNAL HEALTH INDICATORS, PHILIPPINES VERSUS BARMM, 2017 87% 84% 78% 48% 34% 28% 17% 3% 4+ ANC visits No ANC visits Facility-based Skilled health delivery professional Philippines BARMM Source: PSA and ICF 2018 53 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M Health indicators are not the only ones by which BARMM access to toilet facilities and access to a clean water is lagging. As shown in Figure 3.5, while Mindanao as a source, the BARMM region specifically lags even further region lags behind the Philippines national average on behind, in some areas by a large margin. a variety of indicators, including human capital index, FIGURE 3.5: SOCIOECONOMIC INDICATORS, BARMM, MINDANAO AND PHILIPPINES OVERALL, 2017 95% 93% 90% 86% 82% 76% 70% 71% 67% 67% 62% 61% 55% 55% 52% 47% 35% 18% Human Capital % children % children will basic % population with % population with % households with Index who are not immunizations improved water improved water electricity stunted source source Autonomous Region of Muslim Mindanao All Mindanao All Philippines Source: PSA and ICF 2018 FOCUS – IMMUNIZATION IN BARMM ILLUSTRATES THE CHALLENGE TO ADDRESS POVERTY AND INEQUITY IN SUBNATIONAL REGIONS Despite overall improvements in East Asian Immunization coverage in BARMM further countries, indices of maternal and child health illustrates this occurrence. The vaccination rate continue to lag or decline in certain subnational among all children in the Philippines was 70 regions. An examination of selected countries percent in 2017, already a dismal figure, but in shows a consistent pattern, with many of these the then-ARMM region, it was just 18 percent. areas being geographically isolated or otherwise Furthermore, nearly 44 percent of children aged 12– disadvantaged.15 Other population sub-groups 23 months in ARMM had received no vaccinations have been shown to have inequitably low health at all. The following chapter, on immunizations, will indices (for example particular ethnic groups), but consider the various demand side and supply side the geographic concentration of low immunization explanations for this. coverage has particular epidemiological consequences. 15 In Vietnam, by contrast, the lowest immunization rates are found in the wealthy south-eastern part of the country and are likely associated with low demand. 54 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 3.6. ALL BASIC VACCINATION COVERAGE BY REGION IN THE PHILIPPINES Davao NCR CAR Ilocos Region Eastern Visayas Central Luzon CALABARZON Cagayan Valley PHILIPPINES Northern Mindanao Western Visayas Central Visayas Zamboanga Peninsula Caraga Bicol MIMAROPA SOCCSKSARGEN ARMM 0 20 40 60 80 100 Percentage of children age 12-23 (%) Source: PSA and ICF, 2018 Persistently low levels of routine immunization in of vaccine-preventable illness—such as the measles BARMM are comparable to those in the poorest outbreak in 2019—cause morbidity, mortality and countries around the world. Consequent outbreaks increased household poverty. FIGURE 3.7. ALL BASIC VACCINATION COVERAGE BY SELECTED SOUTHEAST ASIAN COUNTRIES AND REGION THEREIN 80 Percentage of children age 12-23 (%) 70 60 50 40 30 20 10 0 Mondulkiri/ National Papua National Savannakhet National Ayeyarmady National Central National South East National ARMM National Ratanakiri Cambodia Indonesia Lao PDR Myanmar Thailand Vietnam Philippines The worst performing Region/Province contrasted with the national average. Source: Cambodia DHS 2014; Indonesia DHS 2012; Lao PDR DHS 2011-12; Myanmar DHS 2015-16; Philippines DHS 2017; Thailand MICS 2015-16; Vietnam MICS 2014. 55 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M FIGURE 3.8. PERCENTAGE OF CHILDREN WITH NO VACCINATION BY SELECTED SOUTHEAST ASIAN COUNTRIES 45 Percentage of children age 12-23 (%) 40 35 30 25 20 15 10 5 0 Mondulkiri/ National Papua National Savannakhet National Ayeyarmady National Central National South East National ARMM National Ratanakiri Cambodia Indonesia Lao PDR Myanmar Thailand Vietnam Philippines The worst performing Region/Province contrasted with the national average. Source: Cambodia DHS 2014; Indonesia DHS 2012; Lao PDR DHS 2011-12; Myanmar DHS 2015-16; Philippines DHS 2017; Thailand MICS 2015-16; Vietnam MICS 2014. Of particular concern are the low levels of the re-introduction of poliovirus transmission by the vaccination against polio, a disease that has received WHO due to an overall insufficient vaccination rate considerable investment attention throughout the of around 80 percent (with a slight decreasing trend world. Epidemiological modeling suggests that a from 2008 to 2017; see Figure 3.9). Indeed, an outbreak national polio immunization rate of at least 90 was declared in September 2019, with cases in both percent is required to ensure that polio-free status Metro Manila and the then-ARMM region. In 2017, the is maintained (herd immunity). After being named rate of complete polio immunization among ARMM “polio-free” by the World Health Organization in 2000, children aged 12–23 months was just 33.3 percent the Philippines was later assessed as high-risk for (PSA and ICF 2018). FIGURE 3.9. POLIO VACCINATION COVERAGE IN PHILIPPINE REGIONS SOURCE: DHS 2008, 2013 AND 2017 100 Percentage of children age 12-23 (%) 80 60 40 20 0 Philippines NCR CAR Ilocos Region Cagayan Valley Central Luzon CALABARZON MIMAROPA Bicol Western Visayas Central Visayas Eastern Visayas Zamboanga Peninsula Northern Mindanao Davao SOCCSKSARGEN Caraga ARMM 2008 2013 2017 Source: Philippines DHS 2008, 2013 and 2017 NSO and ICF Macro 2009; PSA and ICF 2014; PSA and ICF 2018 56 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M The Philippines is not the only country in the region better ways to assist countries to address stark with this problem: disturbingly low subnational domestic disparities in access to health services polio vaccination rates are also seen in Indonesia, will be a priority. The spread of vaccine-preventable Myanmar, Cambodia and Laos (Figure 3.10). In some diseases amongst children in poor regions illustrates subnational regions, the rate of complete polio these disparities most clearly—and illuminates a vaccination attained compares (unfavorably) with clear threat. As global eradication of polio nears, global examples of extreme fragility and violence, the virus finds susceptible populations particularly for example Iraq, where Polio-3 coverage was amongst the poor. In an increasingly mobile world, maintained between 60 to 80 percent between the infectious diseases can spread rapidly to these years 2004 to 2015 (WHO-EMRO 2016). populations – and beyond them to other regions and countries. This is the reality the world is currently The World Bank estimates that 62 percent of the facing with the emergence and rapid spread of the global poor live in lower and upper middle-income Covid-19 pandemic. countries. To achieve inclusive development, finding FIGURE 3.10. POLIO3 VACCINATION COVERAGE BY SELECTED SOUTHEAST ASIAN COUNTRIES 16 90 80 Percentage of children age 12-23 (%) 70 60 50 40 30 20 10 0 Mondulkiri/ National Papua National Savannakhet National Ayeyarmady National Central National South National ARMM National Ratanakiri East Cambodia Indonesia Lao PDR Myanmar Thailand Vietnam Philippines The worst performing Region/Province contrasted with the national average. Source: Cambodia DHS 2014; Indonesia DHS 2012; Lao PDR DHS 2011-12; Myanmar DHS 2015-16; Philippines DHS 2017; Thailand MICS 2015-16; Vietnam MICS 2014. 16 Note on the Analysis: Data presented are from the most recent available DHS reports at the time of analysis and are not necessarily from the same reporting year. Example sub-national regions of Indonesia, Myanmar, Cambodia, Laos PDR, Thailand and Viet Nam were selected on the basis of their lowest reported performance on indicators of Polio3, “Children with no immunization” or “Children with all basic vaccinations.” Source: World Bank analysis. 57 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M The investment case for immunization is strong: Strong vaccine coverage has other positive it has long been accepted that immunization externalities besides reducing vaccine- is one of the most cost-effective public health preventable hospitalizations and other interventions. A recent estimate of net returns preventable utilization of already overwhelmed amounted to 44 times the costs of vaccination health systems. A strong immunization program in low and middle-income countries, including sets a system in place to respond to broader improvements in health system efficiency human security concerns—for example, measles from reducing duration and rates of hospital immunization is a tracer indicator for a country’s admissions (Ozawa et al. 2016). Medical expenses preparedness to deal with pandemic threats. are a key cause of household poverty, including Furthermore, strong capacities in surveillance, in the Philippines. A recent study estimated performance, logistics management and that, from 2016-2030, more than 20 million cases information systems all have potential for of medical impoverishment could be averted increasing health system capacity to address by vaccines if administered in 41 low- and the management of noncommunicable diseases middle-income countries (Chang et al. 2018). in addition to infectious ones. Thus, vaccine By extension, sub-national level health and coverage is not just a highly cost-effective end in household wealth would be improved in BARMM itself, but also a means to improve health system by improving the efficiency and sustainability of performance more generally. maternal and child health service delivery. 58 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M THE BARMM HEALTH SYSTEM Unlike in other parts of the country, the private sector has not figured prominently in BARMM. The country The BARMM health system is unique for its relatively has mixed public-private provision of hospital care and high level of autonomy. As described previously, outside primary health care. Nationally, the private sector has the region, national DOH is the national authority on overtaken the public sector in terms of the number health, while LGUs are responsible for managing and of hospital beds, but in BARMM, the number of public implementing local health programs and services. In sector hospital beds is still more than three times that the case of BARMM, however, this structure differs in of private hospital beds and the majority of care is still that the regional Ministry of Health holds administrative delivered by the public sector. control over facilities and provision of health programs and services.17 Republic Act No. 9054 specified that the Table 3.3 provides a summary of the accreditation status ARG should ‘provide, maintain, and ensure the delivery of facilities in BARMM as of 2017 for several important of, among other things, basic and responsive health primary care benefit packages through PhilHealth. programs.’ On this account—and in contrast to other Notably, a large percentage of BARMM’s RHUs are regions in the Philippines—public health services in the accredited for the Primary Care Benefit (PCB) package provinces of BARMM are managed by MOH rather than and the Maternity Care Package (MCP); 112 of 124 RHUs the LGUs. However, LGUs are still subject to the 1991 LGC (90 percent) are accredited for PCB and 79 percent are mandate that they ensure effective access to health MCP accredited. However, there is evidence to suggest care. This ambiguity in the sharing of responsibility that many facilities are formally accredited before between MOH and LGUs has resulted in confusion in the meeting the minimum standards. This appears to reflect accountability structure in health service delivery. a conscious effort on the part of PhilHealth to increase access to care, a worthwhile goal, though sacrificing quality for access could have unintended consequences. TABLE 3.2. HEALTH INFRASTRUCTURE IN BARMM AND NATIONWIDE, 2016 Barangay Rural Health Government Government Private Private Total Total Average Health Stations Units Hospitals Beds Hospitals Beds Hospitals Beds Beds per Hospital BARMM 464 131 18* 715 7 200 25 915 36.6 Philippines 20,216 2,587 434 47,371 790 54,317 1,224 101,688 83.1 Source: Department of Health - Health Facilities and Services Regulatory Bureau (2016), from Dayrit et al (2018). Note: An inventory of hospitals as consulted with the DOH-ARMM shows that there are in fact 28 government hospitals in ARMM: 23 provincial/district/municipal hospitals operated by the DOH-ARMM; 2 district hospitals operated by the province of Basilan; and 3 national DOH-retained hospitals. 17 The administrative structures of Basilan and Marawi City differ from other parts of BARMM as they became part of ARMM only in 2001, well after the re- gion’s governance structure was laid out by the LGC of 1991. Thus, unlike the rest of BARMM where the BARMM Regional Government is the formal owner and steward of public health services, the LGUs own and run the facilities in Basilan and Marawi City. 59 C H A P T E R T H R E E : T H E H I S T O R I C A L , P O L I T I C A L A N D H E A LT H - S P E C I F I C C O N T E X T O F B A R M M TABLE 3.3. PHILHEALTH ACCREDITATION STATUS OF RHUs IN BARMM, 2017 Accredited for Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi Lamitan City Marawi City Total No. of 39 36 11 19 11 1 1 Municipalities/Cities Total No. of RHUs 39 37 12 19 14 2 1 PCB 39 RHUs 36 RHUs 6 RHUs 18 RHUs 10 RHUs 2 RHUs 1 RHU 1 government 1 BHS 1 other 1 BHS hospital government facility 1 government hospital 6 RHUs 12 RHUs 10 RHUs 2 RHUs 1 RHU MCP 33 RHUs 34 RHUs 1 BHS 2 other 1 other 1 private clinic 6 BHS government government 2 other government birthing facility birthing centers centers 1 private 27 private clinics 1 private clinic hospital 2 private clinics TB DOTS 37 RHUs 35 RHUs 6 RHUs 13 RHUs 10 RHUs 2 RHUs 1 RHU 1 BHS 1 government 1 BHS 1 government 2 government hospital 1 government hospital hospitals hospital Outpatient Malaria 1 RHU 3 RHUs — 5 RHUs 9 RHUs — — Package Source: ARMM Supply Side Readiness Assessment, 2017 Future Directions 3. Within the process of regional transition to BARMM, the shaping of the financing and governance The regional health system is in a period of profound relationships between the new BARMM MOH transition, as is the region overall. The creation of the and national, provincial and LGU counterparts BARMM Ministry of Health has offered an opportunity to respectively. substantially reorganize and increase efficiency of the health system structure. In the new BARMM organization, The MOH is rapidly responding to its mandate by some aspects of the former ARMM structure may be developing a BARMM Health Agenda and Medium-term expected to continue—however, three major political Health Plan. When finalized, it is likely that this will focus factors will profoundly influence how health is financed, on the following priorities: governed and delivered: • Reproductive, maternal and child health, and 1. The implementation of the national UHC Law, with nutrition; its many implications for the role of DOH, provincial • TB and other infectious diseases; administration of health networks, and significant • Noncommunicable diseases (NCDs); reforms in provider payment mechanisms through • Environmental health; PhilHealth. • Mental health and substance abuse; and • Health systems. 2. The consequences of the recent Mandanas v. Ochoa decision of the Supreme Court, which substantially These priorities reflect not only the most pressing current expands the revenue base from which the IRA is deficiencies in health outcomes, but also the central drawn, meaning that LGUs will receive much larger importance of delivering quality health services to the allocations beginning in 2022. This may result in LGUs BARMM population in order to demonstrate clear and being both expected and able to shoulder more of tangible improvements in the daily lives of citizens. the responsibility for financing local health service delivery. 60 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M CHAPTER FOUR: FINANCING HEALTH IN BARMM SUMMARY planning and budgeting processes, reporting and accountability mechanisms, and schedules of • Under the ARMM organization, national government disbursement—challenge health service providers, (NG) appropriations provided up to 65 percent of especially rural health units (RHUs), to efficiently the resources for health, channeled through health program their resources and cover their operating allocations in the appropriations for ARMM, cash and expenses in a consistent and uninterrupted way. in-kind transfers from the national DOH, and funding for national DOH hospitals providing services to • With the non-devolved setup of health care delivery ARMM constituents. PhilHealth payments to health in the region, BARMM experiences some natural facilities also constituted a substantial 26 percent integration of facilities as well as notional “pooling” of total health funding. Several other funding of funding sources, both of which are espoused streams collectively accounted for a small share of by the Universal Health Care Law. However, such the overall funding for health. The ARMM Regional integration and pooling are not fully operational, Government held little authority over the allocation in that facilities in fact mostly operate and make or disbursement of these funds. decisions on their own, including in the funds they generate, with little regional oversight. • Beginning in 2020, NG appropriations to BARMM are in the form of a block grant, which the BARMM • Among all the funding streams, the NG appropriation regional government will allocate for specific (block grant) offers the greatest potential for programs. Under the block grant, the regional increased resources for health; it is also the funding government has more freedom in allocating the total stream over which the regional government has appropriation to the various sectors, including the the most influence. There is also room for LGUs to Ministry of Health (MOH). provide additional resources for health. • BARMM Local Government Units (LGUs) have • Aside from mobilizing additional funds, the BARMM traditionally contributed much less to health service government can also make more resources available delivery than non-BARMM LGUs, due in part to for health by spending more efficiently, in order to ambiguity in the sharing of responsibility between gain value for money. MOH and LGUs in ensuring health care access at • The regional government stands to gain resource the local level. LGUs are set to receive a substantial allocation authority under various future funding increase in their IRAs in 2022 as a result of the recent scenarios, though the national government and Mandanas v. Ochoa legal decision. In anticipation possibly LGUs will still hold a substantial degree of of that increase, the regional government should allocation authority. The BARMM government should work to engage LGUs and encourage them to take proactive steps to develop a regional health dedicate more of their IRAs to health services; better plan and corresponding health financing strategy delineation of the role of LGUs may help generate to ensure that all resources from all levels of concrete support. government are aligned to meet the region’s needs. • The flow of funds into the ARMM health sector Such a strategy must be developed in partnership was complex and convoluted, a situation currently with LGUs and in support of national government unchanged in BARMM. Parallel but uncoordinated program requirements, to enhance buy-in. funding streams—each with their own distinct 61 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M INTRODUCTION This chapter attempts to take stock of the funding situation for the health sector in ARMM, so as to draw lessons and recommendations for the BARMM administration on where and how it might mobilize current and future funding for health, and how to spend it in order to provide more value for money. The documentation identifies the relevant funds made available for health, their provenance, and how they were allocated in terms of type of expenditure and intended health function. The framework used in data collection and analysis in this section is largely inspired by the 2007 study by the International Center for Innovation, Transformation and Excellence in Governance, authored by E. Boncodin et. al., entitled “Towards Strengthening the Fiscal Capabilities of ARMM” (INCITEGov 2007). The INCITEGov study provided empirical data on the region’s fiscal situation by taking an inventory of the funds released to ARMM by the NG systems, making it difficult to consistently identify from 2001 to 2005, in addition to funds raised by the the amounts appropriated, allotted, and disbursed. region itself. For each type of funding, the following Estimates were made for some items; for others, only were identified: the government level from which partial data could be collected. For comparability, the funding was sourced (national, regional, or local), the amount most plausibly earmarked or allocated for ARMM government level with authority to allocate the funds, health systems is that used in the summations and in and the government level with disbursement or spending the comparisons among the different funding streams. authority. An analysis was made on fund utilization by The utilization of the allocated amount is discussed if expense class and by sector, and comparisons were made pertinent. Only data for the years 2016 and 2017 were with other regions of the Philippines. consistently available for the 10 funding streams. This analysis uses data collected from various The totals for 2016 and 2017 were also used in analyzing sources including Department of Health-ARMM (DOH- funding allocations by expenditure class and health ARMM), ARMM health facilities, the national DOH, the care function. In terms of expenditure class, the General Appropriations Act, and the Philippine Health Philippine accounting system classifies expenses Insurance Corporation (PhilHealth). It includes data as either Personnel Services (PS), Maintenance and on the amounts allocated for health 18 over the five- Other Operating Expenses (MOOE), or Capital Outlay year period from 2013 to 2017 and documentation of (CO). Health care functions are classified by the 2011 the funds flow mechanism for each. 19 Such data was Philippines System of Health Accounts (SHA) as either: available for only 10 of the funding streams identified. 1) curative care provided in hospitals; or 2) preventive However, different funding sources (such as government and curative care provided in primary care facilities, appropriations, suballotments by NG agencies, and public health, and administration of health programs and insurance payouts) are tracked using different recording services. Due to data limitations, several assumptions 18 Health funding allocation refers to health funds intended for health care goods and services to be consumed by BARMM constituents during the calendar year period. This definition of scope is in line with the definition in the Systems of Health Accounts 2011 (SHA 2011). 19 Some data from the early stages of the transition to BARMM are also used to assess the direction that the transition is heading. 62 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M were used in breaking down the funds by expenditure collected). Notably, these funding streams (in gray) are class and by type of health care function not known to be significant contributors to ARMM health (explained below). resources, with the exception of household out-of-pocket health expenditure, which does constitute a substantial Despite these limitations, the figures provide a portion of spending for health care. The Philippine comprehensive assessment of the health funding National Health Accounts estimates that household situation in ARMM and how it has affected service out-of-pocket spending has accounted for more than delivery. The results of this financing analysis are half of all health spending in the country for the past presented below, followed by a discussion several years. A later chapter of this report presents a and recommendations. 2019 BARMM household survey which shows that BARMM households spent about PhP 1,155 per household per month on health. There is no similar data available FINDINGS AND RESULTS for the 2013–2017 period and therefore the household spending funding stream is not included in the following Funding Streams analysis. As mentioned, assumptions and estimates had to be used for some funding streams, such as funding for The following is a list of government and non- national DOH hospitals attributable to ARMM. For others, government funding streams identified to have provided including in-kind transfers of national DOH and Official cash or in-kind resources for the ARMM health sector Development Assistance (ODA), only partial data could (Table 4.1). The funding streams listed on the left side of be collected. Nevertheless, these sources are included in the table are those for which data were available. Those this analysis in order to present the most comprehensive on the right side (shaded in gray) are funding streams for picture possible. which data were not available (or could not feasibly be TABLE 4.1. FUNDING STREAMS FOR ARMM HEALTH SECTOR GOVERNMENT Through National Government (NG) Appropriations • NG allocation for ARMM health services • Funding from other national government agencies • Other health-related NG allocations - HELPS providing resources for the ARMM health sector (e.g. • National DOH cash transfers Armed Forces of the Philippines) • National DOH in-kind transfers • Funding for national DOH hospitals Through PhilHealth/National Health Insurance Program (NHIP) • PhilHealth payments Through Regional Government • Local (region) fund allocation for health Through Local Government Units • Province LGU allocations for health • Municipality and city LGU allocations for health PRIVATE AND OTHER NON-GOVERNMENT SOURCES Official Development Assistance (ODA) • Household/individual expenditure on health • Non-government organizations (NGOs), Civil Society Organizations (CSOs) • Other private sources 63 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M Health Funding Allocated for ARMM, 2013-2017 approximately PhP13.3 billion was allocated for the ARMM health sector over those two years, or about PhP1,650 per Table 4.2 shows the amounts allocated for ARMM health capita per year.20 Additional details and data sources on services by each funding stream from 2013 to 2017. As each funding stream—including descriptions, funds flow, noted, it was only for the years 2016 and 2017 that data amount allocated for health in ARMM, fund usage, and were available for all 10 funding streams. In total, reporting and accountability—are presented in Annex A. TABLE 4.2. HEALTH FUNDING ALLOCATED FOR ARMM HEALTH SERVICES, BY FUNDING STREAM, 2013-2017 (IN MILLION PHP) Funding Stream 2013 2014 2015 2016 2017 Total 2016-2017 2016-2017 Amount as a % of Total Through National Government Appropriations NG allocation for ARMM 904 956 1.034 1,325 1,381 2,706 20% health services Other health-related NG not available 103 205 205 355 560 4% allocations - HELPS i/ National DOH cash transfers 162 not available 310 774 773 1,547 12% National DOH in-kind transfers ii/ not available 223 41 449 239 687 5% Funding for national 649 467 not available 1,062 2,125 3,186 24% DOH hospitals iii/ Through PhilHealth/NHIP PhilHealth payments 877 1,089 1,655 1,736 1,682 3,418 26% Through Regional Government Local (region) fund allocation - 31 71 15 10 25 0% for health Through Local Government Units Province LGU allocations 277 219 247 302 271 573 4.3% for health Municipality and city LGU 119 145 157 145 175 320 2.4% allocations for health Private and Other Non-Government Sources Official Development Assistance 184 82 100 161 142 303 2% (ODA) iv/ Total 3,122 3,314 3,819 6,174 7,151 13,325 100% i/ 20 percent of total of ARMM-HELPS (based on a ppt on ARMM HELPS, 20 percent of funds was spent on health); appropriations for 2014 and 2015, allocations for 2016 and 2017 (but which amount is same as appropriation) ii/ Includes only vaccines and in-kind support from Health Emergency Management Bureau iii/ includes the following: i) Amai Pakpak MC (96 %), ii) Sulu Sanitarium (100 %), iii) Cotabato Sanitarium (100 %), iv) Basilan BH (50 %), v) Zamboanga City MC (40 %), vi) Cotabato Regional Med Center (50 %) iv/ ODA includes UNICEF, USAID, and WFP (major players) 20 Based on 2015 ARMM population of 3,781,387 (Philippine Statistics Authority). 64 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Figures 4.1a and 4.1b show that the five funding streams services and ARMM-HELPS—accounted for 24 percent of under the NG appropriations umbrella accounted for total health funding to the region (see Annexes A.1 65 percent of total health funding to ARMM. Three of and A.2). these streams are appropriations to national DOH, which together accounted for nearly 41 percent of total health PhilHealth payments comprised more than one quarter funding: funding for national DOH hospitals (24 percent), (26 percent) of total health funding to the region (Figure national DOH cash transfers (12 percent), and national 4.1a), primarily through payments to health facilities in DOH in-kind contributions (five percent) to ARMM. (See ARMM21 and to the DOH hospitals outside ARMM that Annexes A.3, A.4, and A.5 for details.) The two remaining serve ARMM constituents (see Annex A.6).22 65+26+72D funding streams—NG allocations for ARMM health FIGURE 4.1A. HEALTH FUNDING ALLOCATIONS FOR ARMM, BY FUNDING SOURCE, 2016 TO 2017 ODA Through LGUs 2% 7% Through PhilHealth 26% PHP 13.3 BILLION 65% Through National Government Appropriations Through Regional Government <1% 24+26+43220125D FIGURE 4.1B. HEALTH FUNDING ALLOCATIONS FOR ARMM, BY FUNDING STREAM, 2016 TO 2017 National DOH in-kind transfers National DOH cash transfers 5% 12% Funding for National Other health-related NG 24% DOH hospitals allocation - HELPS 4% PHP 13.3 BILLION NG allocation for ARMM health services 20% 26% PhilHealth payments Local (Region) funds allocation for health 2% <1% 3% 4% ODA Municipality and City LGU Allocations for Health Province LGU Allocations for Health 21 Claims paid to hospitals, infirmaries, and providers of Maternal Care Package, Outpatient Malaria Package, TB DOTS, and Animal Bite Package; and capita- tion/per family payments to providers of the Primary Care Benefit Package. 22 Cotabato Regional Medical Center and Zamboanga City Medical Center. Figures were prorated to attribute to ARMM constituents. 65 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M Local (regional) funds made an insignificant contribution the United States Agency for International Development to total health funding (less than one percent). Data (USAID), the United Nations Children’s Fund (UNICEF), and presented in Annex A.7 show that these revenues are the World Food Programme (WFP). in fact very small compared to funds sourced from the national government, such that health gets a trivial share Locus of Control of local revenues, if any at all. LGU allocations comprise just seven percent of total health funding for the region: The table below indicates the level of government— four percent from provincial LGUs and three percent from national, regional, or local—that served as the source, municipalities and cities (see Annex A.8-9). allocating entity,23 and disbursing entity24 for each of the health funding streams. Figure 4.2 further depicts Finally, external sources, in particular official the distinct shift in locus of control from the national development assistance (ODA), contributed a mere two government, which is the source of nearly all health percent to total health funding for ARMM, mainly from funding, to the regional and local governments, which TABLE 4.3. LOCUS OF CONTROL OF HEALTH FUNDING IN BARMM, BY FUNDING STREAM, 2016-2017 Funding Stream % of Total Source Allocation (Allocating Entity) Disbursement(Disbursing Entity) (PhP13.3 billion) in 2016–2017 Through National Government Appropriations NG allocation for ARMM health services 20% National Government National Government Regional Government (DOH-ARMM and DOH-ARMM IPHOs and Hospitals) Other health-related NG allocations - 4% National Government Regional Government Regional Government (ARG) HELPS (ARG) National DOH cash transfers 12% National Government National Government Regional Government (DOH-ARMM) National DOH in-kind transfers 5% National Government National Government National Government Funding for national DOH hospitals 24% National Government National Government Facility (of National Government) Through PhilHealth/NHIP PhilHealth payments 26% National Government Facility (of National Facility (of National Government Government or Regional or Regional Government or LGU or Government or LGU or private entities) private entities) (to some extent PhilHealth) Through Regional Government Local (region) fund allocation for health 0.2% Regional Government Regional Government DOH-ARMM or Local Government (ARG) (ARG) Through Local Government Units Province LGU allocations for health 4% National Government Local Government Local Government (95%), Local Government (5%) Municipality and city LGU allocations for 2% National Government Local Government Local Government health (95%), Local Government (5%) Private and Other Non-Government Sources Official Development Assistance (ODA) 2% Others (External/ Others (External/ Others (External/ Non-Government) Non-Government) Non-Government) Total 100% 23 The allocating entity refers to the level of government with the authority to determine how much to allocate for health and for what specific health ser- vice or function. 24 The disbursing entity, on the other hand, refers to the level of government that utilizes or spends the fund. 66 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 4.2. LOCUS OF SOURCE, ALLOCATION, AND DISBURSEMENT OF ARMM HEALTH FUNDS, 2016–2017 (PHP13.3 BILLION) 2% 100% 0.3% 0.2% 8%ii/ 8% 90% 8%iii/ 8% 80% 14%iv/ 70% 60% 46%v/ 50% 97%i/ Other/Non-Government 40% 70% Local Government Units 30% ARMM Regional Government 20% 38 National Government 10% 0% Source Allocation Authority Disbursement Authority i/ 65 percent all funding streams through NG appropriations, 26 percent PhilHealth payments, 4 percent province allocations for health (since 95 percent of funding stream is from IRA), 2 percent municipality and city allocations for health (since 95 percent of funding stream is from IRA) ii/ 6 percent PhilHealth payments to private facilities, 2 percent ODA iii/ 4 percent province LGU allocations for health, 3 percent municipality and city LGU allocations for health, 1 percent PhilHealth payments to LGU facilities iv/ 9 percent PhilHealth payments to DOH-ARMM facilities, 4 other health-related NG allocations-HELPS, less than 1 percent region funds allocation for health v/ 20 percent NG allocation for ARMM health services, 12 percent national DOH cash transfers, 9 percent PhilHealth payments to DOH-ARMM facilities, 4 other health-related NG allocations-HELPS, less than 1 percent region funds allocation for health together hold more than 20 percent of allocation Moreover, the NG held 38 percent of disbursement authority and over 50 percent of disbursement authority, specifically over in-kind resources provided authority.25 Further information is provided in Annex B. to the region, funding for national DOH hospitals, and PhilHealth payments to these same hospitals. National Government. The NG is by far the largest Disbursement authority is divested to the regional source of funding for ARMM health services, with nearly government for NG allocations for ARMM Health Services 97 percent of funding originating from the NG through (20 percent of total funding) and National DOH Cash various direct and indirect streams, including IRAs Transfers to ARMM (12 percent). to LGUs. Regional Government. As a source, the Regional Although some allocation authority for the funds Government made almost no contribution to health sourced from the NG was divested to regional and local funding, though it exercised some leverage in terms of governments and non-government entities, Figure 4.2 allocation of funds, as it was the allocating entity for shows that the NG still held most of the allocation 14 percent of resources. However, the majority of these authority for ARMM health services (70 percent). resources were PhilHealth payments to health facilities 25 Each column (on appropriation, allocation, and disbursement) pertains to the PhP 13.3 billion spending in 2016–2017; that is, the figure traces which level of government appropriated, allocated, and disbursed that PhP 13.3 billion. It does not cover any other appropriation that may not have been allocated or spent. For example, the regional government appropriated PhP 25 million for health in 2016–2017, but of that PhP 25 million, only PhP 6 million was allocated and disbursed. Hence only the PhP 6 million is included in the PhP 13.3 billion. 67 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M which controlled their use, even though these facilities of ARMM LGU funds are derived from internal revenue were themselves owned and operated by DOH-ARMM allocations27 from the national government.28 As an (effectively by the regional government). The allocation allocating authority, LGUs had control over eight percent function for ARMM-HELPS funding was also attributed or PhP 1.1 billion of health funding in 2016–2017, mostly to the regional government. The BARMM regional the result of allocation decisions related to their IRAs government has greater allocation authority for health and other local revenues. As shown in Annex A.8, health now that the entire NG appropriation for BARMM is made spending accounted for approximately six percent of the via automatic appropriation in a block grant, and with the total IRA expenditure for the ARMM provinces in 2016– wider base of local revenues the region can allocate for 2017, compared to 22 percent in non-ARMM provinces. The health. Several variations of allocation authority under figures were even lower for ARMM municipalities, where the BARMM administration are presented later in health spending accounted for less than two percent of this chapter. total operating expenditure in 2016–2017, compared to 9 percent in non-ARMM municipalities. Figures presented in Although the regional government had a fairly small Annex A.8 show that NG and regional government health role as a source and allocating authority, it held much spending did not compensate for the relatively low LGU more authority in terms of disbursement of funds, as it health spending in ARMM. was responsible for disbursing nearly half of total health funding. Three levels within the ARG were tasked with Others (External/Non-Government). Finally, it can disbursing these funds: the ARG itself (through the Office be noted that a substantial 23 percent of PhilHealth of the Regional Government), the DOH-ARMM, and the payments were to private health facilities. As such, the health facilities under the jurisdiction of DOH-ARMM. allocation and disbursement functions for the funds are Of these, the health facilities—mostly the provincial, divested to these private facilities. district, and municipal hospitals—had the most funding. For example, as shown in Annex A.1, of the total NG Flow of Funds allocation for ARMM health services, 80 percent went to the Integrated Provincial Health Offices (IPHOs) and their Annex A provides documentation on the flow of respective health facilities for disbursement. In principle, resources for each of the funding streams; Figure 4.3 these entities are accountable to DOH-ARMM and the ARG below combines these into one overall funding scheme. for the use of funds, since they are under DOH-ARMM It is clear that the flow of funds is complex and involves jurisdiction, though in reality DOH-ARMM and ARG are many funding streams that run parallel to each other but largely only involved as conduits for funds and reporting are uncoordinated, each with their own distinct planning forms between the NG and these facilities. Finally, the and/or budgeting processes as well as reporting and health facilities also directly received PhP 1.3 billion as accountability mechanisms. For a health service provider payments from PhilHealth.26 In theory, DOH-ARMM and like an RHU, this means receiving resources from several ARG could have control over both the allocation and streams, some of which are quite unpredictable in terms disbursement of these hospital receipts. of amounts and timing. This makes it difficult for RHUs to program, monitor and account for their resources; it also Local Government Units. Like the regional government, means that, despite the receipt of funds from multiple LGUs contributed less than one percent of self-generated sources, they still may not have enough to cover their funding to health services, largely because 95 percent operating expenses on a regular and uninterrupted basis. 26 It is also discussed in Annex A that PhilHealth capitation payments, comprising a small portion of this PhP1.3 billion, passed through the DOH-ARMM but it is unclear what value this adds to the allocation and disbursement functions. 27 Discussed in Annex A.8. 28 That is, LGU as a source of health funding is only five percent of the seven percent health allocations, equivalent to less than one percent. 68 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 4.3. FLOW OF FUNDS OF HEALTH RESOURCES FOR ARMM 29 4 7 1 1,2 IPHOs 6a ORG (PHOs and Provincial Hospitals) 8 3 Maguindanao, Lanao del Sur, Sulu, Tawi-Tawi 10 DBM 3,4 4 4 National DOH DOH-ARMM DOH-ARMM Hospitals 6a (other than in Basilan and Marawi City) 8 9 6b - District hospital 10 - Municipal hospital 4 8 6 4 IPHO Basilan 6b 6a PhilHealth RHUs & BHUs 8 (other than in Basilan and Marawi City) 6 10 4 8 4 Marawi City 5 Households/ Health Office National DOH Hospitals 6 8 Businesses 10 4 4 1 6a LGU Basilan Health Facilities 8 8 2 10 9 4 ODA 6b 6a Marawi City Health Facilities 8 10 1 – NG allocation for ARMM health services 6b – PhilHealth payments for PCB (capitation) 2 – Other health-related NG allocations - HELPS 7 – Local (Region) fund allocation for health 3 – National DOH cash transfers 8 – LGU (Province, Municipality, City) allocations for health 4 – National DOH in-kind transfers (dotted line) 9 – ODA 5 – Funding for national DOH hospitals 10 – Household Out-of-Pocket 6a – PhilHealth payments for inpatient services and outpatient other than PCB Use of Funds Personnel Services. Roughly PhP 4.3 billion or 32 percent of ARMM health funding in 2016–2017 was allocated for The overall use of health funds is broken down in this PS. Almost half of this was from the NG allocation for report in two ways: by expense class and by type of ARMM health services and paid for the salaries and health care function. Expense class categorization is benefits of DOH-ARMM personnel in the regional office as derived from the Philippines government accounting well as in hospitals and RHUs. PS also accounted for half systems. Health care function is categorized as either of the allocations for national DOH hospitals. curative (hospital-based) or preventive (primary health care or public health programs typically provided by an Data were limited or unavailable for the remaining RHU or BHS). sources of funding for PS, so assumptions were made to provide as close an approximation as possible. Fund use by expense class As shown in Table 4.4 below, at least 20 percent of PhilHealth payments can be attributed to PS, as Table 4.4 sorts health funding allocations into the PhilHealth guidelines indicate that 20–30 percent of following expense class categories: Personnel Services PhilHealth payments must go towards a professional fee, (PS), Maintenance and Other Operating Expenses (MOOE), depending on the specific case or service package being and Capital Outlay (CO). The result is a PS:MOOE:CO ratio delivered. Finally, in the absence of data, 20 percent of of 32:54:14. The set of assumptions used to draw up Table LGU allocations for health can be attributed to PS; this 4.4 are provided in Annex C. only includes the PS allocations for health in Basilan and 29 This depiction of the flow of funds is modeled after the ARMM Financing Flowchart as contained in the ARMM Transition Report (ARMM-RPDO, 2019). 69 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M Marawi City, where health services are devolved to support the building of health infrastructure through the the LGUs. Health Facilities Enhancement Program (HFEP). Maintenance and Other Operating Expenses. MOOE There are a number of caveats to consider in these accounted for PhP 7.1 billion or 54 percent of total expense classifications. First, there are allocations for health allocations for ARMM in 2016–2017. The biggest health human resources (HRH) that are classified in contributor to MOOE was PhilHealth payments, on the accounting records as MOOE, even though they are assumption that 80 percent of PhilHealth payments are primarily used for salaries for contractual positions used for MOOE. This is followed in magnitude by fund or job orders and as such would be more accurately transfers from national DOH. classified as PS. For example, almost 60 percent of DOH cash transfers to ARMM for health services were for Capital Outlay. Capital Outlay allocations comprised salaries and benefits of the health personnel deployed 14 percent of the total, and came from three funding through the various HRH programs of the national DOH, streams: other health-related NG allocations (ARMM- including Doctors to the Barrios, Nurse Deployment HELPS), national DOH cash transfers, and funding for Program, Rural Health Midwives Placement Program national DOH hospitals. Of these, funding for national (RHMPP), and Family Health Associates. These allocations DOH hospitals comprised the largest share. More than were classified as MOOE rather than PS. This suggests 90 percent of the ARMM-HELPS health allocation went that the share of MOOE in the allocations may actually be to providing infrastructure and equipment to barangay smaller than shown in Table 4.4, while the PS allocation health stations, while DOH cash transfers were used to is likely larger. TABLE 4.4. ARMM HEALTH FUNDING ALLOCATIONS BY EXPENSE CLASS (IN MILLION PHP), 2016-2017 in million Php Funding Stream PS MOOE CO Total Through National Government Appropriations NG allocation for ARMM health services 1,891 814 - 2,706 Other health-related NG allocations - HELPS - 56 504 560 National DOH cash transfers - 1,317 229 1,547 National DOH in-kind transfers - 687 - 687 Funding for national DOH hospitals 1,547 459 1,181 3,186 Through PhilHealth/NHIP PhilHealth payments 684 2,735 - 3,418 Through Regional Government Local (region) fund allocation for health - 25 - 25 Through Local Government Units Province LGU allocations for health 115 458 - 573 Municipality and city LGU allocations for health 64 256 - 320 Private and Other Non-Government Sources Official Development Assistance (ODA) - 303 - 303 Total 4,301 7,110 1,914 13,325 as a % of Total 32% 53% 14% 100% 70 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Another caveat pertains to PhilHealth payments and of the total health funding in 2016–2017, while all other capital outlay. In Table 4.4, an assumption of 20:80 health functions comprised only 35 percent. PS:MOOE sharing was used for PhilHealth payments. There is no specific guidance, though, as to whether Two large funding streams are associated with hospital- or not hospitals can use PhilHealth payments for based curative care, worth about PhP 3 billion each: infrastructure or other capital expenditure. However, PhilHealth payments to hospitals,30 and NG funding there is evidence to suggest that some hospitals do for national DOH hospitals (Figure 4.5). Another PhP 2 use PhilHealth payments in this way; for example, billion went to hospitals from the NG appropriations for Maguindanao Provincial Hospital built a new hospital ARMM health services, or 80 percent of all NG allocations wing in 2018 and attributed funding for this project to for ARMM health services. The remaining funding for PhilHealth receipts. hospital-based curative care was from HFEP contributions from the national DOH, 80 percent of which were Funding by Type of Health Care Function assumed to be for hospitals. In Figure 4.4, health funding allocations are classified Just 35 percent of total health funding was allocated into two categories of health care function: curative care to services other than hospital-based curative care, in hospitals, and preventive and curative care in primary which shows the bleak state of funding for primary care care facilities, public health, and administration of health and public health in ARMM. This percentage is based programs. Ideally, this second category could be broken on the assumption that the following funding streams down into several other health care functions for a more were allocated in their entirety to this category: ARMM- definitive picture of types of health care funded, but HELPS, in-kind transfers from national DOH, regional available data precluded drawing these distinctions. fund allocations for health, province and municipality For instance, funding for DOH-ARMM accounts for allocations for health, and ODA contributions. Also the provision of public health care as well as the included in this category are PhilHealth payments for administration of health programs, but it is difficult to primary care benefits, maternity care package (MCP), deduce from available records how much was devoted to outpatient malaria package, TB DOTS package, and animal each. Nevertheless, what is notable is that curative care bite package. 65+35+D in hospitals comprised the vast majority (65 percent) FIGURE 4.4. HEALTH EXPENDITURES BY HEALTH CARE FUNCTION, ARMM, 2016-2017 Preventive and Curative Care in Primary Care Facilities, Public 35% Health, and Administration of PHP 13.3 BILLION 65% Curative Care Health Programs 30 Includes all government and private hospitals in ARMM, and payments to CRMC and ZCMC prorated to ARMM constituents among clients. 71 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M FIGURE 4.5. TYPE OF HEALTH SPENDING BY FUNDING STREAM AND HEALTH CARE FUNCTION, 2016-2017 PhP 13.3 billion 4,000 3,500 3,000 2 016-2017 2,500 2,000 1,500 1,000 500 - National DOH cash transfers NG allocation for ARMM health services Other health-related NG allocations - HELPS National DOH in-kind transfers Funding for National DOH hospitals PhilHealth payments Local (Region) funds allocation for health Province LGU Allocations for Health Municipality and City LGU Allocations for... ODA Preventive and Curative Care in Primary Care Facilities, Public Health, and Administration of Health Programs Curative Care It is important to note that the funders for non-hospital- Perhaps the most stable source of funding for primary based care were generally more unpredictable and ad care and public health comes from the NG appropriation hoc in nature than those for hospital-based curative for ARMM health services. However, as noted earlier, care. For example, the largest share of funds for primary only a small fraction of this goes to non-hospital- care and public health came from fund transfers from based services. While the budget for IPHOs and district national DOH. As noted in Annex A.3, this funding is hospitals is intended to cover RHUs, only the salaries of highly irregular and unpredictable, as it comes from personnel are budgeted, generally requiring the RHUs different programs, each with its own respective planning to look elsewhere for resources to cover their and allocation processes. operating expenses. Annex D provides the assumptions used in classifying the health funds by type of health care function. 72 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FUNDING OF HOSPITALS VERSUS PRIMARY CARE FACILITIES Funding of Hospitals: • National Government (NG) appropriations to ARMM (via the General Appropriations Act): Eighty percent supported Integrated Provincial Health Offices (IPHOs), and district and municipal hospitals throughout the region, to cover personnel and operating costs. Under BARMM, this funding will be appropriated via block grant. • NG funding for national DOH hospitals: There are 3 National DOH hospitals in BARMM, as well as several other hospitals outside BARMM that serve BARMM constituents. These hospitals receive funding directly from the National Government. • PhilHealth: Hospitals receive case-rate payments for inpatient services provided to PhilHealth members. From 2013-2017, nearly 90 percent of PhilHealth funding to ARMM supported hospital-based inpatient care. • User fees/Patient out-of-pocket payments Funding of Primary Care Provided at RHUs: • PhilHealth: Capitation payments for the Primary Care Benefit (PCB) package are placed in trust funds to help cover operating expenses of the facilities where beneficiaries receive services. Rural Health Units (RHUs) in BARMM have not received any capitation payments for at least the past two years, due to the requirement for the use of Electronic Medical Records, which they have not yet adopted. • PhilHealth: Case payments for other primary care packages (i.e Maternal Care Package) • NG appropriations to ARMM: Funding for district and municipal hospitals is meant to cover the operating expenses of RHUs in the hospital’s catchment area, but typically it only covers staffing. • National DOH Fund Transfers support specific priority programs and are often used for workforce deployment programs and health facilities enhancement. • National DOH In-Kind Transfers provide vaccines, medicines, and other health commodities to RHUs. • Special programs, for example ARMM-HELPS, support the provision of essential medicines, construction and repair of barangay health stations and birthing facilities. • LGU and Official Development Assistance (ODA) support Summary of Differences: • Hospital funding is more regular and predictable as it comes from NG appropriations, national DOH, and PhilHealth reimbursements for services already provided. It also tends to pass directly from the allocating entity to the facility that provides the services. • Funding for RHUs is less consistent. Much of RHU funding is either ad hoc and not regularly programmed, including payments from PhilHealth. Nearly all funding for RHUs passes through intermediaries (either hospitals or DOH-ARMM), where bureaucratic and administrative requirements inhibit the flow of funds. 73 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M DISCUSSION The larger allocation for health in 2020 has allowed the BARMM regional government to provide substantially Post-ARMM. The transition from ARMM to BARMM greater budgetary support to the Integrated Provincial includes a shift from an NG appropriation to an Health Offices and the hospitals than in previous years automatic appropriation through a block grant, thus (see Annex E for a breakdown of the appropriations for transferring the allocating authority of the appropriation the Ministry of Health), including funding for capital for the region to the regional government itself. This outlay projects for which the national GAA had not change to a block grant appropriation began in 2020, recently provided appropriations. Moreover, budgets were and in its first year, it did not disappoint: it did indeed allocated for the various health programs of the Ministry give the health sector a monumental increase in funding of Health, which previously relied on funding from the for health. The allocation for health from this funding national DOH and ad hoc funding from other budget stream doubled from the previous year (2019) as shown line items of the region. The increased budget also in Table 4.5. However, as a percentage of the total BARMM allowed for an increase in the personnel complement appropriation, it remained at a similar level to the of the Ministry, including midwives of the Midwives in previous years (4.7 percent), since the total appropriation Every Community (MECA) program who became regular for BARMM also doubled from 2019 to 2020. employees instead of contracted staff.32 Variation 1 in Figure 4.6 below provides a hypothetical It is notable that a substantial 15 percent of the total portrayal of the effect on the base 2016–2017 figures MOH budget in 2020 was allocated for the Family had the appropriations for health from the NG been Health Cluster, primarily for the region’s purchase of doubled and the allocation authority transferred from vaccines. While regional vaccine purchasing did not the NG to the regional government in 2016–2017. 31 Had in fact materialize, funding comparable in magnitude this been the case, the total funding for the region to 2020 budget levels is included for this activity in would have been PhP 16.6 billion instead of PhP 13.3 the 2021 BARMM Expenditure Program (BEP). However, billion, and the regional government would have had Chapter Seven of this report discusses why the regional the allocation authority for 47 percent (40 percent from purchasing of vaccine antigens may not be ideal at this the NG appropriation and seven percent from PhilHealth time. As described in more detail there, the purchasing payments to facilities). and delivery of vaccines to consumers is the final piece TABLE 4.5. NATIONAL APPROPRIATIONS FOR ARMM HEALTH SERVICES AND FOR ARMM (TOTAL), 2016-2019; AND BARMM APPROPRIATIONS FOR MINISTRY OF HEALTH, 2020, IN MILLION PHP 2016 2017 2018 2019 2020 Total, Health Services 1,154 1,292 1,333 1,504 Total, Ministry of Health 3,070 Total, ARMM 28,492 32,262 33,057 31,117 Total, BARMM 65,916 Health Services as 4.1 % 4.0 % 4.0 % 4.8 % Ministry of Health as a % of 4.7 % a % of Total ARMM Total BARMM Appropriation Appropriation Source: General Appropriations Act 2016 to 2019; BARMM Autonomy Act No. 3, 2020 31 All other funding streams fixed, to show only the effect of doubling of the allocations for health from the national government appropriations, and the transfer of allocating authority from national to regional government. 32 In the BARMM Expenditure Program (BEP) for 2021, the allocation for health has increased further, amounting to P5.1 billion. The increase is largely for capital outlay which includes building new rural health units and barangay health stations. It also provides for regular funding for operations of the RHUs and barangay health stations, and for scholarships for medicine and allied medical professional students. If this budget proposal is passed, it will amount to a 67 percent increase in the health budget from 2020, and a three-fold increase from 2019, the last year prior to the block grant. Also, health will comprise a substantial 6.8 percent of the P75 billion total proposed 2021 budget. 74 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 4.6. LOCUS OF ALLOCATION OF HEALTH FUNDS, VARIATION 18,000 16,000 6% 6% 14,000 8% 12,000 8% 47%** 10,000 14%* 8,000 Other/Non-Government 6,000 Local Government Units 4,000 70% 42% ARMM Regional Government 2,000 National Government - Base (Actual 2016-2017) Variation 1 * 9 percent PhilHealth payments to facilities, 5 percent health-related NG allocations for ARMM (other than for DOH-ARMM) ** 7 percent PhilHealth payments to facilities, 40 percent regional government allocations for health from the block grant of a very complex system that involves logistics, planning, Two ways to increase the availability of resources for storage, and capacity building. MOH would do better to health are to increase the magnitude of resources or devote resources to these areas first, so that eventually, mobilize additional resources for health, and to spend when PhilHealth takes over funding of immunization existing resources better or more efficiently such that services as stipulated in the UHC Law, BARMM is ready increased output or value can be obtained. The foregoing and positioned to manage vaccine handling, and as discussions provide a detailed depiction of the funding service provider can then buy the antigens using funding streams that are available for health, as well as their from PhilHealth payments. magnitudes and uses. It is hoped that this will allow planners to envision where and how the region might This example underscores the need for the BARMM mobilize current and future funding for health, as well regional government to understand health funding vis-à- as how to spend it in order to provide more value for vis health service delivery in order to make high-impact money. decisions in the short term to prepare the region for future success. Now that the region has more funding for Mobilizing Additional Resources for Health. Table 4.6 health, the prospect of exploring new spending options presents an analysis of the possibilities for mobilizing generates understandable excitement. However, effective more funds from each funding stream, in order to service delivery depends on stable and well-planned exceed the 2016 to 2017 levels. National government systems, which BARMM now has the opportunity to build. appropriations and LGU funding are the two funding streams which could offer the greatest increase in Future Focus. It is without question that there is a resources, and over which the regional government is need to increase funding for health in the region, likely to have the most influence. A detailed discussion of considering the health outcomes of the population the information contained within Table 4.6 follows. (discussed in greater detail in Chapter 5 of this report). 75 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M TABLE 4.6. POTENTIAL FOR MOBILIZING ADDITIONAL RESOURCES FOR HEALTH FROM VARIOUS FUNDING STREAMS Ease of Anticipated additional Implementation resource (i.e. relative (1-Very Difficult, size/amount – High, Funding Stream Considerations 5-Relatively Easy) Moderate, Low) During ARMM: Retain at least the current share of NG allocations for ARMM 5 High National Government • Prior to BARMM, Health Services comprised 4 percent of Allocation (for ARMM the NG appropriations for ARMM in 2017. A share of 4.7 (additional health services, percent has already P1.7 billion from ARMM-HELPS and been appropriated 2017 level) other line items in the by the region for NG Appropriation) health for 2020 Obtain a larger share of the pie 4 Moderate During BARMM: • Health is among the top priority sectors of BARMM, along Regional Appropriation with education and social services. for Health (from • During ARMM, there were other NG allocations devoted to block grant and other health from other funding streams (e.g. ARMM-HELPS). regional resources) These are best incorporated in the regional appropriations of BARMM for health for better coordination and planning to respond to health needs. • Likewise, the allocations from the region’s own resources will be best incorporated here. LGUs (Provinces, Cities Negotiate with LGUs to allocate more resources for health, 3 High and Municipalities) similar to levels of non-BARMM LGUs (about 20 percent of total (as high as PhP 3.4 spending for provinces, and about 9 percent for municipalities billion if all BARMM and cities). 2016–2017 levels for BARMM LGUs were about 6 LGUs spend as much percent for provinces and cities, and less than 2 percent for as non-BARMM LGUs) municipalities. National DOH cash BARMM should continue to avail of this resource for as BARMM 4 Low transfers should continue to access this resource for as long as national policy allows funds to flow from national DOH. If the policy (that is, current and changes and funds are transferred to the regional offices, amount is large, but BARMM should be mindful that this will be an augmentation, prospect for additional National DOH in-kind not a replacement, of the share in the block grant. resources is low) transfers There is a need for better dialogue with national DOH for medium-term planning for the various programs in BARMM, to assure continuity of funding. Funding for national While the NG funding for (and other income of) DOH hospitals Not applicable Not applicable DOH hospitals has been a major contribution to health services for BARMM constituents, BARMM has little influence on the possibility of increased budgetary allocations. BARMM may focus on how to influence the quality, continuity and availability of tertiary care for its constituents, including whether BARMM should operate its own tertiary hospitals or have a more proactive engagement with the DOH hospitals providing tertiary care to BARMM constituents. 76 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Ease of Anticipated additional Implementation resource (i.e. relative (1-Very Difficult, size/amount – High, Funding Stream Considerations 5-Relatively Easy) Moderate, Low) PhilHealth Payments The scope of benefits of PhilHealth is a matter of national 3 Moderate policy. However, there are ways that the BARMM government can maximize PhilHealth benefits for its population, including by ensuring that constituents know their entitlements, and by investing in electronic medical records and other information systems in health facilities. ODA Development partners are currently eager help BARMM 4 Can be low to high, succeed; BARMM can harness this enthusiasm in support of its depending on health programs. Development partners can also provide loans negotiations. if gaps are identified in health financing plans. As discussed previously, now that the NG appropriation TABLE 4.7. HEALTH EXPENDITURE AS A PERCENTAGE for the region is provided as an automatic block grant, OF TOTAL CURRENT EXPENDITURE, 2016 AND 2017 the regional government has more freedom in allocating 2016 2017 the total appropriation to the various sectors. As mentioned above, the portion of the total appropriation ARMM Province 5.7 % 4.8 % allocated to health in 2020 was similar to the percentage non-ARMM Provinces 20.9 % 22.6 % allocated in the previous year (4.7 percent). However, ARMM Municipalities 1.3 % 1.5 % since the total appropriation doubled, the health allocation doubled as well. The Ministry of Health non-ARMM Municipalities 9.1% 9.1% could make a case for additional allocations for health, ARMM Cities 3.7 % 4.9% considering that health is among the priority sectors non-ARMM Cities 10.6 % 11.1 % of BARMM, alongside education and social services. In addition, other appropriations for health outside the Source: Derived from Statement of Receipts and Expenditure, DOF-Bureau of Local Government Finance appropriations for DOH-ARMM, such as those within the ARMM-HELPS program, may be incorporated into the MOH budget and integrated into the overall health plan how to spend their funds,33 as an autonomous region, for the region. These actions would allow MOH to further the regional government can devise ways to induce LGUs consolidate its budget, improve transparency, reduce to take more responsibility for their constituents’ health fragmentation, and help to develop a more cohesive by providing more funding. A regional health sector plan health system. that clearly delineates responsibilities, including funding roles of different stakeholders, will make it easier for There is also room for local governments to provide LGUs to see what their support would help accomplish, more resources for health. As discussed in Annex A.8, such that they might build such assistance for the health ARMM LGU health spending as a percentage of the total sector into their own planning and budgeting processes. expenditure was much lower than that of non-ARMM For example, the region can make a case for providing all LGUs (Table 4.7). human resources in RHUs if municipalities can regularly budget for other RHU operating expenses. Matching Although BARMM province, municipality, and city LGUs grant mechanisms or performance-based grants could are independent and make their own decisions about also be explored to solicit funding commitments from 33 As discussed in Annex A.8, a large majority of the LGU funds are from internal revenue allotments (IRA). 77 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M LGUs. Building LGU support for the health sector over electronic medical record (EMR) systems among BARMM the next few years is essential in light of the Mandanas RHUs has substantially reduced payments for the ruling, which will significantly increase internal revenue Primary Care Benefit. If the opportunity arises, BARMM allotments for LGUs beginning in 2022. Proactively government should support national-level efforts to enlisting LGU support now could mean further increases improve automation of PhilHealth claims management in LGU funding for health at that time. and information systems and to devise better national- level monitoring and oversight mechanisms. It should BARMM should continue to make use of resources also make sure hospitals and health care facilities in provided by the national DOH in the form of cash BARMM adhere to national guidance or requirements in transfers and in-kind transfers. Policies on NG support these areas. to LGUs, including those in BARMM, may change as the Universal Health Care Law and the Mandanas ruling PhilHealth data also suggests that BARMM constituents are implemented. Both regulations may result in a have low utilization rates of PhilHealth benefits. As decrease of direct financial and in-kind support to LGUs, 34 described in later chapters of this report, low PhilHealth although this is expected to happen gradually. When utilization likely reflects a variety of factors, including changes resulting from the UHC Law and the Mandanas a lack of availability of services as well as household ruling are rolled out, the BARMM government should economic factors that make accessing care financially devise a mechanism to avoid overlap or duplication in challenging if not impossible. The population may the funding of specific goods or activities. Moreover, it also lack knowledge of entitlements, something that should also strive to ensure that any additional resources the BARMM government could help to remedy through mobilized for health increase the total budget for health education of health workers or information campaigns. and do not merely replace other funding. For example, Furthermore, former combatants, whose PhilHealth as previously described, a substantial amount of the membership was sponsored through the government’s block grant allocation for MOH in 2020 is programmed Sajahatra Bangsamoro and Payapa at Masaganang for the purchase of vaccines. Aside from concerns about Pamayanan (PAMANA) programs, have traditionally had the region’s readiness to procure vaccines and handle low utilization rates, due both to a lack of knowledge the inventory, it is not clear whether the vaccines to be about their entitlements as well as a desire to avoid purchased would cover any gap beyond what the national being identified as former rebels. Now that the UHC DOH is already providing, or in effect just replace it. If the Law provides membership to all Filipinos and does not latter, then the substantial amount allocated for vaccine distinguish among different types of non-contributing purchasing does not become an additional resource but members, this should no longer be a concern. merely duplicates or replaces the resource that would have been provided by the national DOH. Other funding streams, such as from development partners, may also provide more resources as the new Regarding PhilHealth payments, the PhilHealth scope of region builds its base. Official development assistance benefits is a matter of national policy. However, BARMM could also be mobilized if a funding gap emerges in spite can devise ways to more efficiently collect what it is of the additional resources mobilized from other due. For example, it could invest in health information funding streams. systems, which will not only aid in collecting necessary health information from the population, but will also Overall, the aim is to increase resources from all possible enable facilities to more efficiently collect payments funding streams in order to reduce household out-of- from PhilHealth. As discussed in Annex A.6, the lack of pocket spending on health, so that health services do not 34 The UHC Law delineates that the national and local governments continue to spend for population-based health services while individual-based health services shall be financed through PhilHealth. On the other hand, although the Mandanas ruling does not require LGUs to spend the additional IRA for specific programs or times, it is projected that the national government will have less funding for their usual support to LGUs for health such as programs on health infrastructure and health human resources, and it is anticipated that LGUs will shoulder these from their increased IRA receipts. The changes in funding assignments due to the UHC Law may happen gradually. 78 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M pose a financial risk to BARMM constituents. As described PhilHealth receipts, user fees, and other receipts—are in Chapter 5 of this report, most BARMM households also in effect “pooled” within the regional government. live very close to or below the national poverty line, and being able to spend less of their income on health However, in spite of this advantage, current service care could mean emerging from these conditions. It is delivery in the region is still in need of further therefore important that the region’s funds are spent integration, as health care facilities in fact mostly operate efficiently and effectively for maximum impact. and make decisions on their own, including in the funds they generate. Despite being naturally organized to do Spending Health Resources Better. The distinct planning so, the regional government has not managed health processes and accountabilities of each funding stream service delivery and resource distribution from a regional bring about two types of inefficiencies. One is that some perspective, instead merely serving as a funding and programs and activities may overlap. The other, which is information conduit. However, it has the opportunity more apparent in BARMM, is that the most critical gaps in to do now: since the region is currently in a period the health system remain unplanned and unfunded. of transition, MOH could create for itself a regional oversight and accountability role, and devise robust Fragmented funding is a reality throughout the country. management systems to facilitate effective integration of The UHC Law recognizes this and encourages the service delivery and pooling of funding sources. Lessons formation of service delivery networks and pooling of learned from this process could inform other provinces resources from different funding streams into a Special as they also work to meet the requirements of the Health Fund to be managed by the health board of the UHC Law. province or city. The ultimate goal is for this funding pool to be used efficiently to pay for health services Figure 4.6 above showed that the regional government and reduce out-of-pocket spending by constituents. had allocation authority over just 14 percent of total BARMM is already a centralized government, so a natural health funding in 2016-2017. Considering the prospects integration of government health care facilities already for additional resources as presented in Table 4.6, Figure exists as they are all owned by and therefore under 4.7 portrays the shift in the locus of allocation authority the purview of the regional government. Furthermore, under three scenarios, using the 2016–2017 situation all funding receipts of the facilities—including national as a baseline. Variation 1, which was first presented in appropriations (now block grant appropriations), Figure 4.6, describes the current situation under the FIGURE 4.7. SHIFT IN ALLOCATION AUTHORITY UNDER THREE SCENARIOS Locus of Allocation 25,000 20,000 5% 22% 6% 6% million PhP 15,000 6% 8% 26% 8% 47% 39% 10,000 14% 11% Other/Non-Government Local Government Units 5,000 ARMM Regional Government 70% 42% 56% 33% National Government - Base (Actual 2016-2017) Variation 1 Variation 2 Variation 3 79 C H A P T E R F O U R : F I N A N C I N G H E A LT H I N B A R M M block grant, where the NG appropriation is doubled and plan for health service delivery and an accompanying the allocation authority is shifted from the national to health financing strategy. A medium-term health sector the regional government. Variation 2 shows the shift plan that dovetails with a detailed health investment in allocation authority if BARMM LGUs were to increase plan and financing strategy will help ensure that scarce their health spending to be in line with non-BARMM LGUs resources are utilized efficiently, and that any additional in terms of percentage of total LGU spending. Variation resources, whether expected or unexpected, will likewise 3 combines these two scenarios. The three variations be efficiently used to support regional goals. A robust assume all other funding streams remain at the health financing strategy will require decision points, same levels. and the analysis in this paper provides insights to help the region make these decisions. For example, the Variation 1, as mentioned earlier, results in an increase strategy can identify which funding streams to pursue for of total health resources from PhP 13.3 billion to PhP 16.6 additional resources, as well as whether to pool other billion, and the allocation authority for BARMM to nearly funding, such as PhilHealth receipts of the hospitals, 50 percent. If the LGUs increased resources for health as together with the current BARMM pool. in Variation 2, this would result in an increase of total health resources to PhP 16.7 billion, with LGU allocation Other decision points not directly addressed in this authority increasing from a mere eight percent to 26 report but important to include in a health financing percent of total health resources, and BARMM regional strategy are those related to the medium- to long-term allocation authority decreasing from 14 percent to 11 financing arrangements for hospitals. For example, percent. Variation 3 shows an increase in resources by will the region introduce performance measures in the 50 percent over 2016–17 levels to PhP 20.0 billion, and allocation of annual subsidies or budgets to hospitals? provides the regional government an allocation authority Likewise, will it expect hospitals to exercise increased of 39 percent. autonomy in the mobilization of funds with a view towards ultimate self-sufficiency? Also, should BARMM In each of the above scenarios, the largest allocation operate its own tertiary referral hospital? If so, will it authority the regional government is able to achieve is build a new one or acquire and upgrade existing ones? 47 percent (though this could possibly be more if health If not, what financing arrangements can it make with the appropriations increased to more than 4.7 percent of existing referral hospitals to ensure the availability of block grant appropriations). The NG retains a significant quality tertiary care for its constituents without posing a share of allocation authority under all three scenarios, substantial financial burden? even when both the NG appropriation for BARMM and LGU health allocations significantly increase, as in Whichever direction BARMM takes should be defended in Variation 3. Finally, LGU allocation authority becomes a written strategy and monitored regularly. Laying out a substantial only if BARMM LGUs raise their health strategy on paper that details all financing dimensions, spending to match that of non-BARMM LGUs. from mobilization to pooling and payment, will help to sustain continuity of implementation in spite of political change and influence. CONCLUSIONS Annexes As described, the BARMM regional government is limited Annex A. Discussion of Each Financing Stream in terms of the degree of authority it holds over resource Annex B. Health Funding Allocations: Source, Allocating allocation, with the national government maintaining a Authority, and Disbursing Authority by Level of significant role. Nonetheless, in order to make the best Government and most efficient use of the resources it can control— Annex C. Assumptions on Expense Class Categories and to help guide the allocation of resources controlled Annex D. Assumptions on Type of Health Care Function by other levels of government towards the goal of Annex E. BARMM Appropriations for Ministry of Health improving regional health outcomes—it is advised to take proactive steps to create an integrated, cohesive regional http://bit.ly/BARMMHFSAAnnexes 80 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M CHAPTER FIVE: ACCESS TO BASIC HEALTH SERVICES IN BARMM – RESULTS AND ANALYSIS OF A HOUSEHOLD SURVEY SUMMARY equipment, diagnostics, and medicines of all regions in the Philippines. • In this study, 34 percent of children aged 12–23 months within the BARMM provinces had basic • Households reported the highest utilization of vaccine coverage, while 24 percent were found health services for mothers and babies, followed by to be completely unvaccinated. The Philippines services for children and adolescents; the lowest NDHS reported these percentages to be 18 percent utilization was for communicable and chronic and 44 percent respectively in 2017, suggesting diseases for adults. This may reflect the young improvements in coverage. These numbers, though average age of the population (17.3 years). Over 80 much better than in 2017, are still worse than for the percent of respondents reported ever accessing child Philippines as a whole. immunization services, a higher percentage than was observed when the vaccine coverage of individual • Vaccine dropout is a significant problem in BARMM. children was assessed. In many provinces, between one quarter and one half of children who received the first dose of a • Across the five BARMM provinces, the average vaccine antigen did not receive the third dose in the monthly cash income was reported at PhP 10,355. series, leaving them under-protected. Three of the five provinces reported average monthly incomes below PhP 9,500. The average per • On average, households spent PhP 1,200 per month capita income was PhP 1,976, a number below the on medical and health care expenses, which were Philippines national poverty line. Only one of the most typically accessed in a nearby public facility, BARMM provinces had a per capita income above the like a public hospital, rural health unit (RHU) or national poverty line (Maguindanao), though both barangay health station (BHS). Just six percent of the expansion areas posted per capita incomes overall reported using PhilHealth to pay for above this line. treatment of their most recent illness. When deciding where to seek care, the most important factors • The nutrition situation of children under five years of noted by respondents were cost and proximity. The age in BARMM is worse than that for the Philippines vast majority of households were located within 30 overall, with 39 percent of children stunted, 10 minutes of a public primary care facility. percent wasted, and 23 percent underweight. Even more alarming than these high rates of • Just 12 percent of respondents reported not undernutrition is the high prevalence of coexisting accessing needed medical care, with cost being the of wasting, stunting and underweight, which was most important factor, though a lack of medicine at found to be 3.2 percent. These children are at highest the health facility was mentioned by more than one risk for severe illness and mortality. Children from in five respondents. Feedback regarding the lack of the island provinces had higher rates of wasting, medicines aligns with findings from the Supply Side stunting, and WaSt (meaning the co-existence of Readiness Assessment, which found that RHUs in both) than those in the mainland provinces. BARMM had the lowest overall availability of basic 81 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y • Nine out of 10 mothers in the five BARMM provinces METHODOLOGY report breastfeeding their babies at birth. However, just 17 percent reported exclusive breastfeeding for The survey was carried out with the use of computer- the first six months of their child’s life. assisted personal interview (CAPI), collecting the following data: household demographics as well as • Within the BARMM expansion areas, data for the household social and economic conditions; access and North Cotabato BARMM barangays are similar to utilization of basic health services; immunization of the five BARMM provinces in terms of economics children aged 0–23 months; height and weight of children and health care access, while the data for Cotabato aged 0–5 years; breastfeeding practices; and caregiver City barangays show a more favorable situation for knowledge and perceptions of stunting and childhood residents there. malnutrition. All five provinces of BARMM (which comprised the former ARMM) were included in this study, alongside the expanded areas that voted for inclusion RATIONALE in BARMM in the 2019 plebiscite. Tables in this report show results for each of the five provinces and results A household survey to examine access to and utilization aggregated across those provinces under the label “Five of basic health services was conducted in 2019 by BARMM Provinces”. Results for the expansion areas are the World Bank in partnership with UNICEF. The study labeled “North Cotabato” and “Cotabato City” and are not collected information on health services and health aggregated with those from other provinces. care expenditures in ARMM, as well as household demographic and socio-economic data. The results of the The following is a shortened description of the data survey form a central part of the HFSA analysis as they collection methodology utilized in this household allow correlation of health system inputs and capacities survey. More complete details can be found in the full with indices of health system outputs. publication of the study (forthcoming). To inform this effort, researchers conducted interviews The Sample Design and Sample Selection. The sampling in 3,004 households in the five BARMM provinces, as well plan follows a two-stage cluster design with probability as 800 households in Cotabato City and the 63 barangays proportional to size. The first stage was the selection in North Cotabato that joined BARMM as a result of the of primary units (barangays per province); the second 2019 plebiscite. Respondents in these households were stage was then the selection of secondary sampling units asked about the recent health needs of those residing (households with children aged 0–24 months). The choice in the home, as well as their utilization of health care of a two-stage design hinges on its manageability and services and any barriers they faced accessing care. cost advantage (see Annex F: How the Sample Primary caregivers of young children in the household was Calculated). were specifically asked about the immunization coverage of their children. This was the first household survey The study goal was to collect information on 3,000 performed exclusively in the BARMM region. It contributes children aged 0–24 months in the five BARMM provinces, to what is known about access to health care in BARMM plus 800 children in the same age range from the by providing the consumer perspective; an assessment expansion areas.35 A sampling frame of all barangays of supply side readiness was conducted previously and is with their population sizes was obtained from the also presented in another chapter of this report. Philippines Statistical Authority 2015 data. Using the population count as the measure of size (MOS), a cumulative distribution was derived. 35 The sample selection was first conducted before the plebiscite and hence included only the five provinces which used to comprise the former ARMM. Additional samples were selected from the expansion areas after the plebiscite. 82 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.1. DISTRIBUTION OF BARANGAYS AND SAMPLE SIZE BY BARMM PROVINCES/CITY Province Number of Number of Estimated Number Number of Sample Household Municipalities Barangays of Households* Barangays to be Selected Sample Size A. BARMM** Lanao del Sur 39 1,149 222,432 21 840 Maguindanao 36 508 249,773 23 920 Basilan 11 216 73,527 7 280 Sulu 19 411 175,475 16 640 Tawi–Tawi 11 203 83,131 8 320 Total 116 2,487 804,338 75 3,000 B. Expansion Areas Cotabato City 37 68,054 7 280 North Cotabato 17 543 313,578 13 520 Total 580 381,633 20 800 * Estimated Number of households based on NDHS (2013) ** Figures are obtained from PSA 2015 except for the estimated number of households. In order to meet the requirement of 3,000 children The resulting sample households were predominantly (80 aged 0–24 months, and to gain a wider coverage in their percent) situated in rural areas, in particular in Basilan distribution, the number of barangays in the five BARMM and Lanao del Sur, where 100 percent of households were provinces to be selected was pegged at 75. An additional classified as rural (Table 5.2). By contrast, all households 20 barangays were selected from the expansion areas to in Cotabato City were classified as urban. Roughly a cover 800 children, for a total of 95 barangays. quarter (26 percent) of sample households were in barangays classified as being in a geographically isolated The selection process started by obtaining the population and disadvantaged area (GIDA). count for each province and by cumulating the counts, then calculating the sampling interval and drawing Pretests demonstrated that eligible respondents must samples from the random start drawn from a table of be restricted to mothers or caregivers, as they were most random numbers. This process was applied to both likely to accurately remember and describe their child’s BARMM provinces and expansion areas (North Cotabato health care utilization. Accordingly, no proxy respondent and Cotabato City). was allowed. A callback was triggered if the respondent was unavailable at the time of the visit, with the number The second stage was the selection of 40 households of callbacks limited to three. in the 95 sample barangays with children 0–24 months old. Overall, a total of 6,439 households were visited Survey Instrument. Interview questions were drawn before identifying the 3,805 households that became from or based on several sources, including: the WHO the sample population of the study. A household was Vaccination Cluster Survey Methodology of 2015; the deemed an eligible respondent household if it had National Nutrition Survey (NNS) questionnaire by the children aged 0–24 months. If it also had children below Philippines Food and Nutrition Research Institute (FNRI); 61 months of age (incidental population), additional data and the World Bank Caregiver Survey. The resulting on anthropometry and breastfeeding were collected on survey instrument was written in English and later these other children (aged 25–60 months). translated into Tagalog. After a series of pretests, the 83 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y TABLE 5.2. DISTRIBUTION OF SAMPLE HOUSEHOLDS VISITED, BY BARMM PROVINCE AND CLASSIFICATION, BARMM, 2019 By province Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato Total number of households visited 1,671 1,372 437 944 461 4,885 597 957 Classification Urban 0.0 14.3 0.0 25.8 26.0 11.5 100 17.3 by Rural 100.0 85.7 100.0 74.2 74.0 88.5 0 82.7 Classification GIDA 9.8 26.1 14.6 23.3 34.9 19.8 12.1 0 by Non-GIDA 90.2 73.9 85.4 76.7 65.1 80.2 87.9 100 Households with Number 848 922 285 655 322 3,834 281 521 children with ages 0-24 months old % 50.7 67.2 65.2 69.4 69.8 62.1 47.2 54.4 (target households) Non-target Number 823 450 152 289 139 1,853 316 436 households visited % 49.3 32.8 34.8 30.5 30.2 40.5 52.9 45.6 Targeted Household Number 840 920 281 643 320 3,004 280 521 that consented to participate % 99.1 99.8 98.6 98.2 99.4 99.1 99.6 100 final version of the survey was translated into the four respondents who might have been selected, but were major languages spoken in the region: Maranao, Tausog, not. The assumption of equal probability comes from Sinama and Cebuano Visayan. Interviewers had access to the fact that primary sampling units were selected with all five versions at the time of data collection, and could probability proportional to size and then a fixed number therefore easily accommodate the respondent’s language of respondents was selected from each cluster. It is preference. All survey versions were converted to CAPI common among household surveys in low- and middle- format and uploaded to Android tablets for income countries to use this design and analyze the data data collection. without survey weights. Anthropometric tools provided by UNICEF were also Furthermore, Table 5.1 indicates that the probability pretested and used to collect data on children’s height of selection is roughly equal across the five BARMM and weight. These consisted of a portable measuring provinces. In other words, the ratio of barangays to board to measure the baby’s length (or the toddler’s households is roughly constant across those provinces. height) and a portable Salter weighing scale with As each respondent in those five provinces represents 25-kilogram capacity. a roughly constant number of eligible children, it thus becomes appropriate to aggregate results across all five Survey weights. The data were analyzed without provinces without using survey weights. Outcomes for using survey weights. They are considered to be self- North Cotabato BARMM barangays and for Cotabato City weighted because the probability that any respondent are reported in separate columns from the five would be selected is assumed to be nearly identical, BARMM provinces. meaning that the selected respondents effectively represent a roughly equivalent number of eligible 84 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FINDINGS and older indicated that they were gainfully employed, and households across the provinces reported an The Population of the BARMM Sample average of 1.4 earners. The 3,004 household respondents in the five BARMM In the expansion areas, an additional 801 households provinces yielded a population of 17,143 with a near equal were visited, yielding a population of 4,430. The average distribution of males and females (Table 5.3). The average age in Cotabato City was the highest of the sampled age of household members across the five provinces was provinces at 18.5, while the average age in the North 17.3 years, with households in Lanao del Sur reporting Cotabato BARMM barangays was among the lowest at the lowest average age at 16.6. Across the provinces, 16.7. The average household size was consistent with 76 percent of those surveyed indicated that they were the five BARMM provinces at 5.8 persons per household married, confirming that early marriage is prevalent in Cotabato City and 5.4 in North Cotabato. Households in the region. The average number of inhabitants per in Cotabato City reported an average of 1.6 earners household was 5.7, with an average of 1.7 children under per household, while those in North Cotabato BARMM the age of five. There was little variation between the barangays reported an average of 1.3. provinces on these measures. Half of those aged 14 years TABLE 5.3. DISTRIBUTION OF SAMPLE POPULATION BY SOCIO-DEMOGRAPHIC AND ECONOMIC VARIABLES, BARMM, 2019 Socio Demographic Variable Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato Number of Barangays Covered 21 23 7 16 8 75 7 13 Sample Population Count 4,890 5,081 1,593 3,715 1,864 17,143 1,615 2,815 Gender Distribution (%) Male 49.2 50.7 50.2 48.5 47.6 49.4 49.1 49.8 Female 50.8 49.3 48.2 51.5 52.4 50.4 50.9 50.2 Average Age 16.6 17.6 17.7 17.3 17.6 17.3 18.5 16.7 Civil status (as % of population aged 12 years and older)* Single (%) 22.3 20.3 17.9 21.3 22.5 21.1 23.2 19.3 Married (%) 74.8 76.4 77.8 75.3 75.3 75.7 71.4 77.6 Widowed/separated (%) 2.9 3.3 4.3 3.4 2.2 3.2 5.4 3.1 Percent engaged in economic activity (as % of populaton aged 14 years and older)** 51.8 53.3 50.7 52.4 53.3 52.8 53 51.7 Type of economic activity (as % of those engaged in economic activity aged 14 years and older) Wage and salary workers 30.9 31.7 38.9 15.6 22.2 27.6 39.3 18.9 Self-employed 36 63.4 57 84.1 75.5 61.3 59.4 79.4 Family owned farm 33.1 4.8 4.2 0.3 2.3 11.1 1.3 1.7 or business * population aged 12 years 2,357 2,648 810 1,857 955 8,627 872 1,419 and older ** population aged 14 years 2,206 2,494 771 1,759 877 8,107 836 1,333 and older 85 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y The distribution by ethnic grouping indicates a There is a predominance of Islam as religious affiliation, concentration of ethnic groups in different locations which was reported by more than 90 percent of (Table 5.4). Lanao del Sur predominantly comprises household respondents in all five BARMM provinces Maranaos (89 percent), while Maguindanao comprises except for Maguindanao, where 18 percent professed to mostly Maguindanaoans (74 percent), though Iranuns be Christians. made up eight percent of Maguindanao respondents. Basilan respondents were essentially a mix of Yakans (57 In the expansion area of Cotabato City, nearly 80 percent percent), Tausug (35 percent), and Sama (7 percent), while of respondents identified as Maguindanaoan, while in Sulu, three-fourths of respondents were Tausag and eleven percent were from “other ethnic groups.” In one-fourth were Sama. Finally, in Tawi-Tawi, more than North Cotabato BARMM barangays, nearly 90 percent half of respondents were Sama (57 percent) and nearly of respondents identified as Maguindanaoan. Nearly 40 percent were Tausug. “Other ethnic groups” can be all respondents in North Cotabato BARMM barangays surmised to be migrants, who comprised nine percent of claimed Islam as their religion; in Cotabato City, 88 respondents in the two mainland provinces; in the case percent claimed Islam, while the remainder indicated of Maguindanao, these were mostly Ilonggo migrants. they were Christians. Migrants comprised three percent or less of respondents in the three island provinces. TABLE 5.4. PERCENT DISTRIBUTION OF HOUSEHOLDS BY PROVINCE/CITY AND SOCIO-DEMOGRAPHIC ATTRIBUTES, BARMM, 2019 Social Variables Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato n= 840 920 281 643 320 3,004 280 521 Average household size 5.8 5.5 5.7 5.8 5.8 5.7 5.8 5.4 Ethnic Affiliations (in percent) Maranao 89.2 0.1 - - - 25.0 1.1 - Maguindanao 1.2 74.2 - - - 23.1 78.6 88.9 Tausug 0.1 0.1 35.2 74.7 39.1 23.5 - - Sama - - 7.1 25.0 57.2 12.1 - - Yakan - - 57.3 0.2 0.3 5.4 - - Iranun 1.0 7.5 - - - 2.6 7.9 7.7 Indigenous People 0.1 9.1 - - - 2.8 1.1 0.4 Others 8.5 8.9 0.4 0.2 3.4 5.5 11.4 3.1 Religion Islam 92.5 82.5 99.6 99.8 96.6 92.1 87.5 96.7 Christianity 7.4 17.5 0.4 0.2 3.4 7.9 12.5 2.9 Others/none 0.1 - - - - - - 0.4 Average number of children 1.76 1.64 1.64 1.69 1.71 1.68 1.65 1.64 who are 0 – 5 years old and living in the household 86 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Household economic conditions those in Maguindanao reported the highest at nearly PhP 13,000. The income distribution per province provides In order to assess the economic situation of the a more detailed picture: more than 50 percent of households interviewed, respondents were asked to households in Basilan had an estimated monthly income estimate household earnings and expenditure for the between PhP 1,000 and PhP 5,000. This was also true for previous month. Across the five BARMM provinces, the approximately 40 percent of households in Lanao del Sur average estimated monthly cash income was PhP 10,355 and Sulu. However, in Maguindanao and Tawi-Tawi, more per household, though provincial variation was observed: than 50 percent of households fell into a slightly higher households in Basilan province reported the lowest income bracket, reporting monthly incomes between PhP average monthly income at just over PhP 8,000, while 5,000 and PhP 15,000 (Table 5.5). TABLE 5.5. AVERAGE HOUSEHOLD INCOME PER MONTH, BY PROVINCE, BARMM, 2019 BARMM Areas Minimum Maximum N Mean Median Std. Deviation Std. Error of Coefficient of the Mean Variation Lanao del Sur 1,000 160,000 840 9,202 6,000 10312 355.8 1.1 Maguindanao 1,500 204,800 920 12,752 9,000 13503 445.2 1.1 Basilan 1,500 180,000 281 8,202 5,000 13323 796.2 1.6 Sulu 1,500 150,000 643 9,155 6,000 12517 493.6 1.4 Tawi–Tawi 1,500 66,800 320 10,787 7,500 10146 567.2 0.9 5 BARMM Provinces 1,000 204,800 3,003 10,355 12,222 12891 209.0 1.2 Cotabato City 3,000 281,000 279 17,202 11,500 20762 1240.8 1.2 North Cotabato 2,000 90,000 521 11,644 8,500 9912 434.3 0.9 FIGURE 5.1. DISTRIBUTION OF HOUSEHOLDS PER INCOME QUARTILE, BARMM PROVINCES, 2019 38.1 49.2 49.3 53.5 62.9 60.0 53.4 40.6 39.6 32.5 24.7 16.6 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Provinces Php40,000 and over (4th quartile) Php15,001 - Php40,000 (3rd quartile) Php5,001 - Php15,000 (2nd quartile) Php1,000 - Php5,000 (2nd quartile) 87 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y TABLE 5.6. PER CAPITA INCOME DISTRIBUTION BY PROVINCE (IN PHILIPPINE PESOS), BARMM, 2019 BARMM Areas N Minimum Maximum Mean Median Std. Deviation Std. Error of Coefficient of the Mean Variation Lanao del Sur 840 200 23,667 1,722 1,200 1800 62.1 1.1 Maguindanao 920 286 29,257 2,453 1,850 2345 77.3 1.0 Basilan 281 150 60,000 1,790 1,000 4408 263.0 2.5 Sulu 643 222 37,500 1,721 1,200 2554 100.1 1.5 Tawi–Tawi 320 321 12,500 1,944 1,500 1641 91.7 0.8 5 BARMM Provinces 3,004 150 60,000 1,976 1,400 2487 45.4 1.3 Cotabato City 280 500 12,714 2,886 2,333 3712 221.9 1.3 North Cotabato 521 464 15,375 2,315 1,667 1865 81.7 0.8 According to the Philippines Statistics Authority, the from relatives. The same was true, though to a lesser national poverty threshold in the Philippines, or the extent, in Maguindanao (32 percent). Fewer than 20 amount needed to meet basic food and non-food needs percent of families in Basilan and Sulu provinces each month, is PhP 10,481 for a family of five, or PhP reported additional sources of income, a factor which 2,096 per family member per month. Among the BARMM may contribute to the low monthly incomes reported provinces, the average per capita income was found to by households there. Among the expansion areas, be PhP 1,976, slightly below this national figure. However, 37.5 percent of households in Cotabato City reported looking at the provinces individually, only households in additional sources of income, as did 40 percent of those Maguindanao saw monthly per capita incomes above the in North Cotabato BARMM barangays. Within these areas, national poverty line; three of the remaining four BARMM a larger percentage of households reported receiving provinces had monthly per capita incomes that fell short income from remittances from abroad than in the five of the national figure by 300 pesos or more. BARMM provinces. Among the expansion areas, households in Cotabato Respondents were asked to indicate how monthly income City reported the highest average monthly income of was used within five categories of expenditure: food, all the provinces at over PhP 17,000, while households medical/health, education, entertainment, and other in North Cotabato BARMM barangays reported a much household expenses. Across the BARMM provinces, nearly lower average monthly income of roughly PhP 11,650. This 40 percent of income was spent on food. Medical and translates to monthly per capita incomes of PhP 2,886 health expenses constituted the second largest category for Cotabato City and PhP 2,315 for North Cotabato, both at just over 11 percent, followed by education. Families above the national poverty figure. reported spending on average nearly PhP 1,200 per month on medical and health expenses, though there Thirty-one percent of respondents from the BARMM was considerable regional variation, with households in provinces indicated that they had other sources of Maguindanao spending just PhP 650 per month, while income besides salaries or earned wages, for example those in Basilan, Lanao del Sur and Tawi-Tawi spent from agriculture or government programs, though over PhP 1,500 each month on medical expenses. Within variation was seen across the provinces (Table 5.7). the expansion area, households reported a similar Half of respondents from Lanao del Sur reported distribution of spending among the five categories of receiving income from other sources, mainly from expenditure. Note that households in Cotabato City government subsidy programs (for example Pantawid reported the highest medical/health expenditure of all Pamilyang Pilipino Program) and financial assistance the surveyed areas, spending nearly PhP 1,900 per month. 88 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.7. HOUSEHOLD ADDITIONAL SOURCES OF INCOME, BARMM, 2019 Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato % Households with other 49.5 31.7 19.6 16.3 21.3 31.2 37.5 40.5 sources of income* Sources of “other income” government monetary 54.8 70.9 41.8 43.8 45.6 57.2 48.6 73.5 assistance/subsidy programs (4P’s, UCT, etc.) gifts/financial assistance from 55.0 18.2 50.9 55.2 45.6 42.6 36.2 15.2 relative/ private sources retirement/pension 3.4 0.7 0.0 1.0 4.4 2.1 2.9 0.9 remittances from abroad 5.3 17.1 18.2 9.5 8.8 10.5 24.8 20.4 TABLE 5.8. AVERAGE ESTIMATED MONTHLY HOUSEHOLD EXPENDITURES IN THE PAST MONTH (IN PHILIPPINE PESOS), BARMM 2019 Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato n= 840 920 281 643 320 3,004 280 521 Average Monthly Income 9,202 12,752 8,202 9,155 10,787 10,355 17,202 11,644 Monthly Expenditures Average estimated household monthly expenditures last month Food 4,515 4,203 3,351 3,559 4,490 4,103 6,760 4,995 Medical/health 1,606 642 1,502 909 1,631 1,155 1,856 994 Education 1,023 545 1,220 973 1,220 905 1,058 767 Entertainment 389 249 651 357 203 344 842 191 Other household expenses 1,216 731 612 414 462 759 1,889 899 Percent of average monthly cash income spent on: Food 49.1 33.0 40.9 38.9 41.6 39.6 39.3 42.9 Medical/Health 17.5 5.0 18.3 9.9 15.1 11.2 10.8 8.5 Education 11.1 4.3 14.9 10.6 11.3 8.7 6.2 6.6 Entertainment 4.2 2.0 7.9 3.9 1.9 3.3 4.9 1.6 Other household expenses 13.2 5.7 7.5 4.5 4.3 7.3 11.0 7.7 89 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y FIGURE 5.2. MONTHLY EXPENDITURES VERSUS AVERAGE MONTHLY INCOME, BARMM, 2019 20000.00 17,202 18000.00 16000.00 14000.00 12,752 11,644 12000.00 10,787 10,356 9,202 9,155 10000.00 8,202 8000.00 6000.00 4000.00 2000.00 0.00 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North Province City Cotabato Food Medical/health Education Entertainment Other household expenses Average monthly income Respondents were asked to quantify their spending on data from other countries. There was little provincial specific expenses within the broader category of medical variation on this measure, though the percentage was and health spending. On average, among the BARMM slightly lower in Tawi-Tawi (62 percent); respondents provinces and the expansion areas, nearly 70 percent of there reported spending a considerably higher amount monthly health spending went towards medicine and on other, unspecified medical expenses. professional fees for doctors, which is consistent with TABLE 5.9. AVERAGE EXPENDITURES PER CATEGORY OF MEDICAL/HEALTH CARE EXPENSES (IN PHILIPPINE PESOS), BARMM 2019 Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato n= 840 920 281 643 320 3,004 280 521 Average estimated household monthly expenditures on medical/health last month (total) 1,606 642 1,502 909 1,631 1,155 1,856 994 Average estimated household monthly expenditures per category of medical/health expenses for the past month medicine 844 292 598 450 658 548 929 528 doctor’s fees 223 97 481 194 367 217 405 154 healthcare providers 108 41 109 74 40 73 47 47 (e.g. midwife, nurse) laboratory/diagnostic tests 83 36 37 31 43 49 105 101 PhilHealth insurance 53 47 18 14 25 37 106 18 medical supplies 158 71 164 109 118 117 106 76 other health/medical expenses 138 58 96 37 380 114 158 70 90 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 5.3. PROPORTIONAL BREAKDOWN OF MEDICAL EXPENDITURE BY CATEGORY, BARMM, 2019 Lanao del Sur 53% 14% Maguindanao 45% 15% Basilan 40% 32% Medicine Sulu 50% 21% Professional Fee of Doctor Payment of Healtcare Providers Tawi-Tawi 40% 22% (e.g. Midwife, Nurse, etc.) Laboratory/diagnostic tests 5 BARMM Provinces 47% 19% PhilHealth (Health Insurance) payment Cotabato City 50% 22% Medical supplies North Cotabato 53% 16% Other health/medical expenses Finally, respondents reported on their household assets, most frequently reported item), while just 11 percent including property, livestock, and consumer durables. reported owning a refrigerator. On average, 75 percent of respondents within the five BARMM provinces reported owning the homes where Compared to the BARMM provinces, fewer households in they currently reside, though in Lanao del Sur just Cotabato City reported home or land ownership, while over 50 percent reported as such; this is not surprising considerably more households in North Cotabato BARMM considering the internal displacement caused by the 2017 barangays did so: more than 85 percent of respondents Marawi siege. Overall, 19 percent of respondents reported there reported owning their homes and over 50 percent owning land, with some variation between the provinces, reported owning land. Cotabato City is an urban area, so from eight percent of respondents in Tawi-Tawi to more it is reasonable to expect that fewer households would than 28 percent in Maguindanao. Of those who owned own land there. Conversely, North Cotabato is a rural land, the average plot was 2.4 hectares, of which more area without a history of violence and unrest (unlike the than 1.6 hectares, or nearly 70 percent, was cultivated. BARMM provinces) and this circumstance has perhaps Of all the consumer durables about which respondents facilitated land ownership. As in the BARMM provinces, were asked, just one was reported to be owned by more cellular phones were owned by more households in the than 50 percent of households—cellular phones—which expansion areas than any other consumer item, followed 80 percent of households reported owning. Forty percent by television sets and audio entertainment items. of households reported owning a television set (the next 91 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y FIGURE 5.4. HOME AND LAND OWNERSHIP, BARMM, 2019 100 80 60 40 20 0 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North Province City Cotabato House in which respondent currently lives Lot on which house is situated Land Safe Drinking Water. In order to delve more deeply it. However, respondents in the island provinces reported into household economic conditions that affect health higher rates of water treatment than respondents in the outcomes, respondents were asked to report on the other provinces, perhaps due to their high use of dug availability of safe drinking water and toilet facilities. wells (with the risk of contamination from nearby According to the Philippines Statistics Authority (PSA), surface sources). safe water sources may include: bottled water or water from a refilling station, piped water tubewells Among households in the expansion areas, nearly 100 or boreholes, protected dug wells, protected springs, percent of those in Cotabato City reported obtaining and rainwater (WHO and UNICEF 2017). In this study, drinking water from an owned or shared faucet or households in the five BARMM provinces reported a bottled source, while in North Cotabato BARMM obtaining drinking water from three major sources, barangays, nearly 50 percent of households accessed namely: bottled water (29 percent), owned or shared water from an owned or shared tubed piped deep well. tubed piped deep-well (22 percent), and owned or Very few households reported obtaining water from an shared faucet (21 percent), all considered “improved” unimproved source, though 16 percent of those in North water sources. Overall, 13 percent of households Cotabato reported using a dug well, which could pose a reported accessing drinking water from a dug well, health risk if unprotected. The majority of households though respondents in the island provinces reported in these two areas reported not treating drinking water much higher use of dug wells than respondents in the prior to consumption. mainland provinces. Dug wells are considered improved water sources if they are covered and protected. Just The 2017 Philippines Annual Poverty Indicators Survey six percent of respondents overall reported drinking showed that 94 percent of Filipino families have surface water or water from an unprotected source, improved sources of drinking water, while six percent though this percentage was twice as high in Lanao del have unimproved sources. The data in this study Sur (13 percent). Sixty percent of households overall corroborate these findings. reported that they do not treat water prior to consuming 92 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.10. SOURCES OF DRINKING WATER, BARMM, 2019 Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato Own/Shared faucet 38.5 11.1 24.9 15.1 10.6 20.8 70.7 2.1 Own/shared tubed piped 17.1 40.7 5.0 10.9 1.9 22.0 1.1 52.2 deep well Tubed/piped shallow well 6.1 3.0 0.4 0.0 0.0 2.7 0.0 13.1 Dug well 2.0 2.7 33.5 23.3 32.5 13.0 0.0 15.9 Protected 2.3 2.5 8.9 5.9 0.6 3.6 0.0 2.3 Rain Water 0.0 0.0 0.0 0.5 26.6 2.9 0.0 0.2 Surface water 8.8 0.0 0.7 0.3 0.0 2.6 0.0 0.6 Unprotected 3.8 3.6 2.8 5.8 0.0 3.7 0.0 1.5 Bought Water, Bottled 20.4 30.5 23.8 38.2 27.8 28.7 28.2 12.1 Note: Boxes shaded in orange represent the most frequently-mentioned water source, while those in green reflect the second-most frequently reported. Note that regional averages obscure the high use of dug wells in the island provinces. TABLE 5.11. TREATMENT OF DRINKING WATER PRIOR TO CONSUMPTION, BARMM, 2019 Safety treatment of drinking water Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato No treatment 77.5 66.0 38.8 33.7 51.3 58.2 71.4 63 Boiled 13.1 12.2 59.4 66.1 46.3 32.0 18.6 11.3 Bleach/Chlorine 0.0 0.3 0.0 0.0 0.0 0.1 - 0.4 Strained through cloth 9.0 8.2 1.8 0.2 2.5 5.5 6.4 9.8 Ceramic, sand, other filter 0.2 6.4 0.0 0.0 0.0 2.0 - 9.8 Let water stand and settle 0.1 7.0 0.0 0.0 0.0 2.2 3.6 5.6 Put salt on water and let it stand - - - - - - - 0.2 prior to drinking Time spent in obtaining drinking 7.0 13.8 13.4 9.0 8.1 10.2 4.6 10.7 water (in minutes) 93 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y Toilet facilities and hand washing. Among households The majority of households in the five BARMM provinces in the BARMM provinces, nearly two-thirds reported (73 percent) report having hand washing facilities in the having a toilet facility in or outside their home, though home, which are usually situated near the kitchen. Half geographic variation was evident: while over 70 percent of these households reported always having soap, while of households in Lanao del Sur, Maguindanao and Tawi- an additional 40 percent reported it was sometimes Tawi provinces confirmed having a toilet facility, just over available. The data did not show whether hand washing— one-third (37 percent) in Basilan reported having such with or without soap—was performed habitually. access. This suggests open defecation may be common practice, as found by the 2017 Annual Poverty Indicators Among households in the expansion areas, nearly 100 Survey among Filipino families in the lowest income percent of those in Cotabato City reported having toilet quintile (PSA 2018a). Among those homes with toilet facilities, mostly with flush to septic tank. In North facilities, owned or shared flush toilets running to septic Cotabato BARMM barangays, this figure was nearly tanks predominate in most provinces except for Sulu and identical to the average for the five BARMM provinces (65 Tawi-Tawi, where overhung latrines above the river or percent). However, a higher percentage of households in sea were the most frequently mentioned. This of course both Cotabato City and North Cotabato reported having raises great health concerns about the quality of that handwashing facilities in the home (93 percent and river or sea water, especially when it is used for purposes 89 percent, respectively). Two-thirds of households in such as fishing, bathing or clothes-washing. Cotabato City reported always having soap available for handwashing, as compared to just under 50 percent of households in North Cotabato BARMM barangays. TABLE 5.12. PREVALENCE AND TYPE OF TOILET FACILITIES, BARMM, 2019 Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato Have toilet facilities 76.2 70.4 36.7 50.1 71.6 64.6 98.9 64.9 n= 640 648 103 322 229 1942 277 338 Most common types of toilet facilities Flush to septic tank (exclusive 70.5 70.8 62.1 40.7 26.2 60.0 90.6 68.3 use/shared by other households) Flush to pit latrine (exclusive 17.0 22.1 6.8 3.7 0.9 14.1 2.5 22.5 use/shared by other households) Pit latrine with/without slab, 10.8 5.4 1.9 0.3 0.9 5.6 0.4 8.9 open pit Hanging toilet above river/sea 0.9 0.3 27.2 50.3 70.3 18.5 6.5 0 94 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M HEALTH On the other hand, the WHO Service Availability and Readiness Assessment (SARA) describes three types This section considers access to and utilization of health of access: physical, economic and cultural. Physical services among sample households, especially those that access denotes availability; economic access refers to can be accessed through basic public health services. affordability of services; and cultural access reflects Health services is defined as the provision of medical appropriateness to the culture. advice, care or treatment from a health professional, provision of medicine/health commodities, or any other This analysis adapts the SARA approach in assessing the complementary health service of like character, whether health service user’s ability to access. Figure 5.5 lists the or not contingent upon sickness or personal injury (such indicators for each access type. Respondents were asked as family planning services and commodities, anti- to provide a detailed accounting of the basic health care tetanus vaccination, Vitamin A, and zinc supplementation services they had accessed in three areas, namely: 1) for pregnant women and children), as well as providing health services during the first 1,000 days post-partum; 2) the household with all other services and goods/ services for child and adolescent health; and 3) services commodities for the purpose of preventing, alleviating, for communicable and noncommunicable diseases. curing, or healing illnesses. Health Services in First 1000 Days. The compelling Access to health services denotes an interaction between importance of a child’s first 1,000 days is reflected in RA health system providers and health service users. The No. 1148, An Act Scaling-Up the National and the Local goal of health services provision is to improve the Health and Nutrition. Known locally as the “Kalusugan health of the population and to respond to people’s at Nutrisyon ng Mag-Nanay Act,” this piece of legislation expectations, while reducing inequalities in both health was described at launch as a strengthened and and responsiveness. The health care needs of the integrated strategy for reproductive health, maternal, population should be met with the best possible quantity newborn and child health care. To gauge service and quality of services produced at minimum cost.36 In utilization for health needs specific to pregnancy and this context, availability and affordability are the antenatal (prenatal) to early childhood period, most desired. respondents were asked if they sought medical advice and subsequently made use of various health services.. FIGURE 5.5: MATRIX OF ACCESS CATEGORY BY INDICATOR, BARMM 2019 Access Category Indicators Physical: availability • Preferred health facilities (reason for preference) • Available, no other health facility • Near place of residence • Regular presence of doctor Economic: affordability • Waiting time • Services and medicine are free/no cost • Distance of health facility from residence • Cost in going to the health facility • Mode of transport Cultural: appropriateness • Gives quality service and providers are approachable • Attending health service provider is one’s choice • Religious prohibition • Trustworthy 36 World Health Organization Evidence and Information for Policy Cluster (EIP), Discussion Paper, 2002. 95 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y Among households in the five BARMM provinces, over seeking a consultation, with 19 percent then going on to 70 percent reported consulting a health professional for actually use the service. A consideration of the provinces these five services: immunizations (82 percent), antenatal individually reveals that respondents in Maguindanao care (79 percent), tetanus toxoid (74 percent), folic acid and Tawi-Tawi sought BEmONC services more often supplementation (73 percent), and iron supplementation than those in other provinces. Family planning services (72 percent). Nearly all respondents who reported were also infrequently sought: on average, 41 percent of consulting a medical professional also took up the respondents reported seeking family planning services, relevant service. with just 38 percent accessing them. Respondents in Sulu reported the lowest utilization of this service (31 percent), Provincial variation was noted for service utilization. while those in Maguindanao reported the highest For example, while nearly 90 percent of families (46 percent). in Lanao del Sur and Tawi-Tawi reported accessing immunization services, only 75 percent of those in Among households in the expansion areas, those Basilan, Maguindanao and Sulu provinces reported doing in North Cotabato accessed health services at rates so. Furthermore, nearly 20 percent more families in comparable to the averages for the five BARMM Lanao del Sur reported making use of newborn care and provinces, with the exception of services for birth postnatal/postpartum care services than the regional delivery, for which 10 percent fewer respondents reported average. In fact, families in Lanao del Sur reported higher accessing services (Table 5.13). However, households than average utilization of nearly all services except in Cotabato City demonstrated very different service for family planning and Basic Emergency Obstetric and utilization patterns. Respondents there were much more Newborn Care (BemONC) services. likely (by more than 20 percentage points) to report accessing family planning (FP), birth delivery, BEmONC, The least utilized service across the five provinces was newborn care and postnatal/postpartum care services BEmONC, for which 20 percent of respondents reported than households in the BARMM provinces. 96 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.13. DISTRIBUTION OF HOUSEHOLDS BY PROVINCE/CITY AND BY HEALTH SERVICE CONSULTED AND ACCESSED/AVAILED, FIRST 1,000 DAYS FOR MOTHER AND CHILD, BARMM, 2019 Type of Health Services Consulted Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North and Accessed in first 1,000 days del Sur Provinces City Cotabato for Mother and child n= 840 920 281 643 320 3,004 280 521 Family Planning Consulted* 37.3 45.8 45.6 36.2 42.8 41.0 63.2 42.8 Accessed/Availed** 36.2 46.1 36.3 31.1 37.2 38.2 58.6 40.7 Antenatal/Prenatal Care Consulted 89.2 77.7 68.7 70.1 86.3 79.4 90.7 81.0 Accessed/Availed 89.2 77.6 65.8 70.1 86.3 79.1 90.7 81.0 Folic Acid Supplementation Consulted 78.0 69.9 65.5 69.8 84.4 73.3 77.9 73.7 Accessed/Availed 81.4 69.2 64.1 69.1 84.1 73.7 77.5 73.3 Tetanus Toxoid Consulted 85.0 73.4 61.6 61.7 79.4 73.7 79.3 77.0 Accessed/Availed 85.7 73.3 59.8 61.3 80.6 73.7 78.9 76.8 Birth Delivery Consulted 71.1 61.1 32.4 30.2 40.0 52.3 82.1 41.5 Accessed/Availed 71.2 60.8 25.3 22.9 38.1 49.8 82.1 40.5 Basic Emergency Obstetric and Newborn Care (BEmONC) Consulted 18.2 24.6 14.6 10.6 31.3 19.6 41.1 24.8 Accessed/Availed 18.7 23.9 10.0 8.2 31.3 18.6 42.9 25.1 Newborn Care Consulted 62.6 58.0 24.9 23.0 35.0 46.3 80.4 44.9 Accessed/Availed 62.6 57.0 18.9 19.3 34.7 44.5 80.7 44.7 Postnatal/Postpartum Care Consulted 64.2 58.0 27.4 22.4 33.8 46.7 67.9 46.1 Accessed/Availed 64.0 56.6 22.4 18.8 34.4 45.0 67.1 45.7 Immunization Consulted 90.0 77.2 77.6 77.4 88.4 82.1 95.0 84.5 Accessed/Availed 90.0 75.5 74.0 76.2 87.5 80.9 95.4 84.5 Iron Supplementation Consulted 83.6 70.4 54.8 62.1 81.6 72.0 75.7 72.0 Accessed/Availed 86.3 70.7 53.4 61.9 81.3 72.7 76.4 72.4 *consultation with a health professional **access/availed health services and commodities in health facility 97 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y Child and Adolescent Health Services. Respondents households). Variation was seen across the provinces, were asked which of a list of eleven health services for though, most notably for adolescent vaccines and older children and adolescents (aged 5–12) they had malaria treatment. While 12 percent of respondents sought a consultation for, or accessed. The list included overall reported accessing adolescent vaccine services, services related to: child malnutrition; supplementation this percentage ranged from a low of just three percent of Vitamin A, iron and zinc; diarrhea, pneumonia, malaria, in Tawi-Tawi province to a high of nearly 17 percent in deworming, child growth monitoring, sexually transmitted Maguindanao. Similar variation was observed for malaria: infections, and vaccines. while the regional average was just eight percent, over 11 percent of respondents in Sulu province and 14 percent Across the five BARMM provinces, the most frequently in Tawi-Tawi province reported accessing this service. This accessed service was Vitamin A supplementation, which aligns with the high rates of malaria in these over 60 percent of respondents reporting accessing. In island provinces. addition, more than 40 percent of respondents reported making use of health services for iron supplementation Among households in the expansion areas, the (46 percent), deworming (45 percent), child growth most frequently accessed service was Vitamin A monitoring (44 percent) and oral rehydration therapy for supplementation. Similar to the regional average for the diarrhea (42 percent). BARMM provinces, 40 percent or more of respondents in both Cotabato City and North Cotabato BARMM barangays Respondents were far less likely to report accessing reported accessing services for child malnutrition, services for sexually transmitted infections (less than iron supplementation, child growth monitoring and one percent); malaria (eight percent); or adolescent deworming. Respondents reported low rates of malaria vaccinations such as HPV and tetanus (12 percent of treatment services, at around two percent. 98 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.14. PERCENT DISTRIBUTION OF HOUSEHOLDS BY PROVINCE/CITY AND BY SERVICE FOR CHILD/ADOLESCENT HEALTH, BARMM, 2019 Type of Health Services Consulted Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North and Accessed/Availed del Sur Provinces City Cotabato n= 840 920 281 643 320 3,004 280 521 Child Malnutrition Consulted 45.7 48.5 33.8 33.3 37.8 41.9 42.9 42.0 Accessed/Availed 46.7 46.7 21.0 27.7 24.4 37.8 41.8 39.5 Vitamin A Supplementation Consulted 54.0 60.0 64.1 58.5 60.3 58.4 65.7 55.7 Accessed/Availed 61.2 60.5 68.0 57.2 59.7 60.6 64.3 54.9 Iron Supplementation Consulted 46.3 51.4 42.3 38.9 40.9 45.3 56.8 43.6 Accessed/Availed 51.5 52.1 41.3 37.0 34.4 45.8 55.0 42.4 ORS for diarrhea Consulted 49.6 49.1 37.7 37.9 47.2 45.6 35.4 43.0 Accessed/Availed 49.6 48.3 31.7 31.4 35.9 42.2 32.1 42.0 Zinc Supplementation Consulted 45.7 44.5 25.6 26.9 28.8 37.6 45.0 31.1 Accessed/Availed 48.9 45.0 23.1 24.6 23.8 37.4 44.6 29.9 Child Growth Monitoring Consulted 48.0 59.2 23.1 28.9 40.9 44.3 53.2 52.4 Accessed/Availed 49.9 58.9 19.6 26.9 36.9 43.5 52.9 50.3 Pneumonia for children Consulted 27.3 18.7 16.7 10.7 15.9 18.9 23.6 21.9 Accessed/Availed 26.3 15.8 12.1 6.2 8.4 15.5 22.1 20.7 Malaria for children Consulted 3.6 8.0 6.0 13.4 16.9 8.7 2.5 2.3 Accessed/Availed 4.5 7.8 5.3 11.2 14.1 8.1 1.8 1.7 Deworming Consulted 36.4 44.5 42.7 47.3 54.1 43.7 46.1 50.1 Accessed/Availed 45.0 43.7 43.8 42.5 50.3 44.5 44.6 50.1 Sexually Transmitted Infections Consulted 0.4 1.5 0.4 0.0 0.3 0.6 1.1 0.2 Accessed/Availed 0.2 1.3 0.7 0.0 0.0 0.5 1.1 0.2 Adolescence/Adult Vaccines (HPV, Tetanus, Flu) Consulted 14.8 17.6 11.4 7.8 3.8 12.6 14.3 18.8 Accessed/Availed 13.7 16.5 11.7 7.3 2.8 11.9 13.9 18.8 99 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y Health Services for Communicable and Non- those from the five BARMM provinces reported they had Communicable Diseases. Respondents were asked sought care for a sick family member, though this number whether they consulted with a medical professional was considerably lower (just 33 percent) in Maguindanao. or accessed services for the following conditions: When care was sought, 46 percent of respondents tuberculosis, malaria, diabetes, cardiovascular diseases, overall reported seeing a doctor, while 25 percent saw cervical cancer, HIV (testing), and chronic respiratory a midwife. Nearly one quarter of respondents reported diseases. Utilization of these services was low: across the visiting a traditional healer or hilot, though in Basilan BARMM provinces, fewer than 10 percent of respondents and Maguindanao provinces this percentage was closer overall reported accessing any of them. However, to one-third. Nearly nine out of 10 respondents reported provincial variation was observed: for example, though that the provider they saw for medical care was their the regional average was seven percent, nearly 12 percent provider of choice. of respondents in Lanao del Sur reported accessing medical care for chronic respiratory diseases, while just A higher percentage of respondents in the expansion two percent of respondents in Sulu did so. There was areas reported ever seeking care for a sick family similar variation for diabetes: on average, just three member than respondents from the BARMM provinces; percent of respondents reported accessing care for this percentage was nearly 100 percent among diabetes, though in Lanao del Sur twice as many did. households in Cotabato City. When care was sought, nearly 70 percent of respondents in Cotabato City Typically, the percentage of respondents who report reported seeing a doctor, a percentage considerably seeking a medical consultation and those who report higher than the BARMM regional average. Households in accessing that same service are quite similar. However, North Cotabato BARMM barangays reported seeking care in the case of tuberculosis among households in Basilan, from doctors and midwives in similar proportion to the fewer than half of the respondents who reported seeking five BARMM provinces. a medical consultation went on to avail of the service. According to the supply side readiness assessment, Overall, when asked which facility they preferred to RHUs in Basilan reported an average of 56 percent of visit, 77 percent of respondents across the BARMM the TB indicators assessed; this was exactly aligned provinces reported a preference for a public facility with the regional average. Considering Basilan did not (RHU, BHS or public hospital), while 13 percent reported demonstrate substantially less readiness than the other a preference for private clinics or private hospitals. The provinces, it does not seem that supply side factors have most important factors for deciding where to access care influenced accessing TB services. were: free or no cost services (reported by 50 percent of respondents), proximity to residence (46 percent), Factors Influencing Health Care Access. Respondents and service of good quality, with approachable staff were asked a variety of questions about their overall and medicine in stock (32 percent). Just 13 percent of experience accessing needed health care as well as respondents overall reported they preferred a facility their general preferences when care was sought. They because it was the only one available. were also asked to recount a recent experience (in the past month) when care was needed and/or accessed, As in the BARMM provinces, roughly 80 percent of primarily to gauge the financial impact but also to households in Cotabato City and North Cotabato reported identify potential barriers to access from the preferring to access care at a public facility. Nearly two- consumer perspective. thirds of households in the expansion areas based their preference on the low cost of services or medicines. Beginning with general preferences, respondents were Far fewer households there emphasized proximity to asked if they had sought health care services for a family residence than did households in the five member who had ever been sick. Overall, 69 percent of BARMM provinces. 100 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.15. HEALTH CARE SERVICE PREFERENCES, BARMM, 2019 Lanao Maguindanao Basilan Sulu Tawi-Tawi Total Cotabato North del Sur City Cotabato n= 840 920 281 643 320 3,004 280 521 Percent seeking health services for 93.7 33.8 69.8 81.0 82.2 69.2 97.5 74.7 members who had ever been sick Health provider approached when health services were met Traditional hilot/healer 14.6 32.3 31.3 22.7 16.3 23.5 8.6 16.3 Midwife 7.9 34.7 18.9 30.9 39.4 25.4 22.9 33.8 Nurse 3.5 3.8 3.6 9.2 5.0 5.0 0.0 2.7 Doctor 74.0 29.2 46.3 37.2 39.4 46.1 68.6 47.2 Preference for health facility Private clinic 7.0 3.8 10.3 7.8 7.8 6.6 7.1 3.5 Private hospital 8.1 5.3 7.8 3.6 4.7 5.9 11.1 9.4 Public hospital 36.4 18.9 22.1 22.4 16.3 24.6 42.1 22.1 Rural Health Unit 35.5 9.7 16.0 11.7 22.2 19.2 4.6 31.5 Barangay Health Station 9.4 52.7 25.6 40.1 36.3 33.6 32.1 27.8 Traditional hilot/healer 3.6 9.6 18.1 14.5 12.8 10.1 2.9 5.8 Reasons for the preference Reasons for the preference Services and medicine are 59.5 58.7 45.2 35.5 29.7 49.6 62.1 60.1 free/no cost Near place of residence 36.7 56.1 38.8 45.3 51.3 46.2 17.9 29.2 The only available facility 10.8 10.4 12.5 17.3 18.4 13.0 0.0 2.1 A doctor regularly calls on 14.9 4.2 10.3 13.4 14.7 10.9 8.6 12.3 the facility Knows and trust health providers 21.4 14.3 17.4 24.9 38.4 21.4 7.9 15.5 Gives quality service, 28.9 28.4 29.9 35.9 39.4 31.5 29.6 23.4 approachable, have a stock of medicine available Services and medicine affordable 1.7 1.0 2.1 1.4 2.5 1.5 1.8 0.6 and PhilHealth beneficiaries can access Trust services of traditional 0.7 3.3 0.4 0.3 0.0 1.3 1.1 0.2 healer and it cost less Note: Green highlighted boxes represent provincial rates that are 15 percentage points or more below the regional average. Yellow highlighted boxes represent provincial rates that are 15 percentage points or more above the regional average. 101 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y Respondents were next asked about the health care reported longer travel times, with just 53 percent facility nearest to their residence (not necessarily spending less than 15 minutes, while nearly 25 percent their preferred provider). Among those in the BARMM reported spending more than 30 minutes in transit. The provinces, the vast majority (85 percent) reported average one-way fare for transportation to the health spending 30 minutes or less in transit to the nearest facility was just 10 pesos in Cotabato City and 26 pesos facility. While just five percent of respondents overall in North Cotabato, considerably lower than the regional reported spending two hours or more in transit, nearly average for the BARMM provinces. 10 percent of respondents in Basilan and Tawi-Tawi reported long travel times. The average one-way fare PhilHealth Coverage. Overall, just 47 percent of to reach a health facility was PhP 40 (most frequently respondents in the five BARMM provinces reported having for a motorcycle or tricycle ride), though respondents PhilHealth coverage (Table 5.16). Of those, over 55 percent in Basilan and Tawi-Tawi reported an average fare reported receiving coverage through NHTS-sponsored approximately twice this amount. This may reflect both programs, though there was provincial variation: just the mode of transportation and the distance traveled. 45 percent of respondents in Maguindanao reported receiving PhilHealth coverage via NHTS-sponsored Among households in the expansion areas, nearly 95 programs, as compared to nearly 80 percent in Sulu. percent of those in Cotabato City reported spending less than 15 minutes traveling to the nearest health facility. In Forty-seven percent of households in North Cotabato North Cotabato BARMM barangays, however, respondents BARMM barangays reported PhilHealth membership, a TABLE 5.16. DISTRIBUTION OF HOUSEHOLDS BY PROVINCES/CITY AND BY TYPE OF PHILHEALTH MEMBERSHIP, BARMM, 2019 Type of PhilHealth Membership Lanao Maguindanao Basilan Sulu Tawi-Tawi Total Cotabato North del Sur City Cotabato n= 840 920 281 643 320 3,004 280 521 Percent Affirming PhilHealth 54.4 48.2 52.7 36.7 42.5 47.3 57.1 46.6 membership Type of Membership Employed, DepEd 6.3 0.7 0.7 5.5 8.8 4.1 1.9 3.3 Employed, Govt other than DepEd 5.0 5.6 2.7 5.1 5.1 5.0 10.0 0.8 Employed, Private 1.8 11.7 0.0 1.3 0.7 4.5 16.9 4.5 Individually-Paying/Voluntary 18.2 16.3 6.1 2.1 4.4 12.3 38.8 7.0 NHTS-Sponsored, Cash 49.0 44.7 62.8 78.0 70.6 56.0 30.0 60.5 transfers/4Ps Provincial LGU – Sponsored 7.2 3.6 5.4 1.3 1.5 4.4 0.6 1.6 Municipal/City LGU – Sponsored 9.4 14.7 7.4 2.1 2.9 9.0 6.9 20.6 Congressman/woman-Sponsored 0.4 0.2 0.7 0.0 0.0 0.3 0.0 0.0 OFW 0.2 0.5 0.7 0.0 1.5 0.4 3.1 1.2 Lifetime Member/Retirees 0.7 0.0 0.0 0.0 0.0 0.2 0.6 0.0 Senior Citizen Member 2.8 1.6 4.1 2.1 4.4 2.6 4.4 3.3 Length of membership (in years) 6.1 5.6 4.5 6.7 5.6 5.9 6.7 5.6 102 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M percentage equal to the regional average for the BARMM 2) no doctor available or no health provider on duty (22 provinces. Of these, 61 percent reported membership percent); and 3) no medicine in the health facility through an NHTS-sponsored program, while 20 percent (21 percent). were sponsored by the LGU (at municipality or city level). However, in Cotabato City, 10 percent more respondents Very few respondents (less than two percent overall) reported PhilHealth membership (57 percent) than the reported that geographic distance from a health facility BARMM regional average. Of these, nearly 40 percent was a barrier to accessing care. However, this does not were individually paying members, a percentage more necessarily imply that respondents generally live close to than three times higher than the ARMM regional average a health facility; instead, it may mean that the location of and five times higher than the percentage in the facility is less important than other factors. North Cotabato. When care was accessed, respondents reported spending Recent Health Seeking Behavior. Across the BARMM an average of 914 pesos on medical services for the most provinces, 50 percent of respondents reported that recent illness of a household member, which included at least one family member had been sick in the past the professional fee and the cost of medication (Table month. Meanwhile, 12 percent reported forgoing needed 5.17). Average costs were higher in Tawi-Tawi (nearly 1,400 care in the past month, suggesting that the majority of pesos) than in the other provinces. Over 95 percent of households do access care when it is needed. Among respondents reported paying for these medical services those families that reported forgoing medical care, the out-of-pocket. Just six percent reported using PhilHealth most frequently cited reasons were: 1) no money to pay to pay for medical care, though this percentage is more for services or to buy prescribed medicine (40 percent); than twice as high in Basilan province (14 percent). TABLE 5.17. COST OF MEDICAL SERVICES AND MODE OF PAYMENT FOR MOST RECENT ILLNESS, BARMM, 2019 Lanao Maguindanao Basilan Sulu Tawi-Tawi Total Cotabato North del Sur City Cotabato n= 840 920 281 643 320 3,004 280 521 Average cost of medical services 909.34 821.87 803.21 858.18 1392.89 913.19 1586.06 1036.56 and medicine with most recent illness (in Philippine Pesos) Mode of payment for medicine and medical services for most recent illness (percent) PhilHealth Coverage 8.2 4.7 14.4 3.4 5.0 6.1 7.2 7.2 HMO/other Health Insurance 0.0 0.1 0.0 0.7 0.0 0.2 0.0 0.0 Own Pocket 96.7 96.0 87.8 96.6 98.2 95.8 97.1 96.3 No payment (Services/ 0.0 0.1 0.6 0.0 0.0 0.1 0.7 0.0 medicines/ vaccines are free) Government sponsor/donor 1.2 1.3 1.1 0.5 0.5 1.0 1.1 0.0 (PCSO, LGU, DSWD) Private sponsor/donor (family 9.2 3.7 5.0 8.5 7.2 6.5 5.8 5.7 members, relatives, friends, mosque/church) Through loans (government 2.6 4.0 0.6 0.0 0.0 2.0 0.7 0.6 loans, private lenders, friends, relatives) 103 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y Among respondents in the expansion areas, 83 percent of those in Cotabato City and 77 percent in North Cotabato BARMM barangays reported having a sick family member in the past month, percentages that were substantially higher than the average for the five BARMM provinces. Meanwhile, 12 percent of those in Cotabato City and 21 percent of those in North Cotabato reported not accessing needed medical services in the past month. The most frequently cited reason for not accessing care was the inability to pay for services: 47 percent of households in Cotabato City reported as such, while over 70 percent of those in North Cotabato did so. Respondents in Cotabato City reported spending an average of PhP 1,586 for health care services and medicine for the most recent illness—more than PhP 600 higher than the average for the five BARMM provinces. On the other hand, households in North Cotabato BARMM Items for each composite index were culled from barangays spent on average PhP 1,040 on the most recent responses on the reasons why respondents failed to medical visit, a figure much closer to what was reported access services, and on practices in seeking health by households in the BARMM provinces. Finally, as was services. Affirmation and averages for each item were seen among the five BARMM provinces, more than 95 obtained by selecting the category of responses that percent of households in the expansion areas reported generated the most affirmations or highest average paying for these medical services out of pocket. among numeric responses. Weights were given according Health Access Composite Indices. Statistical indices were to the percent of those affirming.37 constructed to provide quantitative data on the three Results indicate that physical access (availability) was categories of access to care—physical, economic and low, but economic access was better in that the cost cultural—as previously described. incurred was manageable. Cultural access also received a The indicators of physical access were focused on high index score. the availability of services, the health facility, and the Access indexes are presented in Table 5.18 for the entire presence of health providers. These indicators included: sample areas. Physical access was given a composite preferred health facility, the only facility available (no index of 3.93, indicating poor access. Economic access choice), nearness of health facility to residence, and suggests services are highly affordable, waiting time is the regular presence of a doctor. For economic access, short, costs are low because medicine is free, and the indicators included: average waiting time (in minutes) health facility is within walking distance—overall, the cost to access services, services and medicine being free incurred is manageable. The score for this index indicates of charge, distance of health facility from residence, economic access is high. transport costs, and mode of transport. Finally, socio- cultural access included variables depicting how clients Finally, cultural access implies appropriateness of were accommodated, whether they were given the option health services because consumers have a choice of to choose their attending service provider, religious providers, and they were treated courteously and kindly prohibition, preference of traditional healer, fear of side- during service provision. The composite index score of effects, and trust in the service providers. appropriateness was found to be high. 37 A forthcoming technical publication will provide further details on these indices, including the selected indicators and the weighting protocol. 104 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.18. PHYSICAL, ECONOMIC AND CULTURAL ACCESS INDEXES, BARMM, 2019 Proportion Affirming/Average Weights Index Scores Physical access (Availability) Index Item Description • preferred health facility 0.327 4 1.30 (Barangay Health Station) • available, no other health facility 0.109 3 0.33 • near place of residence 0.418 5 2.09 • regular presence of doctor 0.106 2 0.21 Total 3.94 Economic Access (Affordability) Index Item Description • waiting time (5 – 15 minutes) 0.26 2 0.52 • services/medicines are free 0.52 4 2.08 • distance of health facility 0.547 5 2.74 (5 – 15 minutes’ walk) • cost in going to the health facility 0.367 3 1.10 (36.70 pesos) Total 6.44 Cultural Access (Appropriateness) Item Description • gives quality service 0.302 4 1.21 • the attending health providers are ones’ choice 0.886 5 4.43 • religious prohibition 0.014 2 0.03 • health providers are trustworthy 0.196 3 0.59 Total 6.26 IMMUNIZATION COVERAGE months are eligible to receive more vaccine doses, considering these children gives a more complete picture In addition to collecting data on access to health care of a community’s dedication to childhood vaccination. services, respondents were asked a series of questions about the immunization status of the child or children A total of 1,872 children aged 12–23 months were in their homes aged 0–23 months. In order to conform to included in this study; of these, 1,521 live within the five WHO recommendations and accommodate the reporting BARMM provinces. As mentioned previously, only the format followed in the Philippines, data were analyzed primary caregiver of the child was interviewed, under separately for children aged 0–11 months and 12–23 the assumption that this person would have the most months. The results presented below are for children accurate knowledge of the child’s immunization history. aged 12–23 months; findings for the younger age group Among children aged 12–23 months in the BARMM are presented in Annex G. Since children aged 12–23 provinces, 93 percent of respondents were the child’s 105 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y mother. This percentage was below 90 percent in the The WHO survey guidelines recommend summarizing expansion areas of Cotabato City and North Cotabato; coverage two ways: the proportion of children who have more grandparents were primary caregivers in any evidence whatsoever of having received the dose, these areas. regardless of source or timing, which is sometimes called crude coverage, and the proportion of children who have Since data collection for this study was performed date-based evidence of receiving the dose when they in respondents’ homes, interviewers were able to were age-eligible to do so, which is sometimes called physically view home-based vaccination records (HBR), valid coverage (WHO, 2018; WHO 2019). Crude coverage namely vaccination cards, or evidence of immunization, includes evidence from HBRs and from caregiver recall, for example scars from the BCG vaccine, to confirm and if from HBRs, it includes doses that were early, timely immunization status. This is considered the most or late. accurate way to determine a child’s vaccine coverage. However, fewer than 40 percent of respondents in the Crude Coverage. Among those aged 12–23 months BARMM provinces were able to produce a vaccination residing within the five BARMM provinces, approximately card. Only in Cotabato City did more than 50 percent 34 percent exhibited basic vaccine coverage, a proportion of respondents produce this record. Over 30 percent of substantially higher than reported in the 2017 NDHS (18 respondents in the BARMM provinces reported never percent). Twenty-four percent of children in this age receiving a vaccination card; this percentage was close group had no vaccine history. Although this is higher than to 40 percent in Basilan and Sulu provinces. Among the 2017 Philippine national average, it is substantially those who had received vaccination cards but could lower than the percentage reported for ARMM in that not produce them at the time of the interview, the most same year (43 percent). These changes should be cited explanation was that it had been lost, though interpreted with caution, as they may reflect both an many declined to say why the card was missing. For improvement in coverage as well as differences in those respondents without cards, interviewers asked survey methods. the primary caregivers to recall whether their child had received all the vaccines for which they were eligible (based on age). The issue of recall bias is significant. FIGURE 5.6. VACCINE COVERAGE, BARMM AND PHILIPPINES, 2017 AND 2019 100% 90% 80% 70% 70% 60% 50% 44% 40% 34% 30% 24% 20% 18% 10% 9% 0% 2017 Philippines 2017 ARMM 2019 BARMM Household Survey Basic vaccine coverage No vaccine coverage Source: PSA and ICF 2018 (2017 data); BARMM Household Survey 2019 (2019 data) 106 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Provincial variation was observed among the BARMM with other data collected in the household survey, which provinces. For nearly all vaccine doses, children in Lanao showed improved health care access in Cotabato City del Sur and Tawi-Tawi had the highest rates of coverage. compared to the five BARMM provinces, and a situation These provinces also had the highest percentages of more closely resembling the BARMM provinces in North children with all basic vaccine doses as well as the Cotabato BARMM barangays. highest percentage of fully vaccinated children, and the lowest percentages of children who were completely Figure 5.8 below provides additional detail about vaccine unvaccinated (Figure 5.7). Basilan province had half coverage among children in the five BARMM provinces as many fully vaccinated children compared to the overall. Coverage estimates per province are included region as a whole (six percent versus 12 percent), while in Annex H. The height of each bar corresponds to the Maguindanao province had the highest percentage of estimated proportion of children who received the dose. children with no vaccine history (30 percent compared to The horizontal dashed line across the figure indicates 24 percent across the five provinces). the proportion of respondents who showed a vaccination card (HBR). Vaccine timeliness, as gauged by a review of As for the expansion areas, vaccine coverage estimates the vaccination card, is also noted in the following figure. are higher in Cotabato City than in the BARMM provinces, The colored portions of the bars indicate whether a and lower in North Cotabato BARMM barangays. Over child received a vaccine dose when they were too young one-quarter of children aged 12–23 months in Cotabato (early), on time (timely), less than two months late, or City were fully vaccinated, while just eight percent were more than two months late. For respondents who did not completely unvaccinated. By contrast, in North Cotabato, show an HBR to the interviewer, or whose HBR date was just three percent of children were fully vaccinated, illegible or nonsensical, the timing of the vaccination is much lower than the BARMM regional average, though 31 unknown (timing unknown). percent had received all basic doses. These findings align FIGURE 5.7. PROVINCIAL VARIATION IN VACCINE COVERAGE, BARMM, 2019 60 50 48.0 43.5 40 36.8 33.9 32.3 30.9 29.6 30.8 30 27.6 29.0 23.9 21.4 20 17.4 16.7 13.5 10 7.8 0 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North Provinces City Cotabato All basic doses* All doses** No doses * Basic doses include BCG, OPV1-3, Penta1-3, MMR1 **All doses include BCG, HepB0, OPV1-3, Penta1-3, PCV1-3, MMR1 107 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y FIGURE 5.8. VACCINE COVERAGE AND TIMELINESS, BARMM, 2019 Vaccination Coverage & Timeliness: 5 BARMM Provinces 72.4% 17.3% 64.0% 53.1% 44.0% 66.7% 57.7% 43.4% 56.3% 45.0% 37.7% 17.5% 52.5% 36.4% Coverage 1521 1521 1521 1521 1521 1521 1521 1521 1521 1521 1521 1521 1521 1521 N 601 601 601 601 601 601 601 601 601 601 601 601 601 601 N with HBR 475 499 380 366 375 462 444 441 371 426 471 390 440 556 N effective 100% Showed HBR Estimated Coverage (%) 80% Timing Unknown 2+ Months Late 60% <2 Months Late 40% Timely (within 28 days) Timely within 1 day 20 Timely (within 5 days) Early 0 BCG HEPB0 PENTA1 PENTA2 PENTA3 OPV1 OPV2 OPV3 PCV1 PCV2 PCV3 IPV MMR1 MMR2 Crude vaccination coverage, among children ages 12-23 months, accepting evidence from home-based immunization records (HBR) and caregiver recall. Timing unknown means evidence is from caregiver recall or a partial or illegible date on the HBR. Pink definition of timely (within 5 days) is for BCG alone. Blue definition (within 1 day) is for HepB0 alone. N is the number of children who were old enough to have received the dose by the time of the survey. N efffective is the simple random sample N that would give precision equivalent to the clustered N from this survey. Each dose shows a two-sided 95% survey-adjusted Wilson confidence interval. Vaccination Coverage Survey, BARMM, 2019. Several features are notable in this figure. First, as mentioned above, the majority of evidence in this study is from caregiver recall, and thus the timing of the doses is unknown. Second, a large portion (about one-third) of children who receive the first dose in the Penta, OPV and PCV series do not go on to complete the series. These children are said to drop out of the vaccination program. Third, a notable portion of the sample with evidence of vaccination on the HBR spent more than two months unprotected by these doses after they were eligible to receive them. In some cases, more than half the bar beneath the timing unknown section is dark green, for example, PCV3 and IPV. Crude vaccination coverage was also considered by Finally, crude vaccination coverage was analyzed by income level. As expected, in most cases, coverage gender. Overall, vaccination rates per vaccine dose and was found to increase with household income; ability for all basic doses were slightly higher for girls than to produce a vaccination card, or HBR, also increased boys throughout the five BARMM provinces, though with household income. The differences in Penta1 and the observed gender differences were not statistically Penta3 coverage across income groups were found to be significant. In the expansion areas, coverage rates statistically significant among those in the five BARMM generally favored boys for nearly all antigens, though the provinces (Table H-1, Annex H). differences were small (Table 5.19). 108 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.19. CRUDE COVERAGE FOR CHILDREN AGE 12-23 MONTHS, BY GENDER, BARMM, 2019 BARMM Provinces Expansion Areas Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato BCG Boys % 79.5 65.3 68.1 68.2 85.3 72.1 85.2 78.4 95% CI 71.1 - 86.0 55.3 - 74.1 48.0 - 83.2 56.6 - 77.9 64.5 - 94.9 67.3 - 76.5 65.0 - 94.7 64.9 - 87.7 Girls % 79.3 64.5 69.3 68.9 86.5 72.8 83.3 73.0 95% CI 73.3 - 84.3 52.4 - 75.0 58.2 - 78.6 54.1 - 80.7 69.2 - 94.8 67.7 - 77.4 61.8 - 93.9 60.7 - 82.5 HepB0 Boys % 19.0 15.1 14.5 17.2 30.7 18.1 37.0 12.0 95% CI 13.5 - 26.2 9.0 - 24.3 8.1 - 24.7 9.5 - 29.2 12.4 - 58.1 14.3 - 22.7 25.4 - 50.4 5.7 - 23.5 Girls % 17.8 12.5 6.7 19.5 24.0 16.5 36.7 9.0 95% CI 13.2 - 23.6 7.1 - 21.1 2.9 - 14.7 12.9 - 28.3 11.6 - 43.0 13.4 - 20.2 14.9 - 65.7 3.6 - 20.8 Penta1 Boys % 67.1 60.4 59.4 57.0 76.0 63.1 68.5 70.4 95% CI 59.8 - 73.7 47.6 - 71.9 38.5 - 77.4 45.3 - 67.9 48.2 - 91.5 57.4 - 68.4 43.6 - 86.0 56.3 - 81.4 Girls % 69.7 64.0 57.3 59.5 75.0 65.1 71.7 71.2 95% CI 63.2 - 75.6 51.7 - 74.7 42.8 - 70.7 43.4 - 73.8 50.2 - 89.9 59.4 - 70.5 59.2 - 81.5 55.3 - 83.1 Penta2 Boys % 54.3 47.3 46.4 47.0 68.0 51.2 66.7 58.4 95% CI 47.5 - 60.9 35.3 - 59.7 27.8 - 66.0 36.1 - 58.3 37.0 - 88.5 45.5 - 56.8 41.3 - 85.1 44.9 - 70.8 Girls % 59.1 54.0 40.0 51.1 67.7 55.0 58.3 53.2 95% CI 50.8 - 67.0 41.3 - 66.2 25.6 - 56.4 35.3 - 66.6 45.0 - 84.3 49.0 - 60.9 40.0 - 74.6 37.4 - 68.3 Penta3 Boys % 44.8 36.3 33.3 37.1 60.0 40.9 55.6 43.2 95% CI 37.5 - 52.2 25.7 - 48.5 18.3 - 52.7 26.7 - 48.8 34.0 - 81.4 35.6 - 46.5 34.0 - 75.2 28.2 - 59.6 Girls % 51.9 47.0 32.0 42.6 58.3 47.2 43.3 37.8 95% CI 41.9 - 61.8 35.3 - 59.1 18.3 - 49.7 27.2 - 59.7 40.6 - 74.2 41.3 - 53.2 26.7 - 61.6 22.5 - 56.1 OPV1 Boys % 69.5 63.3 60.9 60.9 76.0 65.6 75.9 76.0 95% CI 61.6 - 76.4 51.8 - 73.4 42.9 - 76.3 51.1 - 70.0 48.9 - 91.3 60.5 - 70.4 52.6 - 90.0 62.1 - 85.9 Girls % 75.5 63.0 60.0 65.3 74.0 68.0 83.3 71.2 95% CI 69.2 - 80.8 50.8 - 73.8 40.6 - 76.7 49.8 - 78.1 52.3 - 88.0 62.4 - 73.1 62.6 - 93.7 57.5 - 81.9 OPV2 Boys % 59.5 55.5 44.9 51.7 65.3 55.9 70.4 64.8 95% CI 52.8 - 65.9 43.3 - 67.1 28.8 - 62.2 41.9 - 61.3 37.0 - 85.8 50.4 - 61.2 43.1 - 88.2 48.3 - 78.4 Girls % 67.8 55.5 45.3 57.4 65.6 59.6 68.3 56.8 95% CI 61.2 - 73.8 43.3 - 67.1 30.4 - 61.2 41.2 - 72.1 46.2 - 80.9 53.8 - 65.0 55.8 - 78.7 38.3 - 73.5 OPV3 Boys % 44.3 40.8 33.3 37.7 53.3 41.7 57.4 42.4 95% CI 37.7 - 51.0 30.1 - 52.5 19.2 - 51.3 27.7 - 49.0 31.2 - 74.3 36.7 - 46.9 36.5 - 76.0 29.1 - 56.9 Girls % 47.6 45.5 26.7 44.2 55.2 45.1 48.3 40.5 95% CI 39.4 - 55.9 34.6 - 56.9 16.0 - 41.0 29.4 - 60.1 38.8 - 70.5 39.7 - 50.7 36.2 - 60.7 27.0 - 55.7 PCV1 Boys % 62.4 51.4 43.5 51.7 70.7 55.7 64.8 47.2 95% CI 54.9 - 69.3 39.4 - 63.3 26.0 - 62.7 40.3 - 62.8 39.9 - 89.7 50.1 - 61.3 42.4 - 82.2 34.1 - 60.7 Girls % 61.5 52.5 48.0 53.2 71.9 57.1 63.3 46.8 95% CI 53.4 - 69.1 39.5 - 65.2 33.2 - 63.2 38.2 - 67.5 45.4 - 88.7 51.1 - 62.9 50.7 - 74.4 31.5 - 62.8 109 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y BARMM Provinces Expansion Areas Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato PCV2 Boys % 45.2 38.8 36.2 41.1 62.7 43.2 61.1 34.4 95% CI 38.7 - 52.0 27.9 - 50.8 25.9 - 48.0 30.9 - 52.0 34.5 - 84.3 38.0 - 48.6 39.5 - 79.1 22.3 - 49.0 Girls % 51.4 40.0 38.7 45.3 60.4 46.8 46.7 27.0 95% CI 43.5 - 59.3 29.9 - 51.0 24.0 - 55.7 30.6 - 60.8 39.4 - 78.1 41.3 - 52.5 29.3 - 64.9 17.2 - 39.7 PCV3 Boys % 40.0 30.2 27.5 31.8 49.3 34.9 55.6 24.8 95% CI 32.8 - 47.7 21.5 - 40.7 18.4 - 39.0 21.4 - 44.4 29.0 - 69.9 30.3 - 39.9 34.0 - 75.2 13.3 - 41.6 Girls % 44.2 33.5 29.3 41.6 54.2 40.6 41.7 17.1 95% CI 35.0 - 53.9 24.8 - 43.4 16.8 - 46.0 27.6 - 57.0 36.2 - 71.1 35.3 - 46.1 24.1 - 61.6 8.6 - 31.3 IPV Boys % 12.9 19.6 13.0 11.3 29.3 16.4 40.7 14.4 95% CI 7.8 - 20.4 12.2 - 29.9 4.8 - 30.8 5.5 - 21.6 12.0 - 55.8 12.5 - 21.2 20.3 - 65.0 6.9 - 27.5 Girls % 12.5 28.0 6.7 18.4 21.9 18.6 38.3 13.5 95% CI 8.4 - 18.2 18.2 - 40.4 1.8 - 21.4 11.1 - 29.0 9.4 - 43.0 14.7 - 23.2 20.1 - 60.6 5.9 - 28.0 MMR1 Boys % 58.6 44.9 52.2 45.0 57.3 50.7 50.0 57.6 95% CI 51.8 - 65.0 34.5 - 55.8 31.0 - 72.6 32.9 - 57.8 39.0 - 73.9 45.5 - 55.8 33.9 - 66.1 44.6 - 69.6 Girls % 64.4 50.5 44.0 46.8 64.6 54.5 56.7 52.3 95% CI 55.8 - 72.2 37.0 - 63.9 28.2 - 61.1 32.9 - 61.3 44.5 - 80.6 48.6 - 60.3 40.8 - 71.3 37.6 - 66.5 MMR2 Boys % 37.6 31.4 44.9 31.1 46.7 35.9 37.0 46.4 95% CI 31.3 - 44.3 22.6 - 41.8 27.7 - 63.5 22.0 - 42.0 28.1 - 66.2 31.5 - 40.5 25.4 - 50.4 33.9 - 59.4 Girls % 41.3 32.5 33.3 32.6 47.9 36.9 31.7 32.4 95% CI 32.6 - 50.6 23.0 - 43.7 20.7 - 48.9 22.4 - 44.9 29.5 - 66.9 32.1 - 42.1 21.3 - 44.2 20.9 - 46.6 All basic Boys % 33.8 26.9 23.2 25.8 44.0 30.0 46.3 32.8 doses * 27.8 - 40.4 18.5 - 37.5 12.0 - 40.0 17.6 - 36.1 26.2 - 63.5 25.7 - 34.6 28.3 - 65.3 20.0 - 48.8 95% CI Girls % 39.9 39.0 20.0 34.7 51.0 37.8 41.7 28.8 95% CI 32.2 - 48.1 27.8 - 51.4 12.5 - 30.4 22.0 - 50.1 35.8 - 66.1 32.7 - 43.2 24.5 - 61.1 16.9 - 44.6 Boys % 13.3 8.2 7.2 8.6 24.0 11.2 29.6 4.0 All doses 9.4 - 18.6 4.3 - 15.0 2.1 - 22.3 4.5 - 15.8 10.4 - 46.1 8.6 - 14.4 16.3 - 47.7 1.2 - 12.1 95% CI Girls % 12.5 8.0 4.0 14.7 18.8 11.8 26.7 1.8 95% CI 8.7 - 17.7 4.0 - 15.3 1.4 - 11.1 9.3 - 22.6 8.8 - 35.6 9.3 - 14.9 9.7 - 55.3 0.3 - 11.2 Boys % 17.6 28.6 29.0 27.8 14.7 24.0 9.3 15.2 No doses 12.0 - 25.1 20.4 - 38.5 15.3 - 48.0 18.3 - 39.8 5.1 - 35.5 19.9 - 28.6 2.7 - 26.9 8.7 - 25.1 95% CI Girls % 15.9 30.5 25.3 30.0 12.5 23.7 5.0 19.8 95% CI 11.5 - 21.4 20.7 - 42.4 13.6 - 42.2 18.5 - 44.8 5.2 - 27.0 19.3 - 28.7 1.7 - 13.7 11.2 - 32.6 Boys 210 245 69 151 75 750 54 125 N 208 200 75 190 96 769 60 111 Girls Abbreviation: CI = Confidence Interval Note: N=3 respondents age 12-23m did not indicate whether they were a boy or a girl. * Basic doses include BCG, OPV1-3, PENTA1-3, MMR1 110 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Preferences for Vaccine Delivery Location. On average, against the relevant disease. Conversely, in the BARMM over 60 percent of respondents within the BARMM provinces, nearly 19 percent of children with documented provinces reported bringing their child to the barangay consecutive dose dates experienced at least one interval health station (BHS) for vaccinations, though this that was shorter than the recommended 28 days, percentage was much lower in Lanao del Sur, where the rendering the second dose invalid (Table 5.20). majority of respondents reported receiving vaccinations at an RHU. More than 80 percent of respondents in the When children are brought to a provider to be vaccinated, BARMM expansion areas reported accessing vaccination it is plausible that they would receive all doses for which services at barangay health stations. Private facilities they are eligible at that time, not just the one or ones played a negligible role in vaccine delivery: just two specifically scheduled for that day. In this way, children percent of respondents in the BARMM provinces reported can be brought towards full vaccine coverage without accessing immunization services at a private clinic. This further delay and without the need for caregivers to percentage was higher in Cotabato City (six percent). make extra visits. If they are not given all doses for which they are eligible at the time of the visit, this is considered Vaccine Timeliness and Catch-up Opportunities. In a missed opportunity for simultaneous vaccination, Figure 5.8 above, it was shown that many children or MOV. Table 5.21 documents that in the five BARMM receive vaccine dose pairs more than two months apart, provinces, of the 3,571 vaccination visits (for 596 children) leaving them under-protected for a period of time. A documented on HBRs where children were eligible to review of all HBRs that contained dates for at least two receive one or more doses, the child missed one or more consecutive doses in a series showed that, in the five eligible doses (experienced an MOV) on 66 percent of BARMM provinces, 53 percent of respondents with dates those visits. These children experienced an average of for two consecutive Penta, OPV or PCV or MMR doses one MOV per vaccination visit, representing a very high had at least one interval that exceeded 56 days. Thus, a incidence of missed opportunities. Fortunately, among large portion of children who go on to receive the later those children who experienced MOVs, 35 percent had doses (that is, do not drop out) receive them after having all of their MOVs corrected by the time of the household spent at least an additional month under-protected survey, meaning that although they missed receiving TABLE 5.20. INTRA-DOSE INTERVAL TIMELINESS, CHILDREN AGES 12-23M, BARMM, 2019 BARMM Provinces Expansion Areas Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato % who received 12.7 21.1 14.7 20.6 25.0 18.6 5.5 16.0 at least one dose pair (Penta, OPV, PCV or MMR) with < 28 days between (%) N 150 185 34 97 60 526 55 81 % who received 41.3 63.2 61.8 56.3 41.7 53.1 40.0 71.3 at least one dose pair (Penta, OPV or PCV) with > 56 days between ( %) N 150 185 34 96 60 525 55 80 N is the number of respondents whose HBR had dates for at least two consecutive doses in a series. Note that the > 56 days analysis does not include MMR because it is perfectly acceptable for the MMR1 to MMR2 interval to exceed 56 days. 111 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y TABLE 5.21. MISSED OPPORTUNITIES FOR VACCINATION, BY VISIT, CHILDREN AGES 12-23M, BARMM, 2019 BARMM Provinces Expansion Areas Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato Vaccination visits 58.6 74.9 77.8 59.8 51.8 65.5 40.5 78.6 that include MOVs (%) N visits eligible for 903 1,365 239 637 427 3,571 373 501 doses MOVs per 0.8 1.2 1.4 1.0 0.7 1.0 0.6 1.3 vaccination visit Visits per MOV 1.3 0.8 0.7 1.0 1.4 1.0 1.7 0.8 N 168 211 38 113 66 596 62 92 N is the number of children who showed an HBR and had a vaccination visit date where they were eligible for at least one dose. the dose on one or more visits, they had received all all the doses for which they were eligible, suggesting of their previously missed doses by the time of the a clear opportunity for education of caregivers about survey interview. By contrast, 21 percent of those who what constitutes “full vaccination” and how to ascertain experienced MOVs had none of their MOVs corrected beyond doubt that a child has this coverage. before the survey (Table H-2, Annex H). Perceptions aside, caregivers of children who were not Dates from the HBR may be used to identify the date fully vaccinated were asked to indicate why their child of a child’s first MOV for a particular dose. When a had not received all vaccine doses. Across the BARMM child receives that dose on a later visit, the MOV is provinces, the most common responses to this question described, as above, as having been corrected. The time were: mother is too busy (29 percent), immunization to correction is the number of days between the MOV times are inconvenient (22 percent), and child ill and and the correction; the child spends that number of days not brought to immunization center (21 percent). Just un- or under-protected and those days could have been seven percent of respondents explained that the child avoided if the child had received the dose at the first was not fully vaccinated yet, and that they had to return opportunity. For most doses and provinces, the median for age-specific vaccines (indicating an understanding time to correction was one month or more, though in of the need to return for subsequent doses), though some cases it was more than three months (Figures H-8, this percentage is nearly twice as high in Tawi-Tawi Annex H). (13 percent). Finally, while fewer than 20 percent of respondents overall reported that their child was not Caregiver Perceptions and Knowledge about fully vaccinated because the immunization location was Vaccinations. Caregivers of children who received too far, nearly 35 percent of those in Basilan province vaccinations were asked whether they believed their reported as such. Among respondents in the expansion child had received all doses for which they were age- areas, a much larger percentage reported that their child eligible. In the five BARMM provinces, 34 percent of was not fully vaccinated because of a fear of adverse caregivers believed their child was fully vaccinated, effects or reactions (21 percent in Cotabato City and 19 though just four percent of all caregivers were correct percent in North Cotabato BARMM barangays, compared in this belief. This means that the vast majority of those to 11 percent for the BARMM provinces). children believed to be fully vaccinated had not received 112 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.22. MOST COMMON REASONS CHILD IS NOT FULLY VACCINATED BARMM Provinces Expansion Areas Lanao Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Cotabato North del Sur Provinces City Cotabato Immunization not 4.9 5.8 4.3 10.3 13.2 6.8 7.9 5.4 yet completed, have to go back for age – specific vaccine (%) Place of 12.0 12.4 34.8 23.1 22.6 17.4 9.5 8.5 immunization too far (%) Time of 23.9 19.9 24.6 22.2 17.0 21.7 11.1 15.5 immunization inconvenient (%) Mother too busy 23.4 22.6 27.5 41.0 47.2 28.7 25.4 15.5 (%) Child ill--not 25.5 25.7 10.1 12.8 17.0 21.0 22.2 24.8 brought to immunization center (%) Child ill--brought 9.8 14.6 13.0 6.8 7.5 11.1 4.8 17.8 but not given immunization (%) Fear of adverse 12.0 12.4 13.0 5.1 9.4 10.8 20.6 18.6 effects/reactions (%) N 184 226 69 117 53 649 63 129 * N is the number of children not fully vaccinated to whom the question was asked. Note: Columns may sum to more than 100%because respondents were able to select all answers that apply. Over 20 percent of respondents in the BARMM provinces In the expansion areas, this percentage was closer to reported having taken their child to be vaccinated only eight out of 10. WHO guidelines indicate that children to return home without receiving the vaccine dose. The can be vaccinated when they are experiencing mild caregiver almost invariably reported that this arose either symptoms. These two pieces of data—that parents do not because the child was sick, or because there was no wish to take their sick children to be vaccinated and that vaccine in stock. In the expansion area of North Cotabato, providers sometimes send sick children home without nearly one-third of respondents reported returning administering any vaccine—suggest that education home without an intended vaccine dose, with ten percent about vaccinating sick children could be directed to both reporting that they were turned away because it was not caregivers and providers. the scheduled day for vaccination. This suggests that an inflexible provider schedule might pose an unnecessary Finally, caregivers were asked about the messages barrier for caregivers already committed to vaccinating they had heard about childhood vaccination. The most their child. commonly reported message was the importance of receiving all recommended vaccines, which 50 percent Regarding vaccinating children when they are sick with of respondents across the BARMM provinces reported fever, rash, diarrhea or mild cough, nearly nine out of hearing. It is interesting to note, however, that only 20 10 respondents in the BARMM provinces reported they percent of respondents in Basilan reported hearing this would not take their child to be vaccinated at this time. message. Just eight percent of respondents within the 113 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y FIGURE 5.9. MESSAGES ABOUT VACCINATION, BARMM, 2019 About campaigns (%) 11 Importance of routine vaccination (%) 32.3 Where to get routine vaccination (%) 5.2 Age for routine vacination (%) 6.4 Return for the next doses of routine vaccination (%) 8.2 About new vaccines (%) 1.4 Importance of receiving all recommended vaccines to complete child’s vaccinations (%) 50.3 For good health of children/to protect child against diseases/illnesses (%) 13.3 Adverse effects of vaccines (%) 4.7 Child will not be given any vaccination when sick (%) 1.9 Not to be alarmed if child has fever right after vaccination (%) 2.5 No vaccination, family against it, don’t have faith in immunization (%) 1.4 Do not know, have not heard anything about vaccination (%) 8.3 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi 5 BARMM Provinces 114 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M five BARMM provinces reported hearing the message Second, among children with a verified vaccine history, about returning to the provider for subsequent doses it was commonplace for them to receive just the vaccine of routine vaccines. Finally, while eight percent of they intended to receive during a visit to their health respondents overall reported that they did not recall provider, rather than all vaccines that they were eligible hearing any messages about vaccination, 14 percent of for at that time but had not yet received. These are those in Basilan and Sulu provinces reported as such. considered missed opportunities to improve a child’s vaccine coverage. The study did not probe the reasons for Vaccine coverage of children age 0-11 months. A review these missed opportunities, but it seems likely that it is of the data for children aged 0–11 months reveals similar a provider issue or supply issue rather than a consumer findings to those for the next cohort, aged 12–23 months. issue, since these are instances where the initiative had When reviewing the findings in Annex G, it is important already been taken to bring a child to a health provider to keep in mind that those at the younger end of this for vaccine administration. age spectrum were only eligible for a few vaccine doses, while those aged 9–11 months were eligible for all The study found caregiver perception of vaccine coverage first-year-of-life doses. One piece of good news is that to be unreliable. For example, nearly 30 percent of coverage of the Hepatitis B birth dose (HepB0) is higher respondents within the BARMM provinces believed their among children aged 0–11 months than among those child to be fully vaccinated when in fact the child was 12–23 months. As all the evidence for HepB0 comes from not. Caregivers gave a variety of explanations for why HBRs, this appears to document an improvement their child was not fully vaccinated, the most frequently- in coverage. reported being: immunization times were inconvenient, mother was too busy, or an unwell child was not brought Summary and Recommendations for Increasing Vaccine for vaccination on account of the symptoms. However, Coverage. Several important pieces of information were over 20 percent of respondents in the five BARMM gathered from the BARMM household survey that have provinces reported at least one instance when they implications for the BARMM MOH as it considers the brought their child to a provider to be vaccinated only organization of the immunization program. First, overall to be turned away without receiving the needed dose. vaccine coverage rates obscure provincial variation The two most common reasons for this occurrence, as in coverage, suggesting a clear need for targeted reported by respondents, were that the provider did not interventions in those provinces and communities with have the needed vaccine (vaccine stockout) or the child particularly low coverage rates overall and for specific was sick. antigens. Furthermore, many children with a verified vaccine history (that is, who had a vaccination card Over 50 percent of respondents from the BARMM that was reviewed by the research team during data provinces reported hearing messages about the collection) experienced intervals between vaccine doses importance of receiving all recommended vaccines. that were either too short or too long, leaving them However, fewer than 10 percent reported hearing the under-protected against the diseases targeted by the message that they had to return to their health provider vaccine antigens. Nearly 19 percent of children across to receive subsequent doses of routine vaccines. the five BARMM provinces received a vaccine dose too soon after a prior dose, rendering this subsequent dose These findings suggest many opportunities for invalid, while over 50 percent of children received a improvement in the delivery of vaccinations to BARMM vaccine dose more than two months after a prior dose, children, which MOH is best positioned to spearhead. leaving them with a period of time when they were Messaging about the importance of vaccinations must under-protected. be clearer and delivered more robustly to make a more profound impression on the caregivers’ thoughts 115 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y and behavior. Caregivers must be reminded to return perhaps through varying the schedule or creating for subsequent vaccine doses, and when to do so; immunization “outposts” in more remote barangays; providers could follow up via phone or text to remind any schedule changes would need to be communicated them and perhaps offer incentives for caregivers who effectively. Providers could also be educated about return in a timely manner. In this connection, caregivers the importance of providing all vaccines that a child must be given vaccination cards at every child’s birth is eligible for during a visit, in order to reduce missed and reminded to bring them each time a vaccine is opportunities; they might also be reminded that children delivered (and replaced if they are lost or destroyed), with mild illnesses can be safely vaccinated. Of course, as they are an invaluable tool for tracking an individual educating caregivers and training providers is just one child’s vaccination coverage (in addition to providing an element of a comprehensive approach; the issue of important population measure). Immunization times and vaccine supply is a major factor which will be locations should be made more accessible to caregivers, discussed below. SUMMARY OF RECOMMENDATIONS FOR INCREASING VACCINE COVERAGE • In the beginning, prioritize interventions to provinces and communities with particularly low immunization coverage. • Work to ensure that caregivers bring children for second and third doses in a vaccine series, through demand creation programs like text message reminders and incentive programs. Prioritize getting vaccine cards to all parents so they can track their child’s vaccine requirements and progress. Educate health care providers to reduce missed opportunities to vaccinate. Open-vial wastage reduction should be balanced against achieving full immunization. • Work with National Department of Health to ensure BARMM Rural Health Units (RHUs) receive an adequate and timely supply of antigens to fully vaccinate all children in the coverage area. • Train RHU providers to check a child’s vaccine eligibility during routine visits, and to administer required vaccines as appropriate (and available). Monitor provider performance and consider an incentive scheme to improve this. • Utilize results of 2019 Household Survey to educate providers as well as LGU officials and health boards about the barriers to access reported by parents and caregivers. Also utilize results to plan and implement public education campaigns about the importance of vaccines. • Organize trainings for providers about contraindications to administering vaccines (and, conversely, when children can be safely vaccinated despite mild illness). 116 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M NUTRITION, BREASTFEEDING AND wasted and stunted, a condition that is referred to as PERCEPTIONS ON STUNTING WaSt. A recent review of WaSt (Myatt et al. 2018) found that all children who are both wasted and stunted are also underweight, as seen in the children surveyed in Nutritional Status of Children Under 5 Years of Age. BARMM. In that review, children with WaSt had more Collecting data on average height and weight of children severe stunting as well as more severe wasting than aged 0–5 years old allowed the study to assess the either condition alone. The condition was more likely prevalence of underweight, stunting and wasting. to be seen in younger children and in males, and was Anthropometric data was collected for nearly 5,000 associated with a high mortality similar to that of severe children aged 0–5 years old within the five BARMM wasting (known as severe acute malnutrition, SAM). In provinces and an additional 1,300 children from the BARMM, the co-existence of these deficits is indeed BARMM expansion areas using UNICEF-approved height seen more among males, in particular those in their boards and weighing scales. second year of life (Table 5.23). This has implications for The nutritional status of Philippine children overall current intervention paradigms that distinguish between was recently assessed using the Expanded National treatment (for wasting) and prevention (for stunting), and Nutrition Survey (eNNS). Compared to the Philippine between moderate and severe conditions. For all intents 2019 eNNS average, the prevalence of underweight, and purposes, WaSt encompasses the priority group that stunting 38 and wasting 39 are higher for all BARMM requires urgent intervention. provinces and expansion areas, except for the prevalence The 2020 Global Nutrition Report highlights the of underweight in Lanao del Sur and stunting in Cotabato coexistence of multiple nutrition problems as a way of City, which are both lower than the Philippine average identifying priorities for intervention. Fragile and conflict- (Table 5.23). The island provinces of Basilan, Sulu and affected states were found to have a WaSt prevalence of Tawi-Tawi are of particular concern as their rates are 3.5 percent compared to 2.2 percent for more stable ones; notably higher than the mainland provinces for all BARMM’s WaSt prevalence is 3.2 percent and closer to three metrics. the profile of unstable states. From this perspective, the Global Nutrition Goals for 2025 have been targeted for provinces with the highest WaSt prevalence (more than wasting (<5 percent) and stunting (40 percent). Based three percent) are the island provinces and the North on survey results, none of the BARMM provinces nor the Cotabato BARMM barangays (Table 5.22). Sulu stands out expansion areas are meeting the wasting target, and both with an alarmingly high 5.3 percent prevalence of WaSt. It the island provinces and the North Cotabato BARMM must be recalled that these are the same provinces with barangays have failed to meet the stunting target.. the highest stunting rates. Coexisting Wasting and Stunting among BARMM The study also considered the prevalence of moderate Children. Evidence is now emerging that children and severe stunting and wasting in the BARMM; survey with more than one anthropometric deficit may have results and a discussion of these undernutrition a compounded risk for morbidity and mortality. This conditions are presented in Annex I. appears to be particularly true for those who are both 38 Stunting, while often referred to as a form of chronic undernutrition, and often thought to be due to long-standing exposure to insufficient food intakes, has more recently been thought of as a syndrome “…in which multiple pathological changes marked by linear growth retardation in early life are associated with increased morbidity and mortality, reduced physical, neurodevelopmental and economic capacity and an elevated risk of metabolic disease into adult- hood” (Prendergast and Humphrey, 2014). 39 Wasting, also referred to as acute malnutrition, is the result of an acute insult, either from a severe reduction in food intake (as may occur during famine or a disaster) or an emaciating disease condition or both. 117 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y TABLE 5.23. PREVALENCE OF UNDERWEIGHT, STUNTING AND WASTING OF CHILDREN AGES 0-59M BY PROVINCE/CITY, BARMM, 2019 Nutritional Status (%)40 Sex/ Age Group/ Province n Stunted Wasted Stunted and wasted <-2SD <-2SD 5 BARMM Provinces 4,981 39.1 10 3.2 Lanao del Sur 1,459 37.8 6.6 2.1 Maguindanao 1,490 36.4 8.3 2.8 Basilan 454 43.2 12.3 3.1 Sulu 1,045 41.8 14.2 5.3 Tawi-Tawi 533 41.3 13.5 3.6 BARMM Expansion Areas Cotabato City 455 24.4 9.9 2.2 North Cotabato 840 40.1 8.2 3.2 Age 4,981 10 3.2 0-5 m 876 11.5 17.6 1.6 6-12 m 914 26.8 11.4 2.2 13-24 m (1-2 y) 1,477 48.1 7.7 4.1 25-36 m (2-3 y) 558 48.2 7 3.2 37-48 m (3-4 y) 642 52.3 8.1 3.6 49-59 m (4-5 y) 514 55.3 6.4 4.9 Gender 4,981 Stunted Wasted Stunted and wasted Male 2,489 40.9 11 3.9 Female 2,492 37.2 8.9 2.5 Residence 4,981 Rural 4,373 39.3 9.6 3 Urban 608 37.2 12.8 4.8 Wealth Quintile 4,981 Lowest 1,152 47.7 11.3 4.2 Second 1,036 42.4 10.8 3.8 Middle 1,000 38.4 10 3.2 Fourth 1009 37.5 9.3 2.5 Highest 784 24.9 7.7 2.0 ARMM (2015, NNS) 45.2 8.2 Philippines (2015 NNS) 33.4 7.1 Philippines (2019 eNNS) 28.8 5.8 40 Child Nutritional Status classifications are based on the following: Underweight: weight for age < –2 standard deviations (SD) of the WHO Child Growth Standards median Stunting: height for age < –2 SD of the WHO Child Growth Standards median Wasting: weight for height < –2 SD of the WHO Child Growth Standards median Overweight: weight for height > +2 SD of the WHO Child Growth Standards median Values between -2 and -3 SD (or conversely +2 and +3 SD) are classified as moderate, while those <-3 SD (or +3 SD) are classified as severe. 118 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M KEY NUTRITION FINDINGS FROM THE 2019 BARMM HOUSEHOLD SURVEY • Throughout the region, nearly forty percent of children 0-5 years old were found to be stunted, and 10 percent wasted. These rates are considerably higher than for the Philippines overall: in 2019, the national stunting rate was 29 percent and the wasting rate 6 percent. Provincial variation in these nutrition metrices was observed, especially with regards to the prevalence of wasting: while just 7 percent of children in Lanao del Sur were found to be wasted, over 14 percent of those in Sulu province fell into this category. • The regional average for coexisting wasting and stunting (known as WaSt) was 3.2 percent, a high rate that is typically observed in fragile and conflict-affected areas. Sulu province had a markedly higher WaSt rate of 5.3 percent. • The prevalence of stunting was found to increase with age, while that of wasting decreased from year to year. Boys experienced slightly higher rates of wasting, stunting and WaSt than girls. • Only three-fourths of mothers reported initiating breastfeeding within one hour of birth, while 25 percent did not do so. This practice is strongly recommended for the health benefits it imparts on both the mother and baby. • Fewer than one in five mothers maintained exclusive breastfeeding for 6 months, about half the already low Philippines average of just 35 percent. In addition, a substantial proportion of infants were either exclusively breastfed for more than 6 months or inappropriately given food as early as 4 months of age. • Mothers tended to disagree that psycho-cultural or religious influences, genetics, nurturance factors (including exclusive breastfeeding, sufficient sleep and antenatal care), parental care, and access to water and toilets can affect child growth and stunting. These misperceptions, especially with regards to nurturance factors, suggest ample opportunities for nutrition education. Nutritional Status of Infants and Young Children (0-24 rates increase with age, and disturbingly so after the months). The enactment of the First 1,000 Days law first year of life. By Year 2, about half of BARMM children (November 2018) focuses on a “window of opportunity” are stunted compared to less than one-third for the for optimal intervention. A sub-group analysis of the Philippines as a whole. prevalence of poor nutritional status of BARMM infants and young children during this period shows that rates Even more disturbing is the occurrence of overlapping are already very high compared to the Philippine national undernutrition problems, which is again more of a averages, especially for males. problem among males and urban residents; furthermore, the WaSt rates increase with age, such that by the second The highest wasting rates are seen during the first five year of life they are roughly twice those for the first year months of life, indicating poor feeding practices not just of life. As noted above, the co-existence of wasting and for the infants, but perhaps as well for the pregnant and stunting (WaSt) is a marker for severe undernutrition and lactating mothers. This is notable not just for BARMM, places children at higher risk for severe illness but for the country as whole. Underweight and stunting and mortality. 119 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y PREVALENCE OF UNDERWEIGHT, STUNTING, WASTING AND CO-EXISTING NUTRITIONAL PROBLEMS OF CHILDREN AGES 0-24M BY AGE GROUP AND GENDER, BARMM, 2019 Nutritional Status (%) Sex/ Age Group/ n Underweight Stunted Wasted Overweight-for- Underweight Underweight Stunted, Province height and stunted and wasted wasted and underweight** <-2SD <-2SD <-2SD >+2SD All 0-5 m 876 15.5 11.5 17.6 3.3 4.7 6.7 1.6 6-12 m 914 17.6 26.8 11.4 3.8 7.9 5.7 2.2 13-24 m (1-2 y) 1,477 23.6 48.1 7.7 3.2 16.7 2.2 4.1 Male 0-5 m 435 18.2 13.1 20.5 3.4 5.7 7.6 2.1 6-12 m 472 18.6 31.4 11.9 4.0 9.1 5.1 2.8 13-24 m (1-2 y) 723 24.9 51.0 9.0 4.0 16.9 1.9 5.4 Female 0-5 m 441 12.9 10.0 14.7 3.2 3.6 5.9 1.1 6-12 m 442 16.5 21.9 10.9 3.6 6.6 6.3 1.6 13-24 m (1-2 y) 754 22.3 45.4 6.5 2.5 16.4 2.4 2.8 Philippines* 0-5 m 7.3 10.9 7.7 4.1 na na na 6-11 m 11.1 14.4 7.2 1.6 na na na 12-24 m 18.6 30.9 6.5 2.3 na na na *2019 eNNS, note slightly different age grouping **all stunted and wasted children are also underweight Breastfeeding Practices. UNICEF recommends that well as for about 25 percent of mothers from the five breastfeeding be initiated within the first hour of a BARMM provinces on average. This is of concern for child’s life, and that children be exclusively breastfed two reasons: 1) from a maternal protection perspective: for the first six months of life. Almost all mothers the infant’s suckling stimulates the release of oxytocin, initiated breastfeeding at birth (94 percent for the five a hormone from the mother’s pituitary gland that BARMM provinces and 98–99 percent in the expansion stimulates the post-partum uterus to contract and helps areas), usually within the first hour after delivery (74 reduce maternal bleeding, so a delay in suckling means percent) (Table 5.25). These figures are comparable to the a delay in this beneficial action; 2) from the infant’s Philippine average of 74 percent initiation within the first perspective: the longer the interval that the infant is not hour after birth (DOST-FNRI 2019). put to the breast, the more opportunity there is for other fluids to be given, which may interfere with successful This lifesaving practice of immediate initiation of breastfeeding. Given the low accessibility of care in the breastfeeding was, however, delayed among 38.5 percent region, timely breastfeeding initiation could contribute to of North Cotabato mothers and 30–31 percent of mothers reduced morbidity, if not mortality, for both mothers in Cotabato City, Lanao del Sur and Maguindanao, as and infants. 120 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 5.25. BREASTFEEDING INITIATION AND EXCLUSIVE BREASTFEEDING PRACTICES, BARMM, 2019 Breastfeeding Initiation Province/ City, Place of Residence/ Proportion of Timing of breastfeeding initiation Proportion of Wealth Quintiles children who children given were initiated Immediately or More than 1 hr or More than 3hrs other liquids breastfeeding within 1 hr after up to 3 hrs after after delivery at birth delivery* delivery Provinces n % % % % % Lanao del Sur 1,463 90.4 69.1 12.9 17.9 5.5 Maguindanao 1,491 95.8 69.5 15.9 14.6 13.9 Basilan 457 94.7 72.7 10.6 16.7 39.2 Sulu 1,056 97.0 81.5 8.8 9.7 7.8 Tawi-Tawi 539 93.3 86.9 4.8 8.3 10.1 5 BARMM Provinces 5,006 94.1 74.2 11.9 14.0 11.5 Cotabato City 457 98.7 68.8 21.1 10.1 1.3 N Cotabato (BARMM areas) 843 98.9 61.5 19.2 19.3 0.7 Residential Type Rural 4394 93.7 73.6 12.0 14.4 11.7 Urban 612 96.7 77.9 10.9 11.1 9.8 Wealth Quintile Lowest 1157 95.1 75.1 11.3 13.6 10.8 Second 1041 94.3 73.6 12.1 14.3 10.3 Middle 1007 94.6 72.4 12.1 15.6 8.4 Fourth 1013 94.0 74.4 12.7 12.9 14.0 Highest 788 91.9 75.8 11.0 13.2 15.1 *this is the recommended practice However, the survey also found that just 17 percent of substantially higher undernutrition rates than breastfed mothers or caregivers reported exclusive breastfeeding infants. Survey findings and a discussion of breastfeeding up to six months, far lower than the already low national practices are presented in Annex I. average of 35 percent. Equally concerning is the practice of extending exclusive breastfeeding to seven or eight Mothers’/Caregivers’ Perceptions/Knowledge regarding months and even beyond, past the time when infant Child Growth and Stunting. In order to have a better growth requires the intake of safe, adequate and understanding of the factors that may be contributing to nutritious complementary foods. Relatedly, a substantial poor infant and young child feeding practices, the survey number of respondents reported introducing other included a component that investigates the perceptions fluids and food much too early, with up to a third of of mothers and caregivers on child growth and stunting. infants being given other fluids as early as four months, This component looks into the factors that affect a child’s and about 40 percent inappropriately given foods at height, conditions that would lead to stunting as well as this age. As a consequence, non-breastfed infants had contribute to the vulnerability of a growing child. 121 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y Among the domains investigated, mothers tended to information systems, financing, and access to medicines agree that poverty factors, particularly carrying heavy and other commodity needs. From the perspective of loads, do affect a child’s height, but that psycho- efficiency and expediency, it makes sense to propose cultural or religious influences, genetics, nurturance, an integrated approach for capacity building, not just parental care and access to water and toilets generally within the health sector, but across the multi-sectoral, do not. Mothers also agreed that a stunted child was all-of-government, and all-of-society framework for not likely to become a professional basketball player, nutrition espoused by the National Nutrition Council but were uncertain how stunting might relate to other (NNC). Within this framework and of particular relevance consequences, including academic achievement (getting to an integrated approach to capacity building are good grades, completing secondary school), getting a job, the following development needs that are ordinarily getting married, or winning the lottery. They were divided perceived to be outside health and nutrition, but are on whether a stunted child would be able to see well in necessary for nutrition outcomes to be achieved: the dark, or get sick as an adult. • Addressing fundamental gaps in basic education These misperceptions regarding the causes and The ways that nutrition-related behaviors could be consequences of stunting, particularly the low salience of changed are often channeled through education the nurturance factors—exclusive breastfeeding, quality and counseling interventions. However, for the and quantity of foods consumed, sufficient sleep and mind to process information received through antenatal (prenatal) care—reveal that there is ample these interventions it must already marshal key scope for nutrition education. sets of skills in reading, numeracy and reasoning acquired through basic education. It is thus perfectly There were differences in perception among mothers reasonable that school curricula have also been depending on their home province: mothers from Lanao targeted for the inclusion of nutrition concepts and del Sur differed from the rest in terms of responses interventions. However, although the Department to the psycho-cultural/religious and genetics factors. of Education (DepEd) is receptive to proposals to Mothers from Basilan, Sulu and Tawi-Tawi were divided accommodate nutrition-related material, it takes about the consensus question on whether a woman years for curricular change to reach target recipients. would have a difficult delivery if she ate a lot during A more expedient process that BARMM could adopt, pregnancy. These differences were notable in terms of through its Ministry of Education, is to work with home province, but not urban/rural residence, nor wealth local school districts, adapting existing templates, quintile, indicating that the variability could be related to including health and nutrition examples, and making ethnic origins. them more pragmatic and specific to local contexts. Recommendations. This survey provides a renewed • Narrowing equity gaps in information access starting point for nutrition in BARMM, albeit while Nowhere is the digital gap more evident than in highlighting the substantial gaps in access to care BARMM. The COVID-19 pandemic has spurred DepEd and service provision that need to be addressed. In to support the use of online learning throughout considering the ways forward, three pathways are the nation, but only 20 percent of the region has proposed and discussed below. internet access. Even access to traditional tri- media is lowest in ARMM (newspaper: five percent; 1. An integrated approach to Capacity Building television: 40 percent; radio: 17 percent). Given the geographic dispersion of BARMM, any efforts Multi-sectoral, Integrated Framework. The capacity- to widely communicate the need for changes in building needs of BARMM are huge and urgent. They behavior will have to overcome the prevailing lack encompass all the building blocks of the health of access to information. The information vacuum system on which nutrition is anchored: leadership allows traditional beliefs and perceptions to become and governance, service delivery, human resources, 122 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M further entrenched. The periodic displacement of Management of Acute Malnutrition in Children under communities due to conflicts and other disasters Five and National Guidelines for the Management further complicates information access issues. of SAM, as well as more recent National Guidelines BARMM could benefit from portable transmission for the Management of MAM (2016). Training on the technology which could be used by multiple users implementation of these guidelines has already been for a diversity of purposes. conducted at regional and provincial levels under the ARMM government. The current challenges are • Meeting food production and system requirements those of implementation: ensuring the supply chain of for sustainable access to adequate, nutrient- commodities, linking the different referral levels, and in dense, safe foods the overall management, supervision and monitoring of The consumption of a nutritious diet starts with the program. the food supply. Although BARMM is predominantly agricultural, factors such as seasonality, biotic and Among BARMM’s biggest challenges, as for most parts of abiotic plant stresses, and climate change-induced the country outside of the metropolitan hubs, is to keep weather disturbances make it difficult to meet the sufficient personnel in all relevant locations, and ensure population’s nutrient needs on a sustained basis. they are adequately trained, updated and supervised. Transportation and standard food storage capacities Staff turnover is high because of the volatile peace and are limited. Food safety systems barely function. order situation, so the need for recruitment and training The entire food system needs to be adapted and is almost constant. integrated in such a way that the food that BARMM farm produce benefits vulnerable people in BARMM. Survey results from this study could contribute to the content of training materials and in the selection of A more extensive discussion of this broader set of context-effective approaches. For example, information development needs could be made through the Inter- on the high rates of the co-existence of wasting, stunting Agency Task Force (IATF) on Zero Hunger and Food and underweight particularly in Basilan, Sulu and Tawi- Security. The IATF could bring together the multiple Tawi, could be applied in identifying priority or focus entities that need to work together; it has both the areas for SAM surveillance. mandate and the political capital to do so. 2. A Women First approach Policy Directions, Program Templates. Capacity building in BARMM already has a springboard, in that the National A second priority would be to focus on Women First Nutrition Council has established the policy frameworks as both an entry point and a focus for nutrition and program templates for the key nutrition programs interventions. From a socio-cultural perspective, a at the national level. What is now needed is regional Women First approach makes sense because women are adaptation. A Regional Plan of Action for Nutrition the one constant in a BARMM household. The unstable (RPAN) has been developed for BARMM and is ready for security situation means that the male population is presentation to the BTA. The implementation of these often in a state of flux: looking for work, or escaping from policies and plans could be guided in terms of the or engaging in conflict-related activities. Women bear the priorities for action discussed below. responsibility for keeping the household together and functioning, regardless of the surrounding situation. Any Priorities for Action. In terms of priorities, because benefit from improving the lives of women—helping to of their high risk for child mortality, severe acute align their beliefs and perceptions with their children’s malnutrition (SAM) and moderate acute malnutrition well-being—will likely benefit the entire household. (MAM) require the most urgent attention, and should be treated as a humanitarian crisis. The Philippine From a temporal perspective, a Women First approach government has the policy guidance in place with that engages women as early as possible will have the DOH Administrative Order (AO 2015-055) on the long-term returns. This is particularly important in the 123 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y BARMM context as women (more often girls, in fact) tend This approach also makes sense in terms of addressing to marry early and have children early. Early intervention the misconceptions regarding the causes and in improving the nutritional status of adolescent girls consequences of stunting that were elicited in the survey. would potentially have collateral benefits for her and her If mothers perceive that the causes of stunting are children in the years ahead. beyond their control—poverty, religion, genetics—they may not feel empowered to do anything to prevent it. But A Women First approach makes sense in terms of if they are made aware of the effects of the nurturance improving breastfeeding and child feeding practices. and parental care factors—exclusive breastfeeding, Studies show that providing counseling from pregnancy appropriate timing as well as adequate quantities and and other forms of home and community support enable qualities of complementary feeding, enough sleep for the mother to breastfeed successfully. It is important both mother and child—they might be motivated to for first-time mothers to succeed at breastfeeding as attempt actions that are clearly not beyond their grasp. this increases the likelihood that they will breastfeed Muslim religious concepts that highlight the values of subsequent children, hence the importance of reaching breastfeeding could be incorporated as part of nutrition out to adolescent girls even if they are not yet married. counseling and education efforts. SUMMARY OF RECOMMENDATIONS FOR IMPROVING NUTRITION METRICS • The BTA should prioritize adopting the BARMM Regional Plan of Action for Nutrition (RPAN), which has already been developed based on national guidance and direction. • In conjunction with this regional effort, MOH should build on previous ARMM efforts to implement national-level guidelines to address undernutrition by focusing specific attention on ensuring the supply chain of commodities, linking referral systems, and developing systems to manage, monitor and oversee activities. These efforts will benefit from interagency collaboration involving multiple sectors, including education, information systems, and food production. • MOH should use the data collected through the 2019 Household Survey to target interventions and surveillance to particularly high-risk areas, especially those with the highest rates of co- existing wasting and stunting. • Nutrition interventions should be targeted to women and adolescent girls as the primary caregivers in BARMM families and due to their role in breastfeeding and caring for infants. Efforts to empower women to adopt pro-nurturance practices would be well worth the investment for current and future generations. 124 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M 3. Feedback channels for Monitoring & Evaluation (M & E) reached most households in the BARMM region. As a matter of regional and national policy, as well as urgent As this survey has itself exemplified, data is needed local action, ways must be found to effectively inform to help define the problem and subsequently assess residents about their benefits and ensure they use them. progress and the impact of interventions. Feedback channels for M&E are crucial, particularly in a region The most vulnerable populations suffer most when of such volatility as BARMM. It is useful to learn from economic conditions deteriorate, and this was observed previous local experience, the better to increase the among BARMM children. The prevalence of underweight, most viable and effective options, while avoiding the stunting and wasting were higher in BARMM than in most predictable obstacles. With the availability of better the Philippines overall, with one quarter of all children communications technology, more innovative feedback aged 0–5 years found to be underweight for their age, mechanisms could be developed, with more timely 10 percent wasted, and nearly two-fifths stunted. Of troubleshooting. The BARMM environment is extremely particular concern is the coexistence of these conditions, challenging for M&E, but with the help of local partners, when children are both wasted and stunted, a condition it can be done. that affected over three percent of BARMM children. The long-term effects of low weight and stunting are severe, In implementing any of these pathways, it will be with an increased mortality risk for both conditions. important to consider the ethnic diversity of BARMM, the The effects of stunting on mental development likelihood of continued instability, and the short lifespan and intellectual capacity inevitably affect economic of the current transitional governance structure, the BTA. productivity, not merely at the individual, personal level, The results of the survey highlight the need for urgent but all the way up to the national level (WHO 2010a). and extensive action on the nutrition situation of the children in BARMM. The problem there is so severe and Exclusive breastfeeding from birth to six months of widespread that the Philippines as a whole is unlikely age is one way that mothers can provide their babies to meet its development goals without any substantial with a nutritional advantage and increased immunity. improvement in BARMM. While nine out of 10 mothers surveyed reported breastfeeding their children at birth, just 17 percent maintained the practice throughout the first six months CONCLUSIONS of their child’s life. Equally troubling are the rates of exclusive breastfeeding beyond six months as well as The economic situation for many families in the the introduction of food and other liquids before six five BARMM provinces is extremely dire, with large months, sometimes as early as four months. There is households subsisting on very little income. Despite this, an opportunity for education of mothers about proper the majority of households do seek care for sick family breastfeeding and infant feeding practices, which should members. They also report seeking health services when be developed with provincial variation and the ethnic needed, such as immunization services and antenatal diversity of mothers in mind. care, though more often for children than for adults. Most of this care is accessed at public facilities like an With respect to immunization, the recent data on basic RHU, BHS or public hospital, which are often chosen coverage (and, conversely, on its total absence) are because the cost of care is low or free, and the location somewhat more encouraging than in the 2017 NDHS, is close to home. Forty-seven percent of respondents but not hugely so. Overall, just 34 percent of children overall reported having PhilHealth coverage, though aged 12–23 months have basic vaccine coverage, and for their last illness, just six percent reported using it this varies by province, from a low of 21 percent to a to pay for medical services, instead paying on average high of 48 percent. Nearly one-quarter of children are nearly PhP 1,000 out of pocket. Despite recent efforts to not covered at all. Caregivers cite a number of reasons expand PhilHealth coverage and the scope of services, why the children in their care are not vaccinated, from it does not unfortunately appear that these efforts have a lack of time to a lack of vaccine antigens at the health 125 C H A P T E R F I V E : A C C E S S T O B A S I C H E A LT H S E R V I C E S I N B A R M M – R E S U LT S A N D A N A LY S I S O F A H O U S E H O L D S U R V E Y facility, to a lack of knowledge about vaccines in general, diseases. Nutrition indices were also better for female and vaccine delivery requirements specifically. It is children than male children. Immunization coverage easy to look to caregivers as the source of these low rates are similar for female and male children. Female- vaccination rates, but vaccination is a matter of regional headed household were enumerated, but no evidence and national—and, as the world is now discovering— of any gender specific barriers to service delivery was global policy. Childhood vaccination protects everyone found at that level. While encouraging, caution should be in the community because it curbs the re-emergence exercised in drawing too strong a conclusion from this and spread of communicable diseases. Vaccination also limited and non-representative sample of services and protects families, who face the potential for extreme households. Further research into gender-specific access economic hardship if a child acquires a vaccine- to and satisfaction with health services—particularly preventable disease, both in the short and possibly long including qualitative research—is recommended. term. Therefore, the onus must be on local, regional, and national policymakers to conceive ways to increase There are many opportunities for the newly organized vaccination rates in the least covered areas, through a BARMM to support its constituents in improving their combination of education and outreach to caregivers and health and in doing so, begin to improve their economic health workers, increased supply and handling of vaccine situation. National government appropriations to antigens to ensure availability, and increased staff (and BARMM are increasing, beginning in 2020, and, as staff training) to deliver vaccines. shown in the Health Financing chapter, there are additional opportunities for the MOH to access other The impact of gender on access to health services was funding streams to further increase its budget. Planning explicitly considered in this survey, and in other sections processes are underway to decide how best to use of the HFSA. Components of the analysis included a this funding to support the most pressing needs of the supply side readiness survey of primary health care community, and how to generate local support to do so. facilities, a survey of households with children of ages This period of transition, of moving away from the history relevant to the basic vaccinations, the households’ of conflict and violence in the region, is the right time for access to health services, and anthropometric measures leaders to begin to envision what BARMM could be and of the children in these households. A vast majority (93 how to bring its people towards that goal. percent) of the primary caregivers of these children were their mothers, less than one percent were the fathers, Annexes while the rest were grandparents and other relatives. Annex F: Details about Sampling of Barangays This sampling, which was designed primarily to look at Annex G: Immunization Findings, Children immunization, necessarily constrained the sample and Age 0–11 Months therefore the sensitivity and generalizability of gender- Annex H: Immunization Findings, Children specific findings. Age 12–23 Months Annex I: Nutrition and Anthropometric Results The study suggests that accessibility and readiness and Discussion of gender-specific services such as for maternal and child health, while challenged in BARMM, are better http://bit.ly/BARMMHFSAAnnexes than services for communicable and noncommunicable 126 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M CHAPTER SIX: SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN BARMM SUMMARY have measles or pentavalent vaccines in stock, and oral polio vaccine (OPV) was available at fewer than • While national surveys provide information on half of the facilities. These gaps are of particular demographic and epidemiological trends in the concern given the alarmingly low vaccination rates area, there is little existing information on the in BARMM. region’s current capacity to provide primary health care services. The results of this survey highlight • Among the specific services considered, capacity the critical importance of equipping the region’s to deliver maternal and child health services public primary health sector to deliver on essential was strong across the region although wide preventive and curative services. variation was observed, depending on the services. Noncommunicable disease services lagged • The number of health facilities has increased in significantly behind due, in large part, to the limited recent years, but not enough to achieve the national availability of relevant medicines and commodities. target of one RHU per 20,000 people. Despite recent For communicable diseases, by contrast, medicines efforts to augment health workforce capacity through and commodities for TB were nearly universally various human resources deployment programs, available, reflecting the priority of the government there are gaps in human resources for health (HRH) and its centralized distribution system. There was no in all five of the provinces. clear geographic trend in performance across the provinces. • Basic equipment is generally available, which reflects the long-lasting nature of such investments as • Investments in supply side readiness are essential if well as the broad applicability of a small number the country, and its BARMM regional government, are of items. There were, however, widespread and to address poor health outcomes in BARMM. systematic gaps in the basic amenities needed to provide services, such as running water, a consistent power supply, and communications equipment. ANALYTIC APPROACH • Gaps in the availability of vaccine antigens reflect Overview challenges in the underlying supply chain. The public health system relies heavily on verticalized programs, In 2017, the World Bank Group initiated an assessment many of which have internal logistic arrangements to of supply side readiness to deliver primary health distribute medicines and diagnostics. While routine care in the BARMM region.41 Data were collected from vaccines were more readily available than non- nearly all RHUs across the five provinces of BARMM. routine vaccines, one-third of the facilities did not The causes of poor health outcomes in BARMM are 41 The full report, entitled, “Preparing for the Transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region of Muslim Mindanao (BARMM),” is available online at: https://openknowledge.worldbank.org/handle/10986/32021?fbclid=IwAR0m7GbXvG-oZfCs_KxqaSni7sLqHYxBO- Jhs-cfmsqSwvl7tdkEzR3drEKk 127 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M complex and multidimensional. However, as emphasized and Readiness Assessment (SARA) survey of the World above, the results of this survey highlight the relatively Health Organization (WHO 2015). The surveys underwent straightforward urgency of effectively equipping the two rounds of field testing in selected municipalities of region’s public primary health sector. Lanao del Norte, an area outside of the survey region that borders Lanao del Sur. As shown in Table 6.1, survey Data Overview teams visited a total of 123 facilities in 118 municipalities across the five provinces. Teams collected data from a total of 123 public facilities in the five provinces of Basilan, Lanao del Sur, The SARA Framework Maguindanao, Sulu, and Tawi-Tawi; 120 of the facilities visited were RHUs. Based on the recommendation of the The survey builds upon the Service Availability and DOH-ARMM, surveyors also visited two City Health Offices Readiness Assessment (SARA), a framework developed (CHOs) in Lamitan City and one BHS in Tawi-Tawi. Survey by the World Health Organization (WHO) to assess teams did not visit facilities in Marawi City as the Marawi the capacity of health facilities to provide care. This siege was ongoing at the time of the survey fieldwork. framework considers the key aspects of health service Annex 1 to the full report includes a complete list of delivery along three dimensions: (a) service availability, the facilities visited. Although Lamitan City falls within (b) service readiness, and (c) service utilization. the geographic boundaries of Basilan, it has a separate Availability focuses on physical access to and distribution administrative structure stemming from its status as a of health facilities. Readiness considers the ability of city. To assist in comparability with similar reports, data facilities to deliver specific types of care. Utilization from the two CHOs visited in Lamitan City are presented considers the uptake of services. In this report, service separately from Basilan whenever possible. readiness was the primary focus. Service readiness assesses whether or not the RHUs have the basic Surveyors collected data on a range of indicators. infrastructure, equipment, diagnostic capacity, medicines, Local enumerators translated the surveys into six local and commodities to provide services in general, and languages (Maranao, Tagalog, Maguindanao, Cebuano, for specified conditions. In addition to general service Tausog, and Sama) and conducted the surveys. Survey readiness, 11 specific services were considered. These teams visited facilities between July and October include five MCH services: family planning (FP), antenatal 2017 and assessed health facility infrastructure and care (ANC), basic obstetric and neonatal care (BONC), equipment, as well as medicines and commodities. immunization services, and child health care; four NCD Facility audits were based on the Service Availability services: diabetes, cardiovascular disease (CVD), chronic TABLE 6.1. DATA COLLECTION BY PROVINCE Province Number of Facilities Assessed Number of Cities/Municipalities Lanao del Sur 39 40 Maguindanao 37 36 Basilan 12 11 Lamitan City 2 1 Sulu 19 19 Tawi-Tawi 14 11 TOTAL 123 118 128 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M respiratory disease (CRD), and cervical cancer screening; national protocols. However, the SARA framework was the as well as two communicable disease services (TB foundational framework for the survey, and alterations and malaria). 42 were limited. The SARA framework is not designed to be tantamount To structure the assessment of service readiness, to an exhaustive list of inputs needed to deliver services. indicators were organized into domains. For general It does however offer a succinct list of items that can service readiness, information was divided into five be realistically captured during survey visits while also domains: basic infrastructure, basic equipment, reflecting the broader system. Operationally, domain- infection prevention, diagnostic capacity, and essential specific SARA indicators were reviewed and compared medicines. For specific health service categories, varying against available data. Because survey instruments were combinations of four domains were presented: staffing adapted to reflect local policies and priorities, not all and training, equipment, diagnostics, and medicines and SARA indicators were included. Some adjustments were commodities. For each domain, both province-specific also made such as adding PhilHealth data and revising and aggregate results were reported (Figure 6.1). the formulation of some indicators to align with FIGURE 6.1. ANALYSIS OVERVIEW Health Services Categories Domain Inputs General Service Facility Density Population Estimates 1 Availability Health Worker Density Number of Facilities Number of Staff Basic Infrastructure Basic Equipment General Service 2 Readiness Infection Prevention Tracer indicators Diagnostic Capacity Essential Medicines Maternal and Child Health Services (MCH) 3 ● FP ● Immunization ● ANC ● Child Health ● BONC Noncommunicable Diseases Staffing and Training (NCDS) Equipment 4 ● DM ● CRD Diagnostics Tracer indicators ● CVD ● CCS Medicines & Commodities Communicable Diseases 5 ● TB ● Malaria Health Service Category score Domain score ● By province ● By province Note: CCS = Cervical Cancer Screening; DM = Diabetes mellitus. 42 The survey was initially designed to include Sexually Transmitted Infection (STI) care under the specific services. However, this information was dropped from the final report as STI diagnosis and management is formally managed by designated social hygiene clinics. Capacity to diagnose syphilis and HIV are included in the reviews of ANC and TB, respectively. 129 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M FINDINGS population and would therefore need to double the number of RHUs to meet the target.43 General Service Availability Provincial averages conceal important variation in To assess service availability, survey teams collected the catchment size—and the associated workload—of information on the distribution of public health individual RHUs (Figure 6.2). As shown in Figure 6.3, facilities and workforce. In some cases, survey data was 68 percent of the facilities failed to meet the target supplemented with publicly available information on catchment population of 20,000; 32 percent of the RHUs population distribution and national workforce estimates. in BARMM had catchment areas of 30,000 or larger, and nearly a quarter of the RHUs served catchment The low facility density across BARMM suggests that populations of more than 60,000 people—a population large portions of the local population have limited or no that should, according to DOH norms, be served by three access to public primary care. The target under DOH- RHUs.44 At the other end of the distribution, 10 facilities ARMM was a density of one RHU per 20,000 people and (eight percent of the sample) served populations of one BHS per barangay. Table 6.2 shows both an overall 10,000 or less (Figure 6.3, Panel A). Panel B shows the shortage and an uneven distribution of the RHUs within ratio of BHS to barangays at the 123 health facilities BARMM. Overall, the region needs to increase the number visited. While the DOH-ARMM had established a standard of RHUs by nearly 50 percent to reach the target density. of one BHS per barangay, just seven RHUs (5.7 percent) While Basilan was the closest to the national target met this standard; 74 percent of RHUs had fewer than for RHU coverage (approximately one RHU per 22,650 one BHS for every two barangays (Figure 6.3, Panel B). population), Sulu had just one facility per 43,400 TABLE 6.2. HEALTH FACILITY DENSITY Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM (2017) Ratio of Health 1:26,806 1:31,728 1:22,650 1:37,391 1:43,407 1:27,908 1:30,743 Facility to Population 43 Butig, Lumbaca Unayan, and Mulondo RHUs did not provide data on catchment populations. 44 Datu Odin Sinsuat, Parang, Sultan Kudarat, Bongao, and Jolo RHUs all report catchment areas of 90,000 or larger. Jolo has the largest reported population: 145,503. 130 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 6.2. THE LOCATION OF RHUS ACROSS BARMM RHU location by municipal population density Source: The RHUs are indicated by black circles on the map. The population density of the municipality is indicated in shades of blue, with the most densely populated areas shaded in navy. Areas with no population data are indicated in white. FIGURE 6.3. RHU AND BHS DENSITY Panel A Panel B 30 1 BHS per barangay 7 Availability of BHS Number of RHUs 20 1 BHS per 1-3 barangay 50 1 BHS per 3-5 barangay 23 10 1 BHS per 5-10 barangay 17 1 BHS per 10+ 0 barangay 17 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 Catchment population No data 9 Pop < 20,000 Pop > 20,000 0 10 20 30 40 50 Average number of Barangays served per BHS Source: BARMM SARA, 2019 Note: Panel A shows the ratio of the RHUs to the population. Bars shaded in blue indicate the number of RHUs with catchment area populations less than 20,000. Those shaded in rose indicate the number of RHUs with catchment area populations greater than 20,000. Individual bars are in increments of 5,000. For example, the first blue bar indicates that six RHUs indicated a catchment population of 0–5,000 people. The first rose-colored bar indicates that 27 RHUs serve catchment populations of 20,000–25,000 people. Panel B shows the ratio of the BHSs to barangays for each RHU. For example, 7 RHUs report 1 BHS per barangay, while 50 RHUs report one BHS for every 2–3 barangays. 131 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M The survey identified significant gaps in the availability of Although 90 percent of the RHUs were accredited to human resources for health (HRH). Staffing requirements provide the primary care benefit (PCB) package, nearly for the RHUs mirror the standards set for facility density half of the RHUs in BARMM failed to meet the staffing across the country: one doctor per 20,000 population, standards established by PhilHealth operational one nurse per 10,000, and one midwife per 5,000. Data on documents. Implementing guidelines for the PCB population and health workforce from national sources package stipulate that clinics should be staffed with suggest that the country suffers from a shortage of HRH— at least one licensed doctor, one licensed nurse, one nationally, there is just one doctor for 35,580 people, licensed midwife, one licensed medical technologist one nurse for 22,067, and one midwife for 5,791. However, able to perform routine laboratory procedures (if the the distribution of personnel is highly uneven across facility houses a laboratory), and one licensed radiology the country. For example, the density of civil servant technician (if the facility offers x-ray services). At least doctors in the Cordillera Administrative Region (CAR) was one member of the RHU staff should be able to conduct more than twice that found in Region XI. Relative to its sputum microscopy. Across BARMM, less than half of the neighbors, ARMM had a very low health workforce density RHUs met these requirements. The gaps were the largest with just one doctor for 49,755, one nurse for 29,087, and in Sulu, where nearly two out of every three RHUs failed one midwife for 7,458 people.45 to meet this standard. By contrast, nearly 70 percent of the facilities in Lanao del Sur met these minimum The distribution of HRH within BARMM was also uneven. standards (Table 6.4). Notably, on the day of the survey, While there were gaps in coverage in all five of the physicians were away from the facility at 40 percent provinces, Sulu had the lowest density of government of the RHUs reporting that doctors are on staff. Among doctors and would need to nearly triple the number those who were out of the office, most (56 percent) of doctors to reach the target coverage rate. Only the were away for between one and five days. About 10 more densely populated Lamitan City achieved the goal percent were away for less than one day, 12 percent were previously set by DOH-ARMM. Among provinces with one traveling for between one and two weeks, and more than doctor for approximately 25,000 people, Lanao del Sur 20 percent were traveling for more than two weeks (Fig. came the closest to meeting the target (Table 6.3). J-1, Annex J). TABLE 6.3. HEALTH WORKFORCE DENSITY Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM (2017) Ratio of Government 1:24,891 1:46,957 1:33,975 1:18,696 1:58,909 1:32,560 1:36,013 Doctors to Populationa Ratio of Nursing 1:4,605 1:6,146 1:2,363 1:4,399 1:6,598 1:4,765 1:4,995 Professional to Population Ratio of Midwives to 1:4,688 1:3,703 1:2,384 1:37,391b 1:5,426 1:3,203 1:4,066 Population Note: a. Includes both generalist and specialist medical doctor; b. Lamitan City has only two midwives for its population of 74,782. 45 Compared to approximately 1 doctor for every 35,580 people, 1 nurse for every 22,000 people, and 1 midwife for every 5,800 people—BARMM SSRA author’s calculations based on data from DOH (2015) and NSO (2012). 132 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 6.4. PROPORTION OF RHUS MEETING PHILHEALTH ACCREDITATION REQUIREMENTS A Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Percentage of the 69.2 40.5 25.0 0.0b 36.8 57.1 48.8 RHUs meeting PCB1 staffing requirements Note: PCB1 = Primary care benefit package -1; a. Accreditation Requirements - RHU with at least 1 doctor, 1 nurse, 1 midwife, and 1 medical technologist; b. Neither of the two Lamitan RHUs had a medical technologist. In the mostly non-devolved context, the DOH-ARMM Every Community in ARMM (MECA) Program deployed 600 owned the public primary health care facilities and midwives across BARMM in geographically isolated and played a particularly significant role in financing health disadvantaged areas (GIDAs). Different administrative personnel; in fact, DOH-ARMM funded nearly 60 percent units of the government emphasize different categories of all government health personnel in the region. In of health staff. The national DOH funded more than half contrast to other parts of the country where the LGUs (57 percent) of all government-funded general doctors in own and operate the RHUs and, accordingly, allocate a BARMM, while the DOH-ARMM was more likely to pay for portion of their IRA to ensure that the requisite health specialist doctors (75 percent), nurses (60 percent), and workforce is in place, very few LGUs in BARMM augmented midwives (84 percent). the human resource in the RHUs. Only Basilan and Lamitan City—which have a different governance General Service Readiness structure whereby the LGUs manage health service delivery—played a meaningful role in financing the General service readiness is a broad category covering RHU personnel. inputs needed to provide basic medical service divided into five domains: basic amenities, basic equipment, In addition to the core staff hired locally, the national standard precautions for infection prevention, diagnostic DOH has instituted several programs to supplement the capacity, and essential medicines (Figure 6.4). Tracer RHU health workforce. Although initially introduced as indicators from each domain were aggregated to create stopgap measures, these programs have been ongoing a domain-specific score for each RHU. These scores were for many years. The Doctors to the Barrios (DTTB) then further aggregated at the province level to provide program started in the early 1990s in response to a greater insights into variations in the distribution of shortage of doctors in remote areas. More recently, the resources across BARMM. Overall, significant gaps in national DOH launched the Nurse Deployment Program general service readiness were apparent across BARMM. (NDP) and the Rural Health Midwives Placement Program For each of the five domains, the mean percentage of (RHMPP). The RHMPP deploys midwives to areas with low tracer indicators available is indicated (Figure 6.4); the utilization of institutional delivery care, immunization, bar aggregates over the five domains to present the and FP services. The DOH-National Nutrition Council mean percentage of the full 54 indicators available and also sponsors barangay nutrition scholars, volunteer the symbols indicate performance for the individual community workers who assist in implementing nutrition domains. Basic equipment was consistently the highest programs in the locality. Under ARMM, a full 30 percent of scoring index, followed by standard precautions and government health staff were deployed by the national amenities; diagnostics and essential medicines lagged DOH; in Tawi-Tawi, this figure was as high as 44 percent. behind these domains. While basic equipment was While HRH programs are concentrated at the national generally available, with an average score of 86.0 percent, level, the DOH-ARMM had also been directly supporting just 31.6 percent of essential medicines were available HRH at the local level. For example, the Midwives in across regions. 133 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M FIGURE 6.4. GENERAL SERVICE READINESS, BY PROVINCE 100 90 80 72.1 70 67.1 66.0 62.4 63.2 60 60.0 57.7 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi ARMM General Service Readiness Basic Amenities Basic Equipment Diagnostic Capacity Essential Medicines Standard Precaution for Infection Prevention The bar indicates the mean percentage of the 54 indicators available at the RHUs within a given province or BARMM-wide. For each province or region, the blue diamonds indicate denote percentage availability of the seven basic amenities, red squares indicate mean percentage availability of the six basic equipment, black checks indicate the mean percentage availability of the nine standard precautions for infection prevention, orange circles indicate the mean percentage availability of the seven diagnostics, and green triangles indicate the mean percentage availability of the 25 essential medicines. The aggregated performance illustrates a need for and visual privacy for patient consultations, access substantial improvement in all provinces of BARMM. to sanitation facilities for patients, communication Overall, the facilities in BARMM had less than two-thirds equipment (telephone or short-wave radio), internet- (63.2 percent) of the indicators assessed. In contrast to enabled computer, and emergency transportation. There the service-specific readiness assessments examined was wide variation in the availability of amenities. While later in this report, interprovincial variation was sanitation facilities were widely available, nearly two out somewhat limited for general service readiness. Of the of three RHUs lacked an internet-enabled computer. The provinces, performance was the highest in Maguindanao, overall score, aggregating the seven indicators across the with an overall average score of 67.1 percent, and the five provinces, was just 68.9 percent (Fig. J-2, Annex J). lowest in Basilan, where facilities maintained an average of 57.7 percent of the items assessed. Table 6.5 highlights important geographic trends. Basilan, in particular, underperformed relative to other provinces, Basic Amenities while Maguindanao and the urban area of Lamitan City performed relatively well. The largest gaps were in access The basic amenities domain assessed the availability to communication and transportation equipment. of nonmedical inputs to care. The domain included seven tracer indicators: power, improved water, auditory 134 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 6.5. AVAILABILITY OF BASIC AMENITIES Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Power 51.3 78.4 33.3 100.0 89.5 92.9 69.1 Improved water 92.3 89.2 91.7 100.0 84.2 92.9 90.2 source; inside or within the grounds of the facility Room with 79.5 67.6 91.7 50.0 68.4 92.9 76.4 auditory and visual privacy for patient consultations Access to adequate 100.0 100.0 100.0 100.0 100.0 100.0 100.0 sanitation facilities for clients Communication 25.6 59.5 16.7 100.0 31.6 92.9 44.7 equipment (telephone or short- wave radio) Facility has access 25.6 59.5 8.3 50.0 26.3 21.4 34.1 to computer with e-mail/Internet access Emergency 59.0 81.1 58.3 100.0 84.2 35.7 67.5 transportation Basic amenities 61.9 76.4 57.1 85.7 69.2 75.5 68.9 Note: Indicators available at 50 percent of RHUs or greater in an area are shaded in green. Indicators available at 49.9 percent or fewer RHUs in an area are shaded in rose. Basic Equipment equipment. For example, almost all (92.9 percent) facilities in Tawi-Tawi had child scales, while only one- The basic equipment domain included six tracer quarter of those in Lanao del Sur did so. Similarly, almost indicators: adult and child scales, a thermometer, a all RHUs in Tawi-Tawi had a suitable light source for the stethoscope, blood pressure (BP) apparatus, and a examination of patients, while nearly one-third of the light source (Fig. J-3, Annex J). The importance of this RHUs in Basilan, Sulu, and Lanao del Sur did not. equipment is reflected by their frequent inclusion in the 11 specific service readiness assessments reviewed in Standard Precautions for Infection Prevention this report. The assessment of standard precautions for infection Adult scales, thermometers, stethoscopes, and BP prevention focuses on the safe handling, management, apparatus were all nearly universally available. However, and disposal of infectious waste. Infection prevention across BARMM, child scales were seen at just over half includes nine tracer indicators: safe final disposal of of the RHUs—this number drops to only 28.2 percent of sharps, safe final disposal of infectious waste, sharps the RHUs in Lanao del Sur and 47.4 percent of those in storage, infectious waste storage, single-use syringes, Sulu. A suitable light for the examination of patients46 disinfectant, soap and running water or alcohol-based was available in 77.2 percent of the RHUs. While overall hand rub, latex gloves, and guidelines on infection performance was relatively high, there was evidence prevention (Fig. J-4, Annex J). of interprovincial variability in the availability of basic 46 The light source could be a flashlight. 135 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M Infection prevention was a relatively high-scoring There is significant variation between provinces; with a domain, with aggregate performance averaging mean performance score of 57.1 percent, Sulu had the approximately 77 percent. Availability of single- highest overall readiness to provide general diagnostic use syringes and safe disposal of sharps were both services. At the lower end of the performance spectrum, nearly universal, and disinfectant availability was also facilities in Basilan and Maguindanao had less than half widespread. However, storage of infectious waste in of the diagnostic indicators on the day of the survey. The a lidded bin with a plastic liner was available at just difference in scores largely reflects the lack of protein over one-quarter of the RHUs in BARMM. Guidelines for and glucose urine dipsticks in the lower standard precautions were also widely lacking. They were performing provinces. available at approximately one-third of the facilities in Lanao del Sur, Maguindanao, and Sulu; no facilities in Essential Medicines Basilan had them in stock on the day of the survey. The essential medicines domain is the broadest The availability of storage for infectious waste varied by of any assessed in this report and includes critical province. While nearly two-thirds of Maguindanao’s RHUs medicines needed to treat a variety of MCH, NCD, and could safely store infectious waste, this was true of just communicable conditions. Specifically, the domain 7.1 percent of the facilities in Tawi-Tawi and fewer than tracks 25 tracer indicators, including calcium channel 20 percent of the RHUs in Basilan, Lanao del Sur, and blockers, amoxicillin syrup and tablet, ampicillin, Sulu. Similarly, 83.3 percent of the RHUs in Basilan were aspirin, beclomethasone, beta blockers, carbamazepine, able to safely dispose of infectious waste, which could ceftriaxone, diazepam, angiotensin-converting-enzyme include incineration, open burning in a protected area, (ACE) inhibitors, fluoxetine, gentamicin, glibenclamide, dump without burning in a protected area, or removal to haloperidol, insulin, magnesium sulfate, metformin, a protected storage area, while the same was true for just omeprazole, oral rehydration solution (ORS), oxytocin, 56.4 percent of the facilities in Lanao del Sur (Table J-1, salbutamol, statins, thiazide, and zinc sulfate. Annex J). The results showed gaps in the availability of essential Diagnostic Capacity medicines at the RHUs. Only amoxicillin, ORS, and oxytocin were available at more than half of the facilities Tracer indicators on diagnostic capacity investigate in each of the five provinces. Beclomethasone, thiazide, the capacity of facilities to conduct eight routine tests ceftriaxone, glibenclamide, and aspirin inhalers were covering a range of priority health conditions. These each available in less than 10 percent of the facilities, include diagnostic capacity for hemoglobin; blood and gentamicin, ampicillin powder, diazepam, salbutamol, glucose; urine dipsticks for protein and glucose; urine and simvastatin were available at less than 20 percent of tests for pregnancy; and diagnosis of malaria, HIV, the facilities. ORS was the most widely available medicine and syphilis. but was still missing at 11 percent of the facilities, while oxytocin was missing at 15 percent of the facilities. The survey found that none of the 123 facilities visited Carbamazepine, fluoxetine, haloperidol, and insulin were provided HIV or syphilis testing, since these were usually not available at any RHU in BARMM. carried out in social hygiene clinics. Urine tests for pregnancy and blood glucose testing were found at 88.6 Supply chain issues reflect poor coordination within percent and 85.4 percent of the facilities, respectively. the health sector. The public health system relies Urine dipsticks for protein and glucose were available heavily on verticalized programs, many of which have in 45.5 percent of the facilities, while malaria diagnostic internal logistic arrangements to distribute medicines tests were available at 61.0 percent of the facilities and diagnostics. Through these, commodities may be (Annex J, Figure J-5). These findings preview relatively distributed to the IPHOs or directly to the RHUs. Key strong performance in MCH programs—particularly in informant interviews at the national DOH, DOH-ARMM, comparison to NCD diagnosis and care. and some RHUs revealed several logistics problems in 136 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M the distribution of the goods from Metro Manila to the Specific Service Readiness Overview RHUs and other facilities nationwide. Supply requests were frequently met up to a year late, jeopardizing Maternal and Child Health the forecasting of required supplies. The distribution arrangements also changed from time to time. There Despite years of policy attention, MCH outcomes in the were conflicting descriptions of certain commodities Philippines continue to lag behind those of regional and being delivered only to the provincial level and others economic peers, and health outcomes in the BARMM delivered directly to the RHUs, over inconsistent periods. region lag even further behind. National policies aimed Buffer stocks were also delivered to the regional office at improving MCH outcomes are well aligned with warehouse, with stocks nearing expiry reportedly international best practices. A 2008 DOH Administrative delivered to the warehouse even if not requested. These Order (AO) aims to eliminate traditional birth attendants events reflected challenges in communications and by authorizing only trained midwives, nurses, and coordination among the different offices of the DOH- doctors to assist women at delivery.47 LGUs nationwide ARMM including the Technical Service Office, the Supplies are expected to ensure that local facilities have the Office, and the Planning Office. The impact of this was resources needed to deliver effective care during evident in the assessment of immunization readiness, childbirth (intrapartum care). PhilHealth reimbursements which showed poor availability of vaccine supplies. One- are applicable for normal delivery at accredited facilities third of the facilities did not have measles or pentavalent through the MCP and for newborn services through the vaccines in stock, and oral polio vaccine (OPV) was complementary Newborn Care Package (NCP).48 The available at fewer than half of the facilities. Vaccines not Reproductive Health Law of 2013 provides universal included on the National Immunization Program (NIP) entitlement to contraception to avoid mistimed, schedule, such as the human papillomavirus (HPV) and unplanned, unwanted, or unsupported pregnancies. rotavirus vaccines, were rarely available, if at all. These Contraceptive use is far less common in BARMM than it gaps are of concern given the alarmingly low vaccination is in other regions of the Philippines (Fig. J-6, Annex J). rates in BARMM. Nationally, the utilization rate of FP commodities stands Performance by PhilHealth Accreditation Status at 54.3 percent, which is about twice the utilization rate (26.3 percent) found in BARMM (PSA and ICF PhilHealth PCB accreditation status did not seem to be International 2018). In 2017, 40.4 percent of all women in a strong indication of the general service readiness of the Philippines used modern contraceptives, compared an RHU in BARMM. As noted earlier, there were relatively to 18.7 percent of women in BARMM. While hormone pills few nonaccredited facilities. Both of the CHOs in were the most commonly used contraceptives in both Lamitan City and all of the RHUs in Lanao del Sur were populations, they were far more popular in the national accredited. General service readiness of PCB-accredited population (57 percent of all contraceptive use) than in facilities appeared to be only slightly higher than that BARMM (43 percent of all contraceptive use). By contrast, of facilities that were not PCB accredited. In Sulu, the injectables were relatively more popular in BARMM, few nonaccredited RHUs had almost the same rating as where they accounted for 32 percent of all contraceptive that of the accredited RHUs. In Basilan, where half of use compared to 15 percent of all contraceptive use the RHUs were PCB-accredited and half not, the average nationwide. Within BARMM, province-level data suggest score of the accredited facilities was five percent above that Maguindanao had the highest reported utilization that of the non-accredited facilities. Moreover, at just rate (50.3 percent), while Basilan had the lowest (24.1 63.9 percent, the average scores for even the accredited percent). Notably, contraceptive use in all five of the facilities showed significant need of improvement. provinces in BARMM remained well below the national DOH target of 65 percent. 47 Administrative Order 2008-0029: Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality. 48 Includes physical examination and screening tests, eye prophylaxis, Vitamin K administration, and Bacillus Calmette–Guérin (BCG), and Hepatitis B (HepB) vaccination, as well as breastfeeding advice for the new mother. 137 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M In contrast to the utilization status as reported in the TABLE 6.6. ANC UTILIZATION RATES (PERCENT OF NDHS, overall readiness to provide FP services was the ELIGIBLE POPULATION) highest of the 12 specific services investigated in this ANC 4- Visit 2013 2014 2015 2016 report. Facilities in BARMM had on average 87.3 percent Basilan 25.7 38.2 37.7 34.3 of the FP tracer indicators, and interprovincial variation was relatively narrow. The most significant gaps related Sulua 35.0 63.0 46.0 42.0 to the staff and guidelines domain. Despite overall high Lanao del Sur 76.9 87.6 88.6 84.7 aggregate scores, gaps remained in ensuring training Maguindanao 61.0 78.0 77.0 70.0 and access to job aids for facility staff. Nearly 30 percent Tawi-Tawi - - - - of the facilities did not have any staff trained to provide Source: DOH-ARMM FP services, one-quarter did not have guidelines related nationwide received ANC from a skilled provider (PSA to the provision of FP services, and two-thirds did not and ICF International 2014). In BARMM, however, this have any job aids on hand. The largest gap in job aids figure was just 52.8 percent in 2013. There has been was found in Lanao del Sur, where less than half (41.0 little measurable progress since then. According to the percent) of the facilities had FP checklists or job aids. most recent figures, 86.5 percent of pregnant women nationwide attended the recommended four visits in The core medicines and commodities included in the 2017; the same was true for less than half—just 47.8 SARA FP service readiness score were widely available, percent—of pregnant women in BARMM (PSA and ICF but there were larger gaps in the availability of other International 2018). Field Health Service Information forms of FP commodities. Of the tracer commodities System (FHSIS) data suggest significant variation in (combined estrogen-progesterone oral contraceptive utilization of ANC among the five provinces of BARMM pill, progestin-only contraceptive pill, injectables and (Table 6.6). The mainland provinces of Maguindanao and condoms), all were available at more than 90 percent Lanao del Sur reported coverage of four or more ANC of facilities and only the progestin-only contraceptive visits (nearly on par with the national average). Data pills were available at fewer than 95 percent of the for the island provinces, however, revealed overall low RHUs. Availability of the four contraceptives investigated coverage and unsteady progress over time. While caution as part of the service readiness score for FP would must be exercised when interpreting routine data, it is demonstrate capacity to provide the basic services. difficult to escape the observation that particularly low However, they comprised a relatively small proportion utilization appear to prevail in those provinces reporting of the contraceptives in general use. The survey found the highest maternal and infant mortality rates: Basilan that estrogen-progesterone combination injectables and Sulu. and female condoms were rarely stocked in BARMM. The long-lasting intra-uterine contraceptive device (IUCD) was Overall, facilities in BARMM had an average of 68.0 available at approximately three-quarters of the facilities percent of the ANC tracer indicators; provincial scores in BARMM. Notably, nearly 20 percent of the RHUs ranged from a low of 58.7 percent in Lanao del Sur to reported IUCDs being out of stock. There was relatively a high of 81.8 percent in Tawi-Tawi (Fig. J-7, Annex J). All little variation in readiness to provide FP services RHUs had equipment to check blood pressure, which across the five provinces. Facilities in the lowest scoring was the sole tracer indicator included in the equipment province—Basilan—had an average of 84.4 percent of domain. There was relatively little variation in the the inputs investigated, while those in Sulu, the highest availability of staff and guidelines (aggregate score of scoring province, had 91.4 percent of the tracer indicators. 62.9), diagnostics (64.6), or medicines and commodities (67.8). Antenatal Care Diagnostic capacity and commodities for ANC were not Traditionally, BARMM has had the lowest ANC utilization consistently available across the region. Survey teams rate in the country. ANC uptake is generally high in the looked for the capacity to perform hemoglobin tests, Philippines. In 2013, 95.4 percent of pregnant women 138 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M and dipsticks to monitor urine protein: the former was reflected the general availability of commodities related found in most—83.7 percent—of the RHUs, but urine to the prevention and treatment of malaria in protein testing capacity was missing in more than half these provinces. the facilities across BARMM. Inputs to prevent and treat malaria among pregnant women were generally available Basic Obstetric and Neonatal Care in areas with ongoing transmission of the parasite but were otherwise not present. In the first quarter of Institutional delivery rates were significantly lower in 2016, just 33 cases of malaria were reported in BARMM; BARMM than elsewhere in the country. Data from the 2017 22 of those cases were in Sulu, nine in Tawi-Tawi, and NDHS indicate that just 28.4 percent of pregnant women the remainder in Maguindanao. The availability of gave birth at a facility, compared to the national average malaria-specific commodities appeared to track with the of 77.7 percent (PSA and ICF International 2018). parasite’s prevalence. About 84 percent of the RHUs in Despite low overall utilization rates, both household Sulu stocked intermittent protective treatment (IPTs) and and routine data indicate that institutional delivery is 74 percent stocked insecticide-treated nets (ITNs). increasing in BARMM. Although the overall facility-based Overall readiness to deliver ANC services was highest delivery rate remained well below the national target in Tawi-Tawi and lowest in Lanao del Sur. Variations of 91 percent, 2017 NDHS data for ARMM indicate that it in performance reflected a combination of factors. had nearly doubled since 2013, when just 12.4 percent of For example, there were substantial interprovincial women gave birth at health facilities. FHSIS data from differences in the availability of trained staff and ARMM suggest significant progress in all five provinces guidelines. Just 38.5 percent of the facilities in Lanao del between 2013 and 2016. Although Sulu had the lowest Sur had guidelines on ANC, and 56.4 percent had staff reported facility-based delivery rate in 2016 at 24.0 trained on ANC. In Basilan and Sulu, less than half of percent, this figure represents a remarkable six-fold the RHUs had at least one staff member trained on ANC. increase over the 2013 rate (Figure 6.5). Meanwhile, higher readiness scores in Tawi-Tawi and Sulu FIGURE 6.5. FACILITY-BASED DELIVERY 2013–2016 100 90 80 70 60 50 Basilan 40 Lanao del Sur Maguindanao 30 ARMM 20 Sulu Tawi-Tawi 10 Lamitan City 0 2013 2014 2015 2016 Source: FHSIS Data from DOH-ARMM. 139 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M The RHUs across BARMM had substantial gaps in probably due to its extreme remoteness, to 84.2 percent their readiness to provide BONC services. Among the in Sulu and 100 percent in Lamitan City. five provinces, Maguindanao had the highest overall readiness score with nearly three-quarters of the tracer Immunization indicators, while facilities in Lanao del Sur had an average of just half of the tracer indicators assessed. Overall, significant gaps in readiness to provide While the score was low in all of the domains, staff and immunization services in BARMM reflected the low guidelines was the lowest scoring domain (Fig. J-8, coverage rate. Facilities had an overall average of just Annex J). more than half (56.6 percent) of the tracer indicators. Among other areas, large gaps related to medicines and Facilities had an average of just under half (47.6 percent) commodities. RHUs stocked an average of 58.9 percent of the staff training and guidelines indicators assessed. of the vaccines included in the assessment. Among the All RHUs in Lamitan City and 70 percent of those in provinces, the largest gaps were found in Lanao del Sur Maguindanao had staff trained in essential childbirth with an average of just 34.0 percent of vaccines care. By contrast, in Lanao del Sur only 30 percent of (Figure 6.6). the RHUs had staff trained in childbirth care, and even fewer had staff trained in newborn resuscitation. Most The availability of immunization service staff and basic equipment was nearly universally available, but guidelines was also low, with the RHUs across BARMM there was wide interprovincial variability in access to receiving an average overall score of 41.5 percent. While emergency transport. Access to emergency transport guidelines were available at nearly three-quarters of the highlighted the extreme variability: while two-thirds of facilities, the survey identified gaps in immunization- the facilities overall had emergency transport, this varied specific training. The most common training covered data from a low of just 35.7 percent of the RHUs in Tawi-Tawi, reporting and monitoring of services, which was available FIGURE 6.6. IMMUNIZATION SERVICE READINESS 100 92.5 90 80 70 62.6 60 55.4 58.2 53.6 56.6 49.9 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi ARMM Immunization Service Readiness Equipment Staffing and Guidelines Medicines and Commodities Source: BARMM SARA, 2019 140 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M at 45.5 percent of the facilities; staff in just 31.7 percent Routine vaccines were more readily available than of the facilities had received ‘reaching every district’ non-routine vaccines, but gaps remained. Of the eight (RED) training. The equipment domain score was 70.6 vaccines assessed, four were included in the national percent overall; the largest gaps related to the capacity routine immunization schedule of the NIP: BCG, DPT- to monitor and log temperature (Fig. J-9, Annex J). In Hib-HepB (pentavalent),49 OPV, and measles. Two-thirds Lanao del Sur, facilities had an average of just half of the of the facilities had measles or pentavalent vaccines indicators considered. While syringes were available at in stock on the day of the survey, and just 40 percent all RHUs, serious issues were noted in following the cold of the facilities had a valid dose of OPV. As for non-NIP chain protocol: fewer than five percent of the facilities vaccines, rotavirus was not available anywhere and HPV had adequate refrigerator temperatures to stock vaccines was available at less than five percent of the facilities. on the day of the survey. FIGURE 6.7. STOCK-OUTS OF NIP VACCINES NIP vaccines Panel A Panel B BCG vaccine and diluent DPT-Hib+HepB vaccine ARMM ARMM Tawi-Tawi Tawi-Tawi Island Province Island Province Sulu Sulu Lamitan City Lamitan City Basilan Basilan Mainland Province Mainland Province Maguindanao Maguindanao Lanao del Sur Lanao del Sur 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100 Available today Non-valid or Currently out of stock Never had it Available today Non-valid or Currently out of stock Never had it Panel C Panel D Oral polio vaccine Measles vaccine ARMM ARMM Tawi-Tawi Tawi-Tawi Island Province Island Province Sulu Sulu Lamitan City Lamitan City Basilan Basilan Mainland Province Mainland Province Maguindanao Maguindanao Lanao del Sur Lanao del Sur 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100 Available today Non-valid or Currently out of stock Never had it Available today Non-valid or Currently out of stock Never had it Source: BARMM SARA, 2019 49 According to the 2017 Demographic and Health Survey (DHS), both DPT-Hib-HepB and DPT-Hib-IPV are commonly referred to as ‘pentavalent’ vaccine. However, the two products can be distinguished, and significant imprecision largely averted, as a consequence of the fact that in public sector facilities, the form of pentavalent given is DPT-Hib-HepB, whereas private sector facilities commonly give pentavalent as DPT-Hib-IPV. When vaccination information was elicited via mother’s recall, a question was posed as a proxy—to assist in identifying the correct pentavalent formulation—namely whether the last dose of pentavalent vaccine was received from a public or private facility. 141 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M For each medicine or commodity, bars shaded in blue Child Health represent the proportion of facilities having supplies in stock on the day of the survey. Bars shaded in green While undernutrition is a serious concern across the represent the proportion of facilities that report having country, it is a particular challenge in BARMM. For all stocked the supply in the past but for where the supply three indicators, BARMM exceeds the national averages. was either out of stock or not valid on the day of the In 2015, 45 percent of children in BARMM were stunted, survey. Bars shaded in rose represent the proportion of compared to 33 percent of children nationally. Further, facilities that report having never stocked the supply. For 25 percent of children in BARMM were underweight example, Panel A shows that, BARMM-wide, 62 percent compared to 22 percent of children overall. These trends of facilities had BCG in stock on the day of the survey, 17 are not appreciably improving over time. percent of facilities were either out of stock or stocked invalid vaccine, and 21 percent of facilities reportedly had The survey identified gaps in the overall readiness to never stocked BCG. provide child health services in BARMM. Among the provinces, facilities in Tawi-Tawi had the lowest average The gaps in immunization capacity were systematic and score, with 59.8 percent of the tracer indicators included widespread in BARMM. The largest supply chain gaps (Figure 6.8). Sulu had the highest overall readiness to were in Lanao del Sur and Basilan; aggregate medicines deliver services, with an average score of 75.9 percent and commodities scores were less than 50 percent of the indicators. Overall, the RHUs in BARMM had for both of these provinces. Gaps in the availability of approximately 70 percent of the indicators equipment were largest in Lanao del Sur, while gaps in under consideration. staff and guidelines were most pronounced in the island provinces of Sulu and Tawi-Tawi (Table 6.7). TABLE 6.7. IMMUNIZATION SERVICE READINESS Percentage Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 49.7 38.9 47.9 87.5 30.9 27.7 41.5 Equipment 58.0 79.1 69.8 93.8 80.3 67.9 70.6 Medicines and 34.0 77.0 41.7 100.0 68.4 76.8 58.9 Commodities Overall Immunization 49.9 62.6 55.4 92.5 58.2 53.6 56.6 Readiness Indicators available at 50 percent of the RHUs in an area, or more, are shaded in green. Indicators available at 49.9 percent of RHUs in an area, or fewer, are shaded in rose. 142 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FIGURE 6.8. CHILD HEALTH SERVICE READINESS 100 90 80 75.0 75.9 69.7 70 66.3 68.4 59.8 60 57.9 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi ARMM Child Health Readiness Equipment Diagnostics Staffing and Guidelines Medicines and Commodities There were large and widespread gaps in the availability of child health services. There was high variability in of trained staff and guidelines for child health services, the availability of individual tests. Just 10.6 percent with an average score of just 39.2 percent for this of the RHUs in BARMM were able to test for parasites domain. Guidelines and training related to integrated in the stool, while 83.7 percent overall could conduct management of childhood illness (IMCI) were less hemoglobin testing. Medicines were mostly provided common than those related to growth monitoring. In centrally from national DOH for child health and were Tawi-Tawi, just 14.3 percent of staff were trained in generally available. Deworming medicine mebendazole or IMCI. No staff in Lamitan City were trained in either albendazole were found at 94.3 percent of the facilities, IMCI or growth monitoring. However, facilities across ORS for diarrhea was available at 88.6 percent of the BARMM did have the equipment needed to address facilities, and paracetamol and Vitamin A were available child growth monitoring and basic health needs. Child at more than 80 percent of the facilities. Zinc sulfate, the and infant scales, length/height measuring equipment, most frequently missing of the medicine indicators, was thermometers, and stethoscopes were all widely available at 56.1 percent of the facilities overall. When available. Overall, facilities had an average of 93.3 comparing across the provinces, survey data suggest that percent of the equipment considered. Only growth charts for medicines the largest gaps were found in Tawi-Tawi: were missing on a regular basis. while 74.0 percent of the facilities overall had amoxicillin, just 35.7 percent of those in Tawi-Tawi had the drug. With an overall score of just 50.9 percent, there were Similarly, just 21.4 percent of the facilities in Tawi-Tawi also gaps in the availability of diagnostic capacity stocked co-trimoxazole, compared to 64.2 percent overall. 143 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M Cardiovascular Disease of Essential NCD Interventions (PhilPEN).50 By contrast, fewer than 10 percent of the facilities in Lanao del Sur or While mortality data at the province level are not Basilan had guidelines. complete, information from the DOH-ARMM indicates that disease patterns in the region are similar to those Equipment needed to provide CVD care was generally found elsewhere in the country, with CVD reported as available. However, large gaps were seen in the the number one cause of mortality in each of the five availability of medicines. Stethoscopes, scales, and provinces. Despite the heavy disease burden, facilities blood pressure monitors were all widely available. had an average of only 56.0 percent of the CVD tracer Only oxygen was found at fewer than 90 percent of indicators across regions. Among the provinces, the the facilities. Medicines and commodities included three island provinces scored the lowest, with the RHUs ACE inhibitors, hydrochlorothiazide/thiazide diuretic in Basilan reporting an average of just 45.8 percent of tablets, beta blockers, calcium channel blockers, aspirin the indicators included, followed by Sulu and Tawi-Tawi. tablets, and metformin tablets. Of these, only metformin While equipment scores were fairly high, and many RHUs was available at most of the facilities in all provinces. did have staff trained in CVD diagnosis and treatment, Aspirin was available at between five and 10 percent of there were large gaps in the availability of diagnostic the facilities, depending on the province, and thiazide capacity and medicines (Fig. J-10, Annex J). diuretics were even less common. Overall, there was high variation in the readiness to deliver CVD care across the Trained staff were more commonly available than were five provinces in BARMM. CVD service readiness scores clinical guidelines on the appropriate management of ranged from a low of 45.8 percent in Basilan to a high CVD. Over half (56.1 percent) of the facilities had at least of 62.4 percent in Maguindanao (Table 6.8). Variations in one staff member trained to provide CVD care, possibly overall scores were largely driven by performance in two due to both national DOH and PhilHealth’s effort to domains: staff and guidelines; and medicines increase nationwide training on the Philippine Package and commodities. TABLE 6.8. CVD SERVICE READINESS Percentage Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 34.6 50.0 25.0 50.0 31.6 28.6 37.4 Equipment 87.2 96.6 95.8 100.0 90.8 91.1 92.1 Medicines and 51.7 43.7 19.4 33.3 21.9 25.0 38.2 Commodities Cardiovascular 60.7 62.4 45.8 58.3 46.5 47.6 56.0 Disease Service Readiness Indicators available at 50 percent of the RHUs in an area, or more, are shaded in green. Indicators available at 49.9 percent of RHUs in an area, or fewer, are shaded in rose. 50 AO (Administrative Order) 0020.s.2013: Adoption of the Philippine Package of Essential Non-Communicable Disease (NCD) Interventions (PhilPEN) In the Implementation of PhilHealth’s Primary Care Benefit Package. 2013. 144 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Diabetes group of conditions includes asthma, chronic obstructive pulmonary disease (COPD), and other conditions The prevalence of diabetes mellitus (diabetes) is growing affecting the airways and lungs. The majority of CRD- rapidly in the Philippines (Tan 2015). The International linked deaths (65 percent) are due to COPD. Asthma Diabetes Federation (IDF) estimates that there are more is also an important cause of mortality, constituting than 3.7 million adults living with diabetes in the country approximately one-third of the CRD-linked deaths.53 It is and the WHO estimates that diabetes accounted for six thought to affect approximately 30 percent of Filipinos, percent of all-cause mortality in the Philippines in 2014 has been recognized as a major driver of health care (IDF 2018).51 Across the BARMM region, the RHUs had costs in the country, and is the top cause of PhilHealth an average of just under half (48.9 percent) of tracer reimbursements (Philippine Health Insurance Corporation indicators to provide diabetes services. While equipment 2016). The RHUs in BARMM had an average of just 26.2 was generally available, widespread gaps were found in percent of the CRD tracer indicators assessed. Only in the availability of staff and guidelines, diagnostics, and Maguindanao did the RHUs have, on average, more than medicines and commodities. Aggregate scores ranged one in four of the tracer indicators assessed. The RHUs from an average of 41.0 percent in Basilan (and equally in Basilan had the lowest aggregate score. Serious gaps low in Sulu) to 53.3 percent in Lanao del Sur (Annex J, were identified in each of the three domains, with the Fig. J-11). largest pertaining to medicines and commodities (Fig. J-12, Annex J). Guidelines on diabetes diagnosis and management were available at just 17.1 percent of the RHUs in BARMM. One-third of the facilities had staff trained in the In Basilan and Lamitan City, no facilities had these diagnosis and management of CRD and just under guidelines on the day of the survey, and just 7.7 percent 15 percent had guidelines for the diagnosis and of those in Lanao del Sur had guidelines on hand. management of CRD available at the facility. BARMM- Trained staff were somewhat more available, with about wide, facilities had a domain score of 23.6 percent and 60 percent of the facilities overall reporting that at least province scores ranged from a low of 4.2 percent in one member of the staff had been trained on diabetes Basilan to 40.5 percent in Maguindanao. While trained diagnosis and management. Facilities across BARMM staff were sporadically available throughout, guidelines had an average of just over half (58.3 percent) of the were nonexistent in both Lanao del Sur and Basilan. diagnostic capacity indicators assessed. Blood glucose tests were most common, made available at 85.4 percent The RHUs in all provinces reported major gaps in their of the facilities, while urine dipsticks for ketones and ability to provide CRD services—overall scores ranged protein were both seen at slightly less than half of from a low of 21.2 percent in Basilan to a high of 32.7 the facilities. percent in Maguindanao. The two CHOs in Lamitan City did not significantly outperform the RHUs visited Chronic Respiratory Disease elsewhere. While equipment availability was high throughout the region, the availability of medicines and CRDs accounted for nearly five percent of all deaths in commodities was uniformly very low. Maguindanao had the country in 2017,52 placing them among the 10 most higher availability of trained staff and guidelines, while prevalent causes of mortality in the Philippines. This this was particularly low in Basilan and Tawi-Tawi. 51 WHO | Diabetes Country Profiles: The Philippines.” WHO 2016 (Online). Available: http://www.who.int/diabetes/country-profiles/phl_en.pdf. Accessed: August 9, 2018. 52 Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from http://vizhub.healthda- ta.org/gbd-compare. (Accessed May 2019). 53 Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from http://vizhub.healthda- ta.org/gbd-compare. (Accessed May 2019). 145 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M Cervical Cancer Screening to expand access to CCS services were more apparent, the RHUs in the provinces had, on average, fewer than Cervical cancer is the second most common cancer 25 percent of the indicators assessed. CCS services were among women and is responsible for seven percent nonexistent at the RHUs in Basilan (Figure 6.9). of all deaths due to malignancy in the Philippines. In an effort to prevent HPV infection (the viral causative The average score for the staff and training domain agent) among the coming generation, the national DOH was just 25.2 percent. When the survey was undertaken, recommends that HPV vaccine be made available at no guidelines for cervical cancer prevention and control cost for girls. At the same time, the government seeks to were only in place at a small number of facilities on the expand access to early diagnosis and prompt treatment mainland provinces—approximately one-third of the for women who have pre-cancerous or cancerous lesions. facilities in Maguindanao and a scattering of facilities Routine screening was included in the 2012 PCB package, in Lanao del Sur. Trained staff were also concentrated although few facilities were then equipped to provide the at facilities on the mainland: 85.6 percent of staff in services. More recently, regional centers to train providers Maguindanao had trained staff available, as did 38.5 to conduct cervical cancer screening (CCS) have opened, percent of the facilities in Lanao del Sur. By contrast, no and the government is in the process of a nationwide facilities in Tawi-Tawi or Basilan had any staff trained rollout of training to support access to CCS for women in cervical cancer prevention and control, and only two across the country. Nonetheless, survey data indicated of Sulu’s 19 RHUs had any staff with relevant training. that few RHUs in BARMM were able to diagnose cervical Overall domain scores range from 0 in Tawi-Tawi and cancer. With the exception of Maguindanao, where efforts Basilan to 58.1 percent in Maguindanao. FIGURE 6.9. CERVICAL CANCER SCREENING SERVICE READINESS 100 90 80 70 65.5 60 50 40 30 28.9 25.0 22.4 20 10 7.9 0.0 3.6 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi ARMM Cervical Cancer Screening Readiness Equipment Staffing and Guidelines Medicines and Commodities 146 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Tuberculosis and HIV/AIDS CONCLUSIONS The prevalence of TB is very high in the Philippines. General Trends While the confidence intervals of the 2013 and 2016 National Tuberculosis Prevalence Surveys (NTPS) overlap, These comprehensive data reveal a number of patterns other sources suggest an increase in TB over the last 10 in service readiness. Table 6.9 provides an overview years, from an estimated incidence of 520 per 100,000 of readiness to provide MCH, NCD, and communicable in 2007 to 554 per 100,000 in 2016.54 In 2016, there were services. Cells are color coded to indicate domain- approximately 345,000 notified cases nationwide.55 specific and overall readiness scores for each province. Among those treated in 2015, the treatment success rate Cells shaded in green have aggregate service readiness was estimated at 91 percent.56 scores of 50 percent or higher, while those shaded in rose have scores of 49.9 percent or lower. The survey found mixed evidence regarding the readiness to provide TB services at the RHUs across BARMM. The The five provinces in BARMM had generally higher facilities visited had an average of 56.2 percent of the readiness to provide MCH services, while overall capacity indicators considered (Fig. J-13, Annex J). Among the to provide NCD or communicable disease-related provinces, Lanao del Sur had the lowest overall score, services was low or variable. Aggregate specific-service with the RHUs there reporting an average of 42.1 percent readiness scores were the highest for the FP services, of the indicators assessed. Maguindanao was the high followed by child health, ANC, BONC, and immunization performer among the provinces, with an average of 73 services (in that order). NCD services lagged significantly. percent of indicators at the facilities; the two CHOs in Communicable diseases service performance was highly Lamitan City had an overall aggregate score of 70.8. variable, pointing to variations in both the priority status of the condition and in the geographic distribution of While most RHUs had staff trained to manage TB, they the conditions. Due to the priority placed on TB, there were less prepared to manage HIV-TB co-infection. was very high availability of medicines and commodities Just one-third of the facilities had relevant guidelines, aimed at treating the disease. Malaria services were compared to 78.9 percent of the RHUs having guidelines limited overall, but readiness tracked the geographic for TB in general. Training followed a similar trend, patterns in disease prevalence. with 77.2 percent of the RHUs having at least one staff member trained in general diagnosis and treatment of The RHUs in Lanao del Sur tended to have more TB, but just under 50 percent having staff trained on significant gaps in MCH service readiness than did TB-HIV co-infection. Staff and guidelines domain scores facilities elsewhere in the region. Of the five provinces, ranged from a low of 39.4 percent in Lanao del Sur to 83.1 Lanao del Sur had the lowest service-specific readiness percent in Maguindanao. TB medicines and commodities score for ANC, BONC, and immunization, with a low were widely available at the RHUs in BARMM. Survey FP score nearly equivalent to that for Basilan; among teams assessed the availability of up to two first-line the five provinces, Tawi-Tawi had the lowest child drugs. Only facilities in Tawi-Tawi reported any gaps: health service readiness score. At the other end of 92.8 percent reported having only one first-line drug. All the spectrum, Sulu had the highest overall readiness facilities in Lanao del Sur, Maguindanao, Basilan, and to provide FP services, and Tawi-Tawi led the group in Sulu reported having at least two first-line drugs. readiness to provide ANC services, while Maguindanao led the provinces in readiness to provide BONC and immunization services. Lamitan City’s two CHOs generally outperformed the RHUs in the five provinces. 54 “World Databank.” World Bank. See http://www.worldbank.org/. Accessed: February 25, 2018. 55 “WHO; Tuberculosis country profiles: Philippines.” See http://www.who.int/tb/country/data/profiles/en/. Accessed: March 22, 2018. 56 Ibid. 147 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M TABLE 6.9. SPECIFIC SERVICE READINESS: OVERALL PERFORMANCE Percentage Mainland Provinces Island Provinces Domain Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM FP 84.6 88.5 84.4 100.0 91.4 86.6 87.3 ANC 58.7 71.0 61.4 68.2 77.0 79.2 68.0 BONC 54.9 73.8 61.5 83.3 67.1 67.9 65.0 Immunization 49.9 62.6 55.4 92.5 58.2 53.6 56.6 Child Health 66.3 75.0 68.4 57.9 75.9 59.8 69.7 CVD 60.7 62.4 45.8 58.3 46.5 47.6 56.0 Diabetes 53.3 51.4 41.0 50.0 41.7 46.7 48.9 CRD 23.8 32.7 21.2 22.7 23.4 24.0 26.2 Cervical Cancer 22.4 65.5 0.0 25.0 7.9 3.6 28.9 Malaria 27.2 40.5 30.2 37.5 71.7 51.8 41.4 TB 42.1 70.5 56.3 70.8 61.0 49.4 56.2 Aggregate scores of 50 percent or higher are shaded in green. Aggregate scores of 49.9 percent or lower are shaded in rose. The main drivers for the variation in performance The equipment domain was consistently among the varied by category. While there were consistently large highest scoring domains. The relatively strong overall differences in the average availability of trained staff performance of the equipment domain likely reflects and service-specific guidelines, there were also large a combination of the long-lasting nature of these differences in the availability of medicines needed to investments and the broad applicability of a small provide ANC and child health services, as well as in the number of items (such as blood pressure monitors). equipment needed for immunization. However, there were gaps in diagnostic capacity at the RHUs across BARMM. While overall diagnostic capacity Broad-ranging gaps in the availability of trained staff was low at the RHUs in BARMM, it was particularly and service-specific guidelines reflect the government’s problematic for the diagnosis of TB (available at just 29.3 high-priority programs and suggest that with the right percent of the RHUs) and cervical cancer (24.4 percent of attention, these areas could be significantly improved. the RHUs). MCH and TB programs have been the most effective at implementing training sessions and distributing Gaps in the availability of essential medicines were the guidelines and job aids, and the results reflect the rollout largest for NCD treatment and, equally alarmingly, large of training and advocacy for specific services. However, for vaccines. With the important exception of vaccines, work is ongoing. For example, for CCS using acetic acid, availability of medicines and commodities for MCH only Maguindanao had been trained. This is reflected services was relatively high. This finding complements in the scores for CCS readiness. Similarly, training on the general service readiness overview provided earlier, management of diabetes using insulin was conducted where the analysis suggested significant gaps in drugs only in late 2017, shortly after the survey work was required for the management of hypertension and other completed. Hence, it is expected that the RHUs’ capacity chronic conditions. to provide insulin services will improve. 148 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M As noted, the national DOH provides several commodities in the RHUs. Key informant interviews at the national DOH, DOH-ARMM, and some RHUs revealed several logistics hurdles affecting the distribution of the goods from Metro Manila to the RHUs and other facilities nationwide. In spite of the temporary and irregular arrangements frequently in place as a partial solution, this survey’s results show that some medicines, in particular FP commodities, did nevertheless find their way to the RHUs. The maintenance drugs were also relatively widely available in the RHUs, although not as widely available as the FP commodities, which may suggest that there is a need to more accurately forecast the volume of supplies required. Vaccines, on the other hand, need special handling and many RHUs did not have enough cold storage space. Vaccines were therefore stored in the provincial hospitals or the RHUs in provincial centers. Other RHUs were required to pick up their supplies when needed, posing a problem for distant specific services are provided below. RHUs obliged to cope with the consequences of poor communications access. A comparison of the two surveys suggests that the RHUs in BARMM are significantly under- resourced when BARMM in the National Context compared to those in other regions of the Philippines. Table 6.10 provides an overview of general service The survey findings may be placed within the national readiness using a condensed set of tracer indicators.59 context by comparison with a 2014 survey covering 14 of Only in infection prevention did BARMM perform above the country’s 17 regions.57 The 2014 survey was designed the national average. Moreover, RHUs in BARMM had to be representative at the national and regional levels, the lowest overall availability of basic equipment, and data were collected at one RHU in each of 240 diagnostics, and medicines of any of the 15 regions LGUs across 14 regions.58 Because that earlier survey visited across the two rounds of data collection. The was designed to inform the implementation of the RHUs in BARMM were able to provide fewer than half government’s PCB1, it was limited to PCB-accredited (46 percent) of the diagnostic tests assessed, compared facilities and did not collect the complete set of to 67 percent elsewhere in the country. Similarly, while indicators included in this survey. For this comparison, the 2014 survey of 14 regions found that the RHUs had, data from the currently presented BARMM survey were on average, 87 percent of the tracer essential medicines, reanalyzed to exclude the tracer indicators that were the RHUs in BARMM had just 46 percent of these same not available in the national survey. Results for the medicines in 2017. five domains of general service readiness and for eight 57 The three regions that were excluded from the national survey include the NCR, which constitutes Metro Manila and was considered to be nonrepresenta- tive of the rest of the country; Region 8, which had been severely affected by Typhoon Haiyan shortly before data collection; and BARMM, which was excluded due to structural differences in the health sector organization that has been described elsewhere in this report. 58 In each province, eight LGUs were randomly selected. Within each selected LGU, the main RHU was visited. In provinces with less than eight eligible LGUs, the balance was randomly drawn from a nearby province within the same region. The final sample included 16 LGUs for all regions, other than Regions 6 and 7 where a total of 24 LGUs were selected for each region. 59 The following changes were made to align the analyses: the definition of basic infrastructure definition was modified to exclude communication equip- ment (telephone or short-wave radio); basic equipment excludes a light source; infection prevention excludes infectious waste storage, disinfectant, and guidelines on infection prevention; diagnostic capacity excludes urine tests for pregnancy; essential medicines excludes ampicillin, aspirin, carbamazepine, ceftriaxone, fluoxetine, gentamicin, haloperidol, insulin, omeprazole, and statins. 149 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M TABLE 6.10. GENERAL SERVICE READINESS: COMPARISON TO THE NATIONAL CONTEXT - A CONDENSED SET OF TRACER INDICATORS. General Service Readiness Region Basic Infrastructure b Basic Equipmentc Infection Preventiond Diagnostic Capacitye Essential Medicinesf Region 3 76 100 81 69 87 Region 4A 78 100 74 66 85 Region 4B 77 100 92 50 85 Region 5 70 100 81 79 83 Region 6 83 99 87 57 88 Region 7 83 98 94 62 85 Region 9 71 99 95 56 89 Region 10 86 97 85 81 88 Region 11 78 100 98 77 89 Region 12 81 98 86 82 86 Caraga 75 100 98 70 84 Philippines a 78 98 87 67 87 BARMM 73 88 90 46 46 a. National data were collected in 2014 and exclude the NCR and Region 8. b. Basic infrastructure includes power, improved water, auditory and visual privacy for patient consultations, access to sanitation facilities for patients, computer with e-mail/Internet access, and emergency transportation. c. Basic equipment includes adult scale, child scale, thermometer, stethoscope, and BP apparatus. d. Infection prevention includes six tracer indicators: safe final disposal of sharps, safe final disposal of infectious waste, sharps storage, single-use syringes, soap and running water or alcohol-based hand rub, and latex gloves. In addition, BARMM had the lowest aggregate readiness lowest readiness score in 2014. There was a 12-point scores for seven of the eight specific services that gap between BARMM and Region 7 for cervical cancer could be compared (Table 6.11). The availability of FP screening readiness, a 13-point gap between BARMM commodities was similar in BARMM to those found at and CAR for CVD service readiness, and a 19-point gap the RHUs elsewhere. While the overall availability of between BARMM and CAR for diabetes service readiness. inputs to provide ANC service was low in BARMM, results For CRD, there was a large 33-point gap between were similar to those found in other regions, including BARMM and Caraga. These findings highlight significant CAR and Region 9. By contrast, BARMM had the lowest differences in the overall availability of basic inputs to aggregate score by a very wide margin for the remaining deliver primary health services in BARMM relative to services. For immunization services, there was a 14-point other parts of the country. gap between BARMM and Region 1, the region with the 150 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 6.11. SPECIFIC SERVICE READINESS COMPARISON TO THE NATIONAL CONTEXT - A CONDENSED SET OF TRACER INDICATORS. Specific Service Readiness Region FP b ANC c Immunizationd Child Healthe CVDf,g DMh CRDi,j CCSk CAR 93 80 77 87 76 77 67 64 Region 1 93 89 70 88 88 88 74 48 Region 2 90 88 78 93 87 90 76 61 Region 3 95 95 83 89 90 98 69 85 Region 4A 99 85 81 86 88 93 72 75 Region 4B 98 82 81 79 87 87 71 48 Region 5 100 93 74 90 79 97 68 70 Region 6 93 86 83 83 86 89 71 60 Region 7 92 87 73 80 85 94 76 47 Region 9 99 81 77 87 86 80 66 53 Region 10 99 97 84 95 89 96 70 74 Region 11 100 95 80 98 86 91 66 66 Region 12 96 96 82 98 82 90 65 53 Caraga 99 92 85 93 88 94 62 63 Philippinesa 96 89 79 89 86 91 70 61 BARMM 98 80 56 76 63 58 29 35 a. National data were collected in 2014 and exclude the NCR and Region 8. b. FP is altered from the main analysis to exclude guidelines on family planning, checklists and/or job aids, and staff trained on FP and progestin-only contraceptive pills. c. ANC is altered from the main analysis to exclude ANC guidelines, ANC check lists and job aids, Intermittent Preventive Treatment (IPT), and Insecticide- treated Nets (ITNs). d. Immunization is altered from the main analysis to exclude all guidelines and training indicators, cold box/vaccine carrier with ice packs, auto-disposable syringes, temperature monitoring, adequate temperature, immunization cards, immunization tally sheets, IPV, and HPV. e. Child health is altered from the main analysis to exclude all guidelines and training indicators, length board, growth chart, and vitamin A. f. CVD is altered from the main analysis to exclude guidelines for diagnosis and treatment of chronic cardiovascular conditions, oxygen, and aspirin. g. The 2014 survey included the availability of lipid profile reagents as a diagnostic, which was not collected in the 2016 survey. h. Diabetes is altered from the main analysis to exclude guidelines for diabetes diagnosis and treatment, measuring tape, insulin, and glucose. i. CRD is altered from the main analysis to exclude guidelines and staff trained for diagnosis and management of CRD, spacers for inhalers, oxygen, and prednisolone. j. The 2014 survey includes an additional medicine indicator for beta blocker, which was not collected in the 2016 survey. k. CCS is altered from the main analysis to exclude guidelines for cervical cancer prevention and control. 151 CHAPTER SIX: S U P P LY- S I D E R E A D I N E S S O F P R I M A R Y H E A LT H C A R E I N B A R M M FINDINGS AND RECOMMENDATIONS systems and parallel efforts to adequately monitor the logistics systems. Reorganization of the health sector This report is the first to provide a systematic under the BARMM MOH would provide opportunities to assessment of readiness to deliver primary health build a better system to address these issues. care services in BARMM. Data were collected prior to transition from ARMM to BARMM, from nearly all RHUs Ensuring the availability of basic amenities such as in the five provinces in the region. Population-based power, emergency transportation, and communication surveys have documented significant demographic and channels is critical for health service delivery at the epidemiological challenges in the area. While the causes frontline level. Approximately 15 percent of the RHUs in of poor health outcomes in BARMM are complex and Sulu, for example, lack access to running water, while multidimensional, the results of this survey highlight nearly 20 percent of the RHUs in Lanao del Sur have the critical importance of equipping the region’s public no source of electricity. Fewer than half of the RHUs primary health sector to deliver essential preventive and in BARMM have access to communication equipment, curative services. such as telephones or short-wave radios, and even fewer have computers with Internet access. Emergency The survey identified important gaps in access to transportation, too, is lacking. Across BARMM, one in care across BARMM; the availability of primary care three facilities lacks transport to evacuate patients; in infrastructure and health personnel fall well below the Tawi-Tawi, this number jumps to two out of every three national targets. The number of all cadres needs to be RHUs. Given the remoteness of some of the provinces, increased, especially in rural and remote areas. The creative ways should be sought—in close collaboration number of government doctors would need to nearly with the regional authorities—to improve emergency triple to reach the national target. However, any program transport and ensure access to a permanent power to increase the number of workers needs to be carefully supply. Moreover, increased access to tax revenues and planned and managed to avoid foreseeable future increased fiscal autonomy would allow for the BARMM challenges. The current reliance on centrally supported government to take charge of improvements in deployment programs risks the long-term sustainability these areas. of HRH in the region. Better distribution of existing health staff could be achieved through incentive mechanisms to PhilHealth has a major role to play in improving services promote deployment in underserved areas. A complete in BARMM. The agency should strengthen accreditation HRH needs assessment would provide a definitive picture systems for the RHUs in BARMM. Findings suggest that of existing gaps and facilitate negotiations with the LGUs most public facilities have been accredited in advance regarding budgetary support for expansion of the of meeting the formal infrastructural requirements, health workforce. likely as part of an aim to rapidly expand PhilHealth’s provider network and, thus, access to care. While this Widespread gaps in consumables undermine the ability is an important initiative, it risks the creation of an to deliver health services. Of the 75 medicines and empty entitlement, where patients are granted nominal commodities assessed, just 11 were available in at least coverage for services that local facilities cannot provide. half of the RHUs in each of the five provinces. There are It is, therefore, critical that PhilHealth uses its leverage similar gaps in diagnostic capacity across every service as a funder to encourage facilities to rapidly move to under consideration. Addressing the critical shortcomings meet actual accreditation requirements. Significant in the logistics and supply chain is an urgent priority. delays in the release of PhilHealth capitation payments In particular, mechanisms must be developed to ensure also need to be addressed. Predictability in the timing timely delivery of medicines and supplies to the RHUs of these payments can greatly aid in the planning across the region. Potential interventions may involve and sustainability of operations and will increase the designating personnel to establish standardized logistics incentive for facilities to meet accreditation standards. In 152 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M the context of the recent UHC Law, PhilHealth’s mandate Finally, while the availability of inputs is a critical becomes increasingly important as an eventual single component of health care, the overall quality of care purchaser of health services. depends on many additional factors, including provider knowledge and communication skills. If the determinants The LGUs should be encouraged to play a larger role in of health outcomes are conceptualized as a traditional health service delivery. This was suggested earlier, with wheel, then supply side readiness is just one spoke in reference to efforts to develop the local workforce, but that wheel, albeit a crucial one. While this is partially extends generally to the strengthening of local publicly captured in the patient satisfaction survey conducted as funded health services. The NG provides IRA transfers part of this study, efforts to gain a more comprehensive to the LGUs to support social services, including health understanding of quality of care of health services in the care. Although the LGUs are authorized to determine region would benefit from a more detailed assessment. the specific allocation of these transfers, few of those More generally, there are currently no routine in the region have chosen to fund health care services mechanisms to assess the quality of care in BARMM, in recent years. Coordination between health officers and these should be instituted as part of the regular and the LGU through a functional local health board supervision process by districts and provinces. can help raise the local profile of the health sector and clarify the specific support that the LGUs might provide. The findings of this report suggest that investments in Potential support includes distribution of commodities, supply side readiness are essential if the Philippines non-personnel operating expenses, infrastructure or is to address poor health outcomes. The BOL and equipment investments, or expansion and capacity formation of BARMM have major implications for the building of local HRH. Accountability mechanisms should health sector. With the expected reorganization of both be introduced to ensure that all parties meet their the management and financing of the health sector, respective financial obligations to the health sector. the region has an opportunity to significantly improve services. The study presented here provides an important The use of real-time information systems using modern baseline of the health sector capacity to deliver key technology would greatly aid in monitoring and decision services which will help the BARMM MOH make informed making for service delivery. The national DOH and decisions even as the region gains autonomy in planning PhilHealth are working to roll out electronic medical and allocating resources. records, but the availability of this system is currently limited to a small part of the five provinces. As evidenced Annexes from this assessment, availability of internet connection Annex J. Additional Figures and Tables from Supply Side and other basic communication channels remains a Readiness Assessment   constraint, particularly in the island provinces. Again, the LGUs should support these efforts. http://bit.ly/BARMMHFSAAnnexes 153 CHAPTER SEVEN: I M M U N I Z AT I O N P R O G R A M I N T H E P H I L I P P I N E S A N D I M M U N I Z AT I O N C O V E R A G E I N B A R M M CHAPTER SEVEN: IMMUNIZATION PROGRAM IN THE PHILIPPINES AND IMMUNIZATION COVERAGE IN BARMM SUMMARY • According to the 2018 SSRA, RHUs lack an adequate supply of the vaccines that are part of the • Basic vaccine coverage in the Philippines is immunization schedule. This may be the result of low overall and has declined in recent years. stockouts at the national level or at the regional/ Immunization rates in BARMM are lower still, with IPHO level, or it could reflect disruptions of the cold just 30 percent of children aged 12–23 months chain during transportation or storage. In addition, exhibiting basic vaccine coverage in 2019, according low overall staffing levels and an overreliance on to the BARMM Household Survey. contractual staff has hampered consistent vaccine service delivery capacity throughout ARMM, and staff • Childhood vaccine antigens are procured centrally by turnover has made it difficult to ensure staff are the national DOH and are delivered to government adequately trained. providers of immunization services like RHUs. There is ongoing debate at the national level as to whether • Supply-side factors, including service delivery vaccines should continue to be procured by the NG arrangements, appear to be more significant causes following the passage of the UHC Law. However, it of low childhood immunization rates in BARMM does not appear that this decision will be made in than the demand-side factors identified in the 2019 the near future. Household Survey. Issues begin with procurement, planning, and forecasting at the national level. In the • Vaccines are distributed from a central warehouse region, these are compounded by supply-side gaps in the national capital region (NCR) to subnational and problems in vaccine handling and vaccine stores and then to final distribution stores distribution systems. throughout the country. Routine vaccines are dispatched via a request system. In BARMM, the five • BARMM, in partnership with UNICEF, has invested IPHOs and two CHOs send requests directly to the in assessing the current state of its vaccine national storage facility; requested antigens are then delivery system, and currently has an opportunity distributed to subnational and final distribution to implement reforms while it is in a period of stores throughout the region. transition. Initial goals for reform should be to improve a vaccine inventory management system, • The NIP was given a budget of PhP 7.4 billion in 2018 train personnel, invest in supply side features and PhP 7.5 billion in 2019, accounting for about such as functional cold storage, and determine seven percent of the DOH budget for both years. In feasible tasks and responsibilities for provincial and 2017, the vaccines dispatched to ARMM amounted to municipal LGUs. These opportunities depend upon almost PhP 200 million or about three percent of the BARMM-MOH taking a much stronger leadership total vaccine budget. However, a general downward role over the immunization program and developing trend was observed in the number of vaccine a comprehensive, detailed plan for meeting the antigens delivered to ARMM. identified program deficiencies. 154 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M OVERVIEW a law, RA No. 10152 or the Mandatory Infants and Children Health Immunization Act of 2011, which mandates that The National Immunization Program (NIP) is founded on free, basic immunizations must be provided at any the mandate of the State to promote and protect the government hospital or health center for infants and right to health of the people as enshrined in the 1987 children up to five years of age. The lack of associated Philippine Constitution. As far back as 1976, Presidential Implementing Rules and Regulations (IRR), however, has Decree No. 996 provided for compulsory basic led to weak implementation of the law. immunization for infants and children below eight years of age. A series of national directives followed, expanding The following is the current national immunization the package of basic immunization services. The latest is schedule: TABLE 7.1. PHILIPPINES NATIONAL IMMUNIZATION SCHEDULE. Age Vaccine 24 hrs old 6 wks old 10 wks old 14 wks old 9 mos old 12-15 mos old Other Target Groups 1 BCG x 2 Hepatitis B x 3 PENTA: DTwP-HepB-Hib x x x 4 OPV (Oral Polio Vaccine) x x x 5 PCV (Pneumococcal x x x Conjugate Vaccine) 6 IPV (Inactivated Polio x Vaccine) 7 Rotavirus x x 8 MR (Measles-Rubella) x Grades 1 and 7 in Vaccine all public schools 9 MMR (measles-mumps- x x rubella) Vaccine 10 Td (tetanus diphtheria) Grades 1 and 7 in all public schools and pregnant women 11 HPV Female: 9-10 years old 12 Influenza Vaccine Senior citizens: 60 years old and above 13 PPV (Penumococcal Senior citizens: 60 polysaccharide vaccine) years old and above 14 JE (Japanese x Children (9 months Encephalitis) to 14 years old) Note: HPV vaccine was introduced only in provinces that belong to 20 priority provinces and city for this disease. In ARMM, the priority areas include the provinces of Sulu, Lanao Sur and Maguindanao. Japanese Encephalitis vaccine will be introduced soon, but will be based on the government capacity to procure vaccines. 155 CHAPTER SEVEN: I M M U N I Z AT I O N P R O G R A M I N T H E P H I L I P P I N E S A N D I M M U N I Z AT I O N C O V E R A G E I N B A R M M The Philippines saw nationwide improvements in immunization coverage from 1998 to 2008, with the proportion of children 12–23 months receiving all basic vaccinations increasing from 73 percent to 80 percent; similarly, the percentage of children with no vaccination history declined over this period. However, the next decade saw a decline in coverage, and by 2017, childhood immunization rates had fallen below 1998 levels. In the ARMM region, however, immunization indicators steadily worsened over this same two-decade period. Vaccine coverage in ARMM, in fact, is far worse than in any other region in the Philippines. In 2017, the percentage of children aged 12–23 months with all basic vaccinations ranged from 48 percent to 84 percent in other regions, compared to just 18 percent in the ARMM region (PSA and ICF 2018). Children with no vaccination history ranged from less than one percent to 31 percent in non-ARMM regions, while ARMM had nearly 44 percent. The 2019 BARMM Household Survey, described age group had no vaccine history: higher than the 2017 in a previous chapter, provided a more hopeful picture, Philippine national average, but substantially lower finding that among those aged 12–23 months residing than the percentage reported in the NDHS for ARMM in within the five former ARMM provinces, approximately 34 that same year (44 percent). These changes should be percent exhibited basic vaccine coverage: substantially interpreted with caution, as they may reflect both an more children than reported in the 2017 NDHS (18 improvement in coverage as well as differences in percent). Furthermore, 24 percent of children in this survey methods. FIGURE 7.1. CHILDREN AGE 12-23 MONTHS RECEIVING ALL BASIC VACCINATIONS 60 AND WITH NO VACCINATION COVERAGE, 1998, 2008, 2017. Children 12-23 Months Receiving All Basic Vaccination Children 12-23 Months with No Basic Vaccination (in percent) (in percent) 100 100 79.5 72.8 69.9 80 50 46.8 60 30.6 43.7 18.0 39.3 40 33.9 0 1998 2008 2017 20 9.4 7.7 5.6 0 Philippines ARMM 1998 2008 2017 Philippines ARMM Source: NSO and Macro International 1999; NSO and ICF Macro 2009; PSA and ICF 2018 60 1998: BCG, measles and three doses of DPT and polio; 2013: BCG, measles, and three doses each of DPT and polio vaccine; 2017: BCG, three doses of DPT, three doses of OPV or IPV, and one dose of measles or MMR. 156 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M KEY IMMUNIZATION FINDINGS FROM THE 2019 BARMM HOUSEHOLD SURVEY • Many families lack vaccination cards or other home-based vaccination records, making it difficult for them to track and adhere to the national immunization schedule. • Thirty-four percent of children aged 12-23 months exhibited basic vaccine coverage, half the already low rate for the Philippines overall (70 percent in 2017). Provincial variation was noted, from a low of 21 percent in Basilan province to a high of nearly 50 percent in Tawi-Tawi. • One-third of children aged 12-23 months received the first dose of a vaccine but failed to receive subsequent doses. • Among children with evidence of two doses of a vaccine, more than 50 percent had at least one interval between doses that exceeded 56 days, leaving them under-protected for a period of time. In addition, nearly 20 percent received a subsequent dose less than 28 days after an initial dose, rendering the dose invalid. • Over 65 percent of vaccine visits involved at least one missed opportunity for vaccination, during which a child could have been given another vaccine for which they were eligible but was not. • Supply-side explanations for these low rates have been described. Demand-side factors reported by survey respondents include: caregiver is too busy or does not have time for a clinic visit, and a fear of adverse effects or reactions. The fragile, conflict-affected environment of several BARMM provinces likely provides an additional explanation. IMMUNIZATION FINANCING are delivered to RHUs and other public health facilities providing immunization services. While health service delivery has been devolved to LGUs since 1991, vaccine antigens are among the essential The NIP has therefore had a budget line item within commodities that the NG has continued to procure national DOH budget appropriations since 1994. As centrally. Republic Act No. 7846 of 1994 provided for the with other line agencies, the DOH budget was prepared appropriation of funds for immunization in the annual annually with incremental increases, which were General Appropriations Act (GAA); this was reiterated in predicated on assumptions for growth and inflation RA No. 10152. (Martin 2008). In 2010 and 2015, national DOH prepared a multi-year spending plan that estimated the medium- That same provision in RA No. 10152 also stipulates that term funding requirements for the NIP based on a target Philippine Health Insurance Corporation (PhilHealth), the of 95 percent coverage of basic immunization for children administrator of the National Health Insurance Program, 0–11 months, as well as specific immunizations for shall include basic immunization in its benefit package. school-aged children, adolescents and pregnant women. PhilHealth provides for the coverage of BCG and Hepatitis The exercise computed a funding requirement ranging B birth dose vaccines through the Newborn Care Package; from PhP 11 billion to PhP 13 billion per year. These these are the only two vaccines covered by PhilHealth, estimates included costs for the vaccine antigens that and they are only covered for births that take place were to be financed through the GAA and the costs of in accredited birthing facilities. All vaccine antigens, syringes and safety boxes to be covered by the however, are made available through national DOH and respective LGUs. 157 CHAPTER SEVEN: I M M U N I Z AT I O N P R O G R A M I N T H E P H I L I P P I N E S A N D I M M U N I Z AT I O N C O V E R A G E I N B A R M M National DOH has successfully secured annual funding level that threaten vaccine supply and distribution in for the NIP at levels requested by the program, in some LGUs (see below), national DOH would benefit from years with budget support financing from the World continued refinement of its forecasting methods in order Bank. Beginning in 2014, the NIP annual budget saw to ensure that the budgets sought for the NIP actually substantial increases as a result of the 2012 Sin Tax law, meet the country’s requirements. Such methods may also which earmarked 85 percent of incremental revenues need to take into account the timing of procurement, to the health sector, including for programs related to limitations in the data on which assumptions of growth the Millennium Development Goals such as the and inflation are based, and weaknesses within the immunization program. overall supply chain, from the national to community levels. Figure 7.3 below shows NIP funding from the baseline year (2013) through 2019. Since 2013, the NIP budget Records of vaccine distribution from 2017 indicate that has more than tripled, from PhP 2 billion to PhP 7.5 ARMM received a share of almost PhP 200 million or billion in 2017, and it has doubled as a share of the total about three percent of the total vaccines dispatched DOH budget, from 3.5 percent in 2013 to more than 7.5 by the national vaccine storage facility. Vaccines are percent in 2017. Budget increases can be attributed to distributed to regions based on population projections Sin Tax revenues beginning in 2014 as well as increases as well as direct requests from recipients, such as LGUs in coverage, for example the expansion of adolescent or IPHOs. In 2015, five percent of all children in the immunizations and the coverage of certain antigens. A country below five years of age lived in ARMM, suggesting DOH multi-year spending plan for 2019–2022 has since ARMM may have received a smaller allocation of vaccine been prepared that projects for incremental increases antigens than it required. Table 7.1 shows a general based only on expected growth and inflation. downward trend in the number of doses of vaccine antigens provided to BARMM in 2017 compared to the In view of low vaccine coverage rates nationally, and the previous two years. recurring problem of vaccine stockouts at the national FIGURE 7.2. NATIONAL IMMUNIZATION PROGRAM FUNDING, 2013 – 2019 Percent of Children ages 12-23 months will all basic vaccines 8.0 7.4 7.5 9.0% 7.1 7.0 8.0% 7.0% 6.0 6.0% 5.0 in Billion Pesos 4.0 5.0% 4.0 3.3 4.0% 3.0 2.5 1.9 3.0% 2.0 2.0% 1.0 1.0% - 0.0% 2013 2014 2015 2016 2017 2018 2019 Budget for Immunization Program as a % of Total DOH Budget 158 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 7.2. VACCINE ANTIGENS DELIVERED FROM RITM TO BARMM, 2014 TO 2017, NO. OF DOSES AND EQUIVALENT IN PHP No. of doses Equivalent in PhP 2014 2015 2016 2017 2014 2015 2016 2017 BCG 209,740 327,600 319,580 95,980 1,363,310 2,583,638 2,200,513 1,827,480 DTwP-HepB-HiB/Penta 1,887,970 570,281 820,445 85,117 186,342,639 12,744,736 143,106,518 16,102,767 Hepa B 91,350 465,020 117,480 35,500 730,800 4,654,509 846,097 1,150,000 Measles 472,330 207,230 53,770 - - - - - MMR Routine 97,705 92,955 123,815 94,250 5,422,628 5,370,468 2,630,554 13,643,123 MR 492,700 187,500 73,000 96,000 15,273,700 6,742,500 - 6,041,000 Polio Bivalent 1,290,480 552,880 575,500 187,020 10,259,316 3,671,040 5,789,440 3,296,577 IPV Imovax - 10,000 36,700 23,700 - - 2,550,000 5,788,200 PCV 13 - 138,000 225,260 71,000 - - 288,526,700 136,634,750 Flu - 3,311 21,000 21,000 - 699,750 - 8,400,000 Rotavirus - 4,994 - - - - - - Td (1-dose) - - 126,898 81,817 - - - 2,018,385 Td (10-dose) - 173,090 21,360 8,400 - - - 266,947 Dengue - - - - - - - - HPV Gardasil - 34,767 17,760 5,840 - - - - Pneumo PCV 10 192,098 65,000 - - - - - - Tetanus Toxoid 333,780 226,520 80,980 - 1,001,340 896,154 776,406 - TOTAL 220,393,733 37,362,795 446,426,227 195,169,229 As mentioned previously, while funding for vaccine equipment, as well as for the purchase of additional antigens has been regularly appropriated in the national vaccine antigens as needed. However, as noted in the budget, costs associated with implementing vaccination health financing chapter of this report, in fact DOH-ARMM activities are assumed to be covered by LGUs, mainly did not have operating funds to dedicate to the different through the operating costs of the RHUs or BHSs that public health programs. As a consequence, operations deliver immunization services. However, in the non- plans, including for the immunization program, were devolved setup of BARMM, the regional MOH operates the never programmed in the budget. Furthermore, aside RHUs, not the LGUs; as such, decisions about budgeting from personnel salaries, DOH-ARMM had no regular and programming are made at the regional level. This is budget for the operating expenses of RHUs. consistent with the organization of ARMM. As a stopgap measure, funding for immunization-related Under the former ARMM, the different DOH-ARMM equipment, supplies, and activities had to be sourced programs prepared annual operations plans, which, from or voluntarily contributed by other sources. for the immunization program, included activities Training and other related activities were solicited from for planning, program review, training of personnel, the national DOH or from other DOH-ARMM budget acquisition of vaccine refrigerators and other related line items. In-kind support, in the form of refrigerators, 159 CHAPTER SEVEN: I M M U N I Z AT I O N P R O G R A M I N T H E P H I L I P P I N E S A N D I M M U N I Z AT I O N C O V E R A G E I N B A R M M vaccine carriers, and thermometers, was often provided is an individual-based service since it can be definitively by the national DOH and development partners traced back to a recipient, it is also a critical public like UNICEF. However, this support was not always health intervention of the sort DOH is currently tasked coordinated, resulting in some IPHOs having unused with delivering. If the decision is made for PhilHealth and duplicate equipment while others lacked equipment to provide immunization coverage, service delivery altogether. As a consequence of the need to constantly units may have to procure their own vaccines and source funds, many activities remained unfunded and immunization supplies and be reimbursed by PhilHealth unimplemented. This lack of regular, programmed for the services rendered, a situation which may make funding greatly hampered program management from access to vaccines even more tenuous. There are planning to delivery of immunization services. indications, however, that a decision on whether or not to do away with central procurement and distribution of The BOL and the provisions for a block grant will likely vaccines will take some time beyond the issuance of the change the financing landscape for the immunization IRR of the UHC Law. program in BARMM. In its first year of passing the appropriations for the block grant, the BTA doubled the Ministry of Health budget from the previous year, IMMUNIZATION SERVICE DELIVERY from PhP 1.5 billion to PhP 3.1 billion. With this, public health programs were finally, formally programmed in The majority of vaccinations in BARMM are delivered the budget. The BARMM MOH work and financial plan in public facilities: in 2017, just 16 percent of residents show that, of the PhP 3.1 billion, a substantial 12 percent reported accessing health care services, including or PhP 363 million is to be devoted to the purchasing of immunization, in a private hospital or clinic, the lowest vaccines. An additional PhP 50 million is budgeted for percentage of all regions in the Philippines (PSA and ICF other expenses related to the immunization program, 2018). The remaining vaccines are delivered in public bringing the total budget for the immunization program facilities, mostly RHUs and BHSs. to more than PhP 413 million or 13 percent of the total regional appropriation for the MOH. Unfortunately, but Table 5.22 in Chapter 5 shows that demand-side factors not unexpectedly, it became apparent that the purchase such as fear of adverse effects/reactions to vaccines of vaccines could not materialize within the year for do not figure prominently as reasons that a child is not a variety of reasons, foremost of which is the lack of fully vaccinated. Chapter 6, on the other hand, reveals cold storage throughout the region, a fundamental significant supply side gaps faced by public primary care requirement for the purchasing and handling of vaccines. facilities in BARMM. The low rate of childhood vaccination Moreover, with the onset of the Covid-19 pandemic, in BARMM is a manifestation of several issues that plague realignments to the overall MOH budget had to be made, the implementation of the immunization program. Each including by redirecting funds for the immunization of these issues will be addressed below. program overall to help fund the emergency response to the crisis. Program Management and Service Provision At the national level, there is ongoing debate as to At the national level, the NIP resides within the Family whether vaccines should continue to be procured by the Health Office of the Disease Prevention and Control NG following the passage of the Universal Health Care Bureau of the national DOH. The NIP unit includes a Law in 2019. The UHC Law aims to delineate the financing national cold chain manager; staff within the unit work of population-based health services (that is, large-scale with other DOH agencies and offices for surveillance of public health interventions) to the national DOH and vaccine-preventable diseases, procurement, laboratory individual-based health services to PhilHealth. However, confirmation, vaccine storage, product registration, there is debate as to where exactly immunization falls information, education, communication, advocacy, in this categorization: while by definition immunization and social mobilization. In BARMM-MOH, there is a designated NIP coordinator who also manages other 160 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FUNDING FOR IMMUNIZATION SERVICES: WHO IS RESPONSIBLE FOR WHAT? • National Department of Health provides vaccine antigens to BARMM via a national-level procurement process. BARMM provinces are responsible for collecting vaccines from designated storage facilities throughout the region. BARMM-Ministry of Health (MOH) plays little to no role in overseeing or managing these provincial processes. As a result, challenges abound, from accurately estimating regional vaccine needs, to coordinating and ensuring safe transportation of antigens from storage facilities to Rural Health Units (RHUs), to properly storing the antigens. • In other regions, provincial and municipal Local Government Units (LGUs) supply vaccine delivery equipment, such as cold chain equipment and syringes, to RHUs. In BARMM, however, LGUs contribute very little to health care service delivery due in part to a lack of clarity about which level of government—regional, provincial or municipal—is responsible for doing so. In the end, the regional government and external groups must provide vaccine supplies, taxing the region’s limited immunization program budget. • Training of health care workers is insufficient, as BARMM LGUs do not fund such trainings and the regional government has minimal budget for training activities. The region must rely on national-level training programs or those conducted by external development groups, which may not be consistently offered or attended. High rates of staff turnover further undermine efforts to build and maintain an adequately trained workforce. • These supply-side limitations are a significant cause of low immunization rates among BARMM children. programs, including the Integrated Management of so contractual personnel have been employed to Childhood Illnesses program. Likewise, in the provinces, provide additional support. RHU and BHS staffing responsibility for the NIP is shared by various personnel has traditionally been supplemented by contractual who also handle other programs, including the child personnel from the various Health Human Resource health, nutrition and rabies programs, as designated by deployment programs of the national DOH, including the Provincial Health Officer. Doctor to the Barrios (DTTB), the Nurse Deployment Program (NDP) and Rural Health Midwives Program In the communities themselves, responsibility for (RHMPP). Furthermore, throughout the past decade, immunization service delivery lies with the Municipal DOH-ARMM supplemented frontline health workers with Health Officer who heads the RHUs and the satellite midwives through the MECA program, many of whom BHSs. RHU nurses and midwives are the main providers began as contractors but have since become permanent of immunization services as well as other public health employees. Finally, some municipal LGUs provide services. In the non-devolved setup of the region, health contractual health workers to augment the personnel workers in the RHU are part of the IPHO network, and as requirements of service delivery in the RHUs and BHSs. such are employed by BARMM MOH: as reported in the Management and oversight of the various staff groups, 2017 BARMM SSRA, nearly 60 percent of all government with their differing funding sources and varying contract health personnel in the region are funded by BARMM terms and requirements, would be a challenge for even MOH. However, there are not enough regionally- the best organized of the Municipal Health Officers. employed staff to meet the health care delivery need, 161 CHAPTER SEVEN: I M M U N I Z AT I O N P R O G R A M I N T H E P H I L I P P I N E S A N D I M M U N I Z AT I O N C O V E R A G E I N B A R M M Despite sourcing staff from a variety of programs, both terms of ensuring adequate training, and indeed the 2017 local and national, the 2017 BARMM SSRA still found a BARMM SSRA found low rates of immunization-specific low health workforce density for BARMM overall and training of staff, especially in transporting and handling geographic variation within the region, with some vaccines. In fact, fewer than half of RHUs were staffed provinces facing severe shortages in medical personnel. with personnel that had been trained in immunization In addition to low staffing levels in general, the fact delivery (Figure 7.4). UNICEF sponsored a cold chain that many are contracted by national DOH suggests the management training in 2018; it had been nearly a inconsistent nature of their positions, as they face the decade since a similar training had been conducted for possibility of being moved elsewhere as a result of DOH the region. Unfortunately, not all cold chain managers reallocation of contracted staff or the completion of their were available to participate. contract terms. Turnover of staff also poses challenges in FIGURE 7.3. PERCENT OF RHUS STAFFED BY PERSONNEL WITH TRAINING RELATED TO IMMUNIZATION DELIVERY 61 Immunization service delivery (immunization in practice (IIP) or any similar Vaccine management/handling of service delivery Data reporting and monitoring of service delivery Disease surveillance and reporting Injection safety and waste management RED (Reaching Every District) New vaccine prior to introduction 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 BARMM Provinces Tawi-Tawi Sulu Lamitan City Basilan Maguindanao Lanao del Sur Source: SSRA, 2019 61 The BARMM SSRA used the Supply-side Availability and Readiness Assessment (SARA) framework of the World Health Organization. The list of trainings that were included in the survey were from the SARA list. 162 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Many public health services, including immunization for NIP result in vaccine stockouts at the national level services, rely heavily on home visits by health workers, and a disruption in the supply chain in LGUs. especially in the most remote areas where there are no barangay health stations. Community residents who live Although there are vaccine requirement forecasts for the far from the health station, or who are unable to visit different LGUs based on population projections, routine on designated immunization days, may be visited by the vaccines are dispatched via a pull system, which is same nurses and midwives who provide these services based on recipient requests. The web-based Vaccination onsite; this is a helpful service, but it may threaten the Supplies Stock Management (VSSM) software is in place availability of staff onsite for patients who come to the for RITM to receive requests and track inventories, facility for other needs. although requests made through phone calls and text messages are also processed. In the case of BARMM, the Finally, the history of conflict and violence in the ARMM five IPHOs and the two CHOs send requests directly to region and the internal displacement that has resulted RITM; BARMM-MOH is informed of such requests by the have threatened the delivery of vaccines in affected IPHOs, and at times requested to help facilitate them. communities. Conflict-affected areas throughout A third-party logistics partner of DOH transports the the world face security threats, damaged health vaccines using RITM-approved vaccine carriers. infrastructure (including not only health facilities, but also roads and utility services) and reduced human From the national storage facility, vaccine supplies are resources to deliver vaccines. In addition, vaccination sent to either subnational (SN) vaccine stores, which outreach efforts and information campaigns in these house the vaccines for distribution to other hubs, or last communities are either cancelled or lack efficacy due distribution (LD) vaccine stores, from which the service to staff shortages and a lack of movement of potential points (RHUs or BHSs) collect their vaccines. As seen beneficiaries due to the security situation (Grundy in Figure 7.5, each of the two mainland provinces have and Biggs 2019). The Philippines has seen success in SN vaccine stores. In Maguindanao, it is the Awang cold delivering vaccines in refugee camps and evacuation chain store, which is conveniently located outside the centers (Nnadi et al. 2017), but even with these efforts, airport and beside the Awang RHU. A portion of vaccine vaccination coverage remains lower in BARMM than supplies are delivered from there to the Maguindanao in other conflict settings, as described previously in Provincial Hospital, which houses the LD vaccine this report, suggesting that the security situation has store for 14 municipality service points; in addition, compounded existing issues in vaccine service delivery the Buluan RHU, which serves as the LD vaccine store rather than creating a new problem. for six municipalities (including Buluan itself), also retrieves vaccines from the Awang cold chain store. Vaccine Inventory Management, Distribution and Supply Finally, the Awang store also directly supplies vaccines to 16 additional municipalities. By contrast, Lanao del As mentioned above, the national supply of vaccines Sur province has one SN store, which is located at the is centrally procured by the NG though government Lanao del Sur IPHO. Two district hospitals collect vaccine procurement processes, with UNICEF acting as procuring supplies from this SN store for further distribution to agent as needed when supplies are scarce. Purchased seven service points; in addition, 32 municipalities collect vaccines are received from suppliers in a central storage their vaccine supplies directly from the SN store in facility at the Research Institute for Tropical Medicine the IPHO. (RITM), located in the National Capital Region, which can accommodate up to three months of vaccine needs The IPHOs in the three island provinces, as well as the for the country. Despite being a DOH priority program, Marawi and Lamitan CHOs, serve as LD vaccine stores for the NIP faces procurement challenges similar to those all the service points within their respective catchment faced by other government programs, suggesting the areas. However, not all municipalities serviced by these barriers may relate to bureaucratic processes or other LD vaccine stores are nearby. For example, some of the inefficiencies within DOH overall. Procurement limitations farthest municipalities of Tawi-Tawi used to obtain their 163 CHAPTER SEVEN: I M M U N I Z AT I O N P R O G R A M I N T H E P H I L I P P I N E S A N D I M M U N I Z AT I O N C O V E R A G E I N B A R M M supplies from DOH Region IX in Zamboanga City, which Service points that are geographically accessible to LD was more accessible than Bongao, the capital of Tawi- stores may obtain their vaccine supplies early in the Tawi province, where the IPHO is located. This sort of morning on immunization days, or the previous day. arrangement has become rare, though, now that vaccine However, municipalities that are far from LD stores, in carriers can carry vaccines for longer periods of time. particular in the island provinces, do not have regular However, help is still sought from DOH Region IX in some schedules for obtaining their vaccine supplies. Instead, cases, such as when typhoons strike and scheduled they must stock up whenever they are at the IPHO; the flights or boats from Zamboanga City to the islands are amount they can retrieve is subject to the capacity of delayed or cancelled. their vaccine carriers as well as refrigeration and power supply in their localities. FIGURE 7.4. VACCINE FLOW FROM RITM TO RHUS IN EACH OF THE FIVE PROVINCES AND TWO CITY HEALTH OFFICES, BARMM Lanao del Sur (39 municipalities) Maguindanao (36 municipalities) RITM RITM IPHO Awang Cold Chain Store Wao District Malabang District IPHO/Maguindanao Butuan RHU Hospital Hospital Provincial Hospital RHUs (2) including RHUs (5) including RHUs (32) RHUs (14) RHUs (6) RHUs (16) Wao Malabang including Butuan including Awang Basilan, Sulu, Tawi-Tawi Marawi City (Lanao del Sur) and Lamitan City (Basilan) RITM RITM Via Zamboanga City if needed IPHO CHO RHUs (designated below) RHU/BHS Basilan Province, 11 municipalities: 3 in mainland, 6 in mainland Marawi City: 2 RHUs serving 72 barangays with islands, 2 in islands Lamitan City: 45 barangays Sulu Province, 19 municipalities: 11 in mainland, 8 in islands Tawi-Tawi Province, 11 municipalities (one with two RHUs, hence 12 RHUs getting vaccine supplies from IPHO): 2 in mainland with islands, 7 in islands 164 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M As described above, the central vaccine warehouse of the vaccine supply chain—SN storage, LD storage, and the regional offices use web-based VSSM to and service delivery points—across the five BARMM track inventories. The information for BARMM-MOH is provinces including Marawi City and Lamitan City. The consolidated periodically at the regional level from EVMA reviewed nine criteria related to supply chain the information provided by IPHOs. However, many operations and four regarding supply chain management. facilities lack a systematic inventory monitoring The results were not very encouraging, and corroborate system for vaccines. Manual logbooks are often used the results of the 2018 and 2019 assessments. Specifically, to record vaccine stocks; important information such the EVMA noted inadequate cold and dry storage as expiration, batch number, and manufacturer may capacity throughout the provinces, as well as insufficient not be recorded. Not only is this inefficient, it can availability and use of equipment to monitor vaccine be dangerous if matching vaccines and diluents are storage temperatures, including during transportation. accidentally exchanged. Overall, the accuracy and quality of information provided to regional offices from RHUs Similarly, a rapid assessment of the cold chain in 2018 and IPHOs strains effective management of inventory at in the mainland provinces of Maguindanao and Lanao the regional as well as the national level. del Sur revealed a host of issues, including a lack of consistent power supply needed to properly refrigerate Cold Chain/Stock Management vaccine antigens (UNICEF and DOH-ARMM 2018). Power interruptions are common in many parts of the region, Logistical issues abound when it comes to ensuring the if there is any electricity at all. The 2017 BARMM SSRA cold chain necessary to maintain vaccine quality and provided more data on this occurrence, revealing that efficacy. Several recent studies62 conducted in BARMM only 58 percent are connected to a power grid, while have identified supply side challenges related to the seven percent of RHUs have no power source. Thirty-four cold chain. Most recently, UNICEF conducted an Effective percent of RHUs rely on generators or solar energy for Vaccine Management Assessment (EVMA) in BARMM in electricity supply; this is most apparent in Lanao del Sur early 2020 (UNICEF 2020), which looked at three levels and Sulu (Figure 7.6). FIGURE 7.5. MAIN SOURCE OF ELECTRICITY BY PROVINCE, BARMM Lanao del Sur 35.9 7.7 38.5 17.9 Provinces Mainland Maguindanao 97.3 2.7 Basilan 58.3 16.7 25.0 Island Provinces Lamitan City 100.0 Central supply of electricity (e.g. National Sulu 31.6 26.3 42.1 or community grid) Generator (fuel or battery 50.0 14.3 28.5 7.1 operated generator) Tawi-Tawi Solar system BARMM 58.5 9.8 24.4 7.3 No electricity 0 10 20 30 40 50 60 70 80 90 100 Source: BARMM SSRA, 2019. 62 2017: SSRA; 2018: Rapid Assessment; 2020: EVMA. 165 CHAPTER SEVEN: I M M U N I Z AT I O N P R O G R A M I N T H E P H I L I P P I N E S A N D I M M U N I Z AT I O N C O V E R A G E I N B A R M M In principle, refrigerators used for vaccine storage are procurement, forecasting and planning processes at effective in maintaining the cold chain without a stable the national level should be a priority for DOH; lessons power supply as long as they are ice-lined and/or learned and improvements made as a result of those solar-powered. However, the 2018 cold chain assessment efforts should be shared with LGUs. showed that there is an inadequate supply of these refrigerators, and many cold storage facilities use regular Overall, the operations of the immunization program domestic refrigerators. Household refrigerators are not in BARMM are driven in large part by the supply and equipped to maintain a consistent, long-lasting cold management of vaccines. The NG provides the supply of temperature during power outages or uneven power vaccine antigens, and upon receipt of the vaccines, the supply, which can lead to warming and subsequent respective IPHOs and RHUs take over the supply chain freezing temperatures. Even if the power supply if stable, and the delivery of the immunization services as guided refrigerators have to be properly ventilated so they do by the national immunization schedule. The regional not overheat, a problem that was also noted. autonomous government has had a very limited role in how the program is run and managed. In instances where ice-lined refrigerators were used, user error threatened vaccine potency. For example, basket However, the MOH has worked with development partners trays were removed in some cases in order to make more to conduct various assessments, which have identified storage space, but this resulted in vaccines being in close specific deficiencies in the delivery of immunization contact with metal that was below freezing temperature. services that are the result of underinvestment in In addition, there were no trained cold chain technicians infrastructure, equipment, and human resources, and in the region to undertake needed repairs. Finally, there a related lack of systems. Specifically, as a culminating were instances where ice-lined refrigerators were not activity of the EVMA, the MOH created a vaccine being used because staff did not know how to management improvement plan, which identified install them. strategic actions for the next five years for developing a vaccine logistic management system, strengthening Poor handling of vaccines was also observed during human resources for logistics, and ensuring efficient transportation, including freeze-sensitive vaccines infrastructure. The effort going forward will be how to having direct contact with ice packs and being exposed implement the plans resulting from this recognition of to freezing temperatures. This handling threatens the deficiencies. There are seemingly cyclical challenges with quality and effectiveness of the vaccine. funding and implementation, wherein plans cannot be implemented because they are unfunded, and even for those plans where resources are available, capabilities DISCUSSION have not been developed to effectively implement systems at either the regional, provincial or RHU level. The immunization program presents a case study on how Nevertheless, the plans ensuing from the EVMA and public health programs are financed and implemented in other recent assessments deserve serious evaluation an autonomous region where the NG not only provides and involvement at the highest level, with corresponding policy direction but also procures essential commodities monitoring of implementation. such as vaccine antigens. It also demonstrates how challenges at the national level, such as in procurement The current transition period in BARMM is an opportune and forecasting, can have implications for the time for MOH to implement these needed and desired implementation and management of regional and LGU improvements, in a considered and coordinated manner. program activities. Beyond resulting in vaccine stockouts Having the budget for procurement of vaccine antigens and disruptions in the supply chain, inadequate M&E is beneficial, but vaccines alone are just one piece in processes at the national level may be mirrored in a complex vaccine delivery process; the availability of the regions, leading to poor oversight of community- funding alone cannot solve the deficiencies in service level program activities and requirements. Improving delivery. Additional program resources should not be 166 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M treated as a windfall but instead carefully planned with government might be tasked with transporting vaccines sustainability in mind. from the provincial hospitals to the district hospitals, while municipal governments could provide the If the MOH initiates procuring vaccines and related transportation to transfer vaccines from the hospitals to supplies on its own, it will need to strengthen its the RHUs. Identifying specific roles for various partners procurement functions. Own procurement of vaccines, could encourage them to more willingly support the however, should be a low priority at this time, and health sector. MOH should not initiate this change without having a properly staffed service delivery and supply distribution The central/regional setting for service delivery and system in place. Such a system could be developed to the funding from the block grant gives BARMM the more accurately forecast the volume of demand for opportunity to implement reforms described in the equipment, vaccines, and related supplies in each area UHC Law. The MOH has an opportunity to manage a and to take stock of inventory that will establish timely natural network of government facilities, with some replenishment of consumables. The system need not be resources to support it. While BARMM cannot provide an electronic system at first, although this should be a much insight into private sector take-up of individual- goal in the longer term. based health services, the BARMM case may instruct the NG as to how the immunization program should be Once there is a clear vaccine supply system, the MOH will funded in the context of UHC. The purchase of necessary have more leverage in obtaining the needed participation vaccine antigens is only one aspect, and supply factors and funding from other stakeholders, especially the LGUs. and procurement capabilities are essential factors For example, the provision of personnel is a customary for whether the NG should continue to purchase the feature of LGU support, and there is a clear need for antigens. However, the BARMM case shows that for the more service delivery personnel. However, in BARMM, other aspects of the program to function, including staffing may be best provided by the MOH, which can logistics in handling the antigens and subsequent more closely capacitate personnel with the necessary provision and monitoring of immunization services, a skills and competencies. Meanwhile, LGUs can be asked well-managed and sustainably-financed primary care to support other regular tasks in the system that are network is required. also tangible and visible. For example, the provincial 167 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT CHAPTER EIGHT: PREPARING FOR EFFECTIVE AND ROBUST GOVERNANCE OF HEALTH IN BARMM - FINANCIAL MANAGEMENT SUMMARY agencies or the general public. This will not change under the BOL, which will make it challenging for the • Within the constraints imposed on BARMM, the BG to develop holistic fiscal policy for the region. Bangsamoro Government (BG) has many unique powers and privileges not available to other regions • Mindanao and BARMM in particular are among the within the Philippines. These include the ways in poorest and least well served areas of the country which it will be governed, its sources of revenue, and in most respects, including health. This adds an the flexibility with which it can manage and allocate extra layer of difficulty for the BG and constituent its resources. It also faces substantial challenges, not LGUs because they are starting this new phase of least of which are the transition from ARMM and the development from a low base, both individually public financial management environment that it has and relative to the rest of the country. Health inherited. programmatic and surveillance data are weak and unreliable, meaning that these inequities are likely • An overall increase in funding will come in the form to be more persistent and intractable than of a block grant. BARMM will have greater autonomy is apparent. over fiscal policies due to the flexibility provided by the block grant and other guaranteed revenue • A coherent health strategy and significant sharing arrangements. Another important new investments are needed for the health system to source of funds for BARMM regional development adapt and improve outcomes. It will be important for under the BOL will be the Special Development BARMM to consider refocusing its efforts in health Fund. This provides for an allocation of five billion on improving outcomes and setting challenging pesos per year for 10 years from the date of the BOL targets in relevant indicators that are needed to for rebuilding, rehabilitation and development of close the gap between BARMM and other regions. conflict-affected communities. This overview suggests that BARMM will face considerable challenges in achieving improvements • All LGUs within the BARMM territorial jurisdiction will in service delivery outcomes in the areas identified continue to receive their annual Internal Revenue as priorities for its budget. This is complicated by Allotment (IRA), which is automatically appropriated the multiple sources of activity from all tiers of in the GAA. LGUs are accountable to the NG as the government that contribute to outcomes, making it source of their IRA. ARMM did not have any control difficult to establish a unified strategy and to ensure over LGU fiscal management and did not receive any complementarity and effective accountability separate information on their financial positions for results. or performance other than what is available to NG 168 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M INTRODUCTION CONTEXT This chapter presents an extract of a study63 led by Legal and regulatory arrangements for Public the World Bank Governance team, which was initiated Financial Management to assist the Government of the Philippines in its socio-economic agenda in Mindanao—particularly The legal and regulatory framework for ARMM consisted BARMM. Improving the efficiency and effectiveness of of separate national laws, executive orders, and regional service delivery to citizens is of high priority for the laws. This resulted in unclear and at times contentious government. The main objective of the report is to assignment of powers, functions and responsibilities document institutions, processes and systems in place among the NG, ARMM, and the LGUs. Much of this for financial management in BARMM, drawing largely complex legal framework continues with BARMM, however on the arrangements in ARMM where there is no clear key features differ. BARMM will have a parliamentary form alternative to be applied in BARMM. This examination of government, meaning that residents will vote directly is intended to provide a basis for the formulation of for their representatives in the Bangsamoro Parliament recommendations on improving the efficiency, reliability (BP). The BP will choose a Chief Minister by a majority and timeliness of resource use, financial management, vote. BARMM executive authority will be exercised by service delivery and results for the region. The findings the Cabinet headed by a Chief Minister. BOL Article V, of the report are of importance to the governance of Section 2 expressly defines 55 exclusive powers that health in BARMM, where the majority of services remain would be devolved to the Bangsamoro people, thereby financed and delivered by the public sector. providing more powers to the Bangsamoro region and less intervention from the NG. The report is intended to identify the strengths, weaknesses and key risks in the financial management Aside from automatic appropriations via a block grant, processes, which are essential for the design of health described above, the BOL also provides for an increase interventions in BARMM. It seeks to identify where in the share for the BG of national taxes collected in processes and controls are operating effectively, and, the Bangsamoro territorial jurisdiction, that is, from conversely, identify areas that require strengthening 70 percent to 75 percent inclusive of the shares of the or additional oversight. This analysis complements the constituent LGUs (BOL Article XII, Section 10). The BP parallel work by the World Bank on the health sector, will enact a law detailing the share of the constituent presented in other chapters in the Health Financing LGUs in the 75 percent share (BOL Article XII, Section 13), Systems Assessment. Further details of the methodology, unlike the ARMM Organic Law (AOL) which itemized the broader analysis, conclusions and recommendations for sharing differently. As provided for in the BOL (Article Financial Management in BARMM may be found in the XII, Section 34), all government revenues generated full report. from the exploration, development, and utilization of all natural resources including mines and minerals in the Bangsamoro territorial jurisdiction shall pertain fully to the BG. The BG share will be apportioned as follows: 30 percent BG; 20 percent to the provinces; 15 percent to the cities; 20 percent to the municipalities; and 15 percent to the barangays (Article XII, Section 35). Under the AOL, NG accounted for a 30 percent share in the taxes imposed on natural resources. 63 Presented in the World Bank publication “Preparing for Effective and Robust Financial Management in the Bangsamoro Region,” published May, 2019. 169 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT The BTA will be the interim government in the • Internal Audit Office Bangsamoro region until a new election is held in 2022 to • Regional Civil Service Field Office coincide with the national election. The 80-member BTA • Bangsamoro Economic and Development Council was sworn in by the President in February 2019, including • Bangsamoro Economic Zone Authority the Interim Chief Minister, who was appointed by • Bangsamoro Electoral Office the President. • Bangsamoro Disaster Risk Reduction and Management Council Institutional arrangements for Public • Bangsamoro Human Rights Commission Financial Management • Bangsamoro Commission for the Preservation of Cultural Heritage The extent of BARMM autonomy and control of public financial management is limited by an ambiguous legal Until the above institutions are established, their framework marked by historical deviations of practice functions will continue to be undertaken by NG. from the provisions of the law. It is also limited by a lack However, the NG will still provide assistance to the BG of complete fiscal autonomy in the territory it covers, on tax administration and fiscal management, including characterized by only partial control over the government capacity-building and training programs. BARMM is functions and services provided within BARMM territory, subject to accountability rules set by the Commission and limited jurisdiction over the constituent sub-regional on Audit (COA) and the Department of Budget and governments. Under the provisions of the BOL, the BP Management (DBM). However, it will not be required to needs to enact priority legislation that will establish justify line item expenditure for release of authorized institutions and define their mandate, outline the funds, and will no longer be subject to the stringent administrative structure including interrelationships with former power of the President or the Secretary of Finance the NG and the LGUs, and operationalize the powers and to reduce, suspend or cancel the release of unaccounted functions including fiscal autonomy over its jurisdiction. funds from the block grant and other shared revenue. This includes: Mechanisms to facilitate coordination and cohesion with the NG on national policies and ensure BARMM’s • Bangsamoro Administrative Code representation and protection of its interests are also • Bangsamoro Budget provided for under the BOL which involve the creation of • Bangsamoro Tax and Revenue Code a number of intergovernmental relations bodies. • Bangsamoro Local Government Code • Bangsamoro Civil Service Law Despite the autonomy granted to ARMM as provided • Bangsamoro Electoral Code for under RA No. 9054 and in the newly enacted BOL, • Legislation on the Share of the Constituent LGUs in it remains an integral part of the territory of the Taxes within BARMM Philippines as provided for in the Constitution. The • Bangsamoro Education Code powers, functions and responsibilities of BARMM are limited by national legislation. Anything not specified in In addition, the BOL defines the key institutions that will the BOL is a NG responsibility. In addition, some powers be established under BARMM, including: and responsibilities are outside the BARMM remit due to explicit legislative provisions in the BOL and elsewhere, • Bangsamoro Budget Office including: National Defense and Security, External • Bangsamoro Revenue Office Auditing by the Commission on Audit and approval of • Bangsamoro Regional Office of the Bureau of Local Official Development Assistance, Grants and Donations Government Finance from foreign countries. • Bangsamoro Treasury Office 170 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M FISCAL PLANNING, BUDGET relating to ARMM local funds from revenue originating PREPARATION AND ALLOCATION within the region. BARMM will have greater autonomy over fiscal policies due to the flexibility provided by the block grant and other guaranteed revenue sharing Fiscal planning and fiscal risks arrangements. It will still be subject to some overarching Ratification of the BOL in February 2019 means that national policies, such as those set out in the future fiscal planning will be founded on a different Administrative Code. There are also explicit requirements basis than previous plans. ARMM prepared fiscal plans in the BOL for revenues to be spent in a ‘programmatic, and budgets, including for the 2019 budget, in much transparent, performance-based, and phased manner’ the same way as did NG departments and agencies. (Art. XII, Sec,1). However, BG would be able to develop This involved reliance on national fiscal planning and its own policies on matters relating to internal fiscal procedural arrangements, taking into account the arrangements, for example on taxes and fees, borrowing, Philippine Development Plan (PDP) and its own Regional issuance of bonds, expenditure allocation and use Development Plan (RDP). The BG will be represented on of funds. The BOL explicitly states that budgetary the national development plan steering committee and arrangements should be consistent with NG provisions participate in National Economic Development Authority under a law created by the BP. (NEDA) planning activities. It will need to prepare a RDP All LGUs within the BARMM territorial jurisdiction will for adoption by the BP, as required under BOL. This is continue to receive their annual IRA that is automatically expected to be based on the existing plans for ARMM, the appropriated in the GAA. LGUs are accountable to the NG PDP and other relevant regional planning documents that as the source of their IRA. As mentioned above, the ARMM have been prepared already by groups within BARMM. did not have any control on LGU fiscal management There may need to be modifications to existing regional and did not receive any separate information on their planning and priorities documents within the BTA as financial positions or performance other than what is they seek to merge existing and new priorities into an available to NG agencies or the general public. This updated planning document for the region. The plan to will not change under the BOL, which will make it be adopted by the BP will provide the basis for budget challenging for the BG to develop holistic fiscal policy preparation and for use of funds provided under the for the region: because they do not necessarily have Special Development Fund referred to in the BOL. access to information on LGU plans, activities and The arrangements for appropriation of revenues to achievements, they cannot use this information as a BARMM from the year after the BOL comes into force basis for developing overall fiscal plans for BARMM. (2020) will not be subject to the GAA. The provisions There is still no obligation for LGUs to provide their for revenue sharing and the block grant are defined by plans to BG or discuss the contents in advance of budget formulae in the BOL and may not be withheld by the preparation. This could result in duplication of activities NG or NGAs. It will be crucial for effective planning and or unintended gaps in services at LGU level. A more budget preparation for BARMM to have clear, reliable and systematic approach is needed to ensure that LGUs are agreed information on the precise amount and timing adequately served and resources allocated efficiently to of fund availability in advance of budget preparation achieve maximum benefit from the perspectives of NG, activities. The BOL provides information on the scope of BG and LGUs. revenue transfers but is not explicit about the timing of Budget preparation availability. It can be assumed that the entire amount of transfers will be available from the start of the fiscal year, Table 8.1 shows the budgets approved for ARMM in the providing the allocation law is in place within BARMM. last three completed fiscal years and the budget proposal for 2019. It shows a steady increase in new appropriations Under ARMM, the legislative branch had no power over for ARMM over the period. 2019 was an exception due to fiscal policies affecting the region, other than those the introduction of annual cash-based appropriations, 171 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT TABLE 8.1. ARMM PROPOSED AND APPROVED BUDGET (IN PESOS MILLIONS) – NET OF RLIP 2016 2017 2018 2019 Tier 1 Budget Ceiling (per DBM) 25, 208 25,803 27,687 32,224 BESF or NEP for Congressional approval 28,492 40,574 32,349 31,117 (excluding automatic appropriations for retirement and life insurance premiums) New appropriations under GAA 28,492 32,262 33,057 31,117 Source: ARMM ORT documents contributing to a reduction in total new appropriations national level. It coordinated the regional line agencies’ proposed for ARMM in that year. submissions and accountability on national budgetary activities, and with ARMM offices and departments The 2016 Public Expenditure and Financial Accountability on local budget preparation for Regional Legislative (PEFA) assessment rated the Philippines national budget Assembly (RLA) appropriations. The RBMO is expected preparation process highly. It scored an ‘A’ for the budget to provide the seed for establishing and growing the process and ‘B+’ for legislative scrutiny of budgets. BBO. The RBMO function was limited to the management In 2019 the budget preparation process would have of local funds as the regional line agencies interacted remained at the ‘A’ level but the legislative scrutiny score directly with the DBM. The BBO will implement the would have been reduced due to the re-enactment of the budgetary laws and procedures to be enacted by the 2018 budget. BP on the Bangsamoro Budget and public financial management (PFM). The PEFA rating of the national budget process provides a somewhat deceptive impression of budget preparation LGUs follow a different process for budget planning and in ARMM because there has been no substantive regional preparation from ARMM and BARMM. The DBM issues budget process or ARMM legislative scrutiny of the a local budget memorandum annually that includes majority of the budget. This is understandable in that the the IRA based on the BIR certification of LGUs’ internal process was controlled by NG and the Congress. However, revenue shares for the third year preceding the current for BARMM there will have to be a major change because fiscal year. The memorandum also contains guidelines on the BP will need to examine, discuss and appropriate the preparation of the annual budget for the next fiscal budgets. The BG will need to establish the necessary year. The relevant DBM Regional Offices (DBMROs) inform rules and procedures for budgets to be planned, the concerned LGUs of their individual IRA allocation. scrutinized and negotiated at administrative and Annual budgets are prepared in accordance with RA No. legislative stages. The BOL requires the establishment of 7160 and the Budget Operations Manual for LGUs for a Bangsamoro Budget Office (BBO) for the preparation of submission to, and budget authorization by, respective a budget.64 The BOL also imposes some strict parameters Local Sanggunians (municipal councils). This process will within which budgets will need to be formulated, not change with the establishment of BARMM. There has particularly in respect to allocation of the annual block been no involvement by ARMM in budget planning and grant.65 For example, the highest budget priorities should preparation by LGUs and there is no indication that this be given to education, health and social services. will change under BARMM without additional legislation or agreement between BARMM and LGUs. The Regional Budget and Management Office (RBMO) of ARMM was the regional counterpart of the DBM at the 64 BOL, Article VII, Section 28. 65 BOL, Article XII, Sections 19 and 20. 172 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M TABLE 8.2. GAA ALLOCATIONS PER ARMM REGIONAL LINE AGENCY (IN PESOS MILLIONS) – NET OF RLIP Department Main expenditure / programs 2016 2017 2018 2019 Amount % Amount % Amount % Amount % Regional DPWH Capital outlay for repairs or improvements, 10,719 38 10,931 34 10,904 33 10,779 33 and construction of road network and other infrastructure facilities. Regional DEPED Personnel and operating costs of 8,066 28 11,553 36 10,258 31 10,894 33 implementing basic education programs. Office of the Operating expenses and capital outlay 5,881 21 5,473 17 7,385 22 4,653 13 Regional Governor for ARMM HELPS, BRIDGE, and PAMANA programs Regional DOH Personnel, and maintenance and operating 1,154 4 1,292 4 1,333 4 1,504 5 expenses for regional, provincial and city health offices, and district and municipal hospital services Office of the Operating expenses for ARMM revenue 807 3 809 3 1,009 3 1,008 3 Regional Treasurer generation and fund management Other 21 ARMM Personnel and operating costs of regional 1,866 7 2,205 7 2,161 7 2,279 8 agencies and the RLA line agencies Total new ARMM 28,492 100 32,262 100 33,057 100 31,117 100 appropriations per GAA Source: Budget documents Budget Allocation Table 8.3 shows the allocation of appropriations amongst expense types. The largest shares of funds are accounted Table 8.2 shows the top allocations to the ARMM regional for by personnel services and capital outlays. Personnel line agencies, which comprise 93 percent of the total services accounted for 45 percent in the budget approved new appropriations for the period 2016–2019 with by parliament for 2019, and 43 percent in 2018. The BOL corresponding regional priority programs, and allocation requires that no more that 45 percent of total annual by general expense class. The regional Department revenue is used for personnel services. This could limit of Public Works and Highways (DPWH) and DepEd the space for the BTA to implement significant new consistently received the largest allocations among the staffing capacity in 2019. In 2020 and beyond, the revenue ARMM line agencies in recent years. The reduction in base will be significantly larger, so the percentage total allocations in 2019 compared with 2017 and 2018 constraint on personnel services expenses should be less coincides with the policy change from obligations to confining. The budget allocation for BG in 2019 will be the annual cash-based appropriations. TABLE 8.3. GAA ALLOCATIONS PER GENERAL EXPENSE CLASS, 2015-2019 (IN PESOS MILLIONS) – NET OF RLIP Department 2015 2016 2017 2018 2019 Amount % Amount % Amount % Amount % Amount % PS 10,868.0 43.1 11,806.2 40.1 15,881.1 47.4 14,661.1 42.9 14,568.4 45.1 MOOE 3,103.4 12.3 4,489.8 15.3 3,994.1 11.8 4,775.0 14.0 4,658.6 14.4 CO 11,258.0 44.5 13,117.0 44.6 13,644.7 40.8 14,742.0 43.1 13,058.8 40.4 Fin Ex - - - - - - - - - - Total 25,229.3 100.0 29,413.0 100.0 33.469.9 100.0 34,178.1 100.0 32,285.8 100.0 Source: CPBRD ABN2018 173 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT 2019 budget for ARMM, which at the time this draft report of five billion pesos per year for 10 years from the was completed, was the re-enacted 2018 ARMM budget. date of the BOL for rebuilding, rehabilitation and The BOL states that the block grant will be calculated development of conflict-affected communities which for the budget year immediately following the effectivity should be covered by the Bangsamoro Development of the BOL, which would be 2020. This means that the Plan to be adopted by BP. degree of autonomy over the use of funds anticipated under BARMM will not apply in 2019. In particular, the b. Funding for NGA activities in the region. National application of NG powers controlling the release of funds, Government Agencies (NGAs) such as DOH, DPWH and the withholding or cancellation of unaccounted and DepEd also allot funds for use in the BARMM. funds, will be an important consideration in whether any Other functions that are not fully devolved provide funds affected by such arrangements could be retained funds for NG actions that required ARMM action but by BARMM for future use. are not controlled by the region, such as national disaster recovery activities. Although these resources REVENUE COLLECTION AND are not revenue for BARMM to allocate as it chooses, it needs to be considered in the overall government MANAGEMENT resources available to the region and used for the benefit of residents. This includes capital outlays ARMM/BARMM revenue and various special purpose funds to implement in relation to programs and projects in areas covered The ARMM derived revenue mainly from: a) NG by counterpart agencies in the BG. Many of those appropriations and budgetary allocations; b) funding funds will continue to be centrally managed and for National Government Agency (NGA) activities in the therefore not devolved to their counterpart agencies region; c) shares in internal revenue (and any taxes in the BG. imposed on the use of natural resources) collected within its area of autonomy; and d) regional taxes, fees c. Shares in internal revenue (and any taxes imposed and charges. BARMM will have the same general sources on the use of natural resources) collected within its of revenue but there will be substantial differences in the area of autonomy. The regional funds from locally size of NG general transfers and revenue shares under raised taxes and fees and BARMM’s share in the IRA the BOL, as follows: (excluding shares for other LGU tiers) is set at 35 percent. These funds are under the full budgetary a. NG appropriations and budgetary allocations. control of the BARMM government. The regional The most significant difference between ARMM and funds are programmed by the Regional Economic BARMM revenue will be the block grant for five and Development Planning Board (REDPB), approved percent of net national revenue collections by the by the RLA and managed by the RBMO. However, Bureau of Internal Revenue (BIR) and the Bureau of tax collection remains highly centralized through Customs (BOC) from the third fiscal year immediately the BIR, which means that regional funds are not preceding the current fiscal year (the budget year). automatically available for use after collection. Block grant funding will be included in revenue for 2020 and every subsequent year. The BOL states that The ARMM did not receive any share in revenues it is intended to be “sufficient for the exercise of from the utilization and development of strategic the powers and responsibilities of the Bangsamoro minerals or from incremental VAT as provided under Government under this Organic Law”. Another the AOL in the absence of clear implementing important new source of funds for BARMM regional guidelines, based on the study conducted by the development under the BOL will be the Special Institute for Autonomy and Governance.66 It would Development Fund. This provides for an allocation be important in terms of equity and incentives for 66 Drawing Lessons for the Creation of Regional Governments Under a Federal Setup—Case Study on the Autonomous Region in Muslim Mindanao published by the CPBRD in partnership with the Institute for Autonomy and Governance in 2017. 174 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M the NG and BARMM to reach agreement on how to revenue allotment (IRA) for LGUs within the BARMM address the anomalies in tax sharing to ensure that makes them fiscally independent of BARMM. The IRA BARMM and its constituent LGUs benefit from growth accounts for more than 90 percent of annual revenue for and wealth increases within its borders. many LGUs. As a result, the LGUs are intensely focused on that source of funding and the conditions under which it d. Regional taxes, fees and charges. The BARMM is provided, regardless of any plans or priorities decided government has powers to raise revenues as by BARMM. provided for in the BOL.67 The amount of funds collected from regional taxes, fees, charges and Tables 8.4 and 8.5 show that BARMM LGUs have received other income aside from NG transfers amounted as much IRA as the non-BARMM Mindanao regions and to less than five percent of total annual revenue higher shares of national tax collections from their for ARMM. The largest source of regional revenue portion of regional government’s share in NG internal has been the contractor’s tax. The range of regional revenue. In 2016 ARMM LGUs were dependent on IRA for revenue sources available to BARMM has increased 96 percent of their revenue compared with the national compared with ARMM but it will be difficult in the average of 64 percent. short term to establish new sources of revenue or to increase charges on Bangsamoro businesses Discussion with selected LGUs revealed that they need and individuals. This is because new taxes will not to be capacitated in local tax administration and raising replace existing taxes, they will merely increase income from public services and economic enterprises the overall burden of taxes. Also, the residents of (as shown on the comparative table below of local Bangsamoro are among the poorest in the country, revenue for Mindanao regions). IRA for LGUs does not so their capacity to pay additional taxes is more lapse, unlike any unused ARMM budget funds, which limited than elsewhere. With the expanded revenue must be reverted. source granted to the Bangsamoro Government, it needs to ensure appropriate planning and The Office of the Regional Treasurer remits to ARMM- coordination with the NG to obtain the necessary LGUs their due portion of ARMM shares in internal assistance on tax administration and fiscal revenue taxes (including any taxes imposed on the use management, including capacity building and of natural resources) which are effectively additional training programs. sources of revenue for LGUs within the jurisdiction. Non- IRA municipalities receive financing assistance from the LGU revenue ARG and/or from their host municipality and provincial LGU. The amounts remitted to LGUs exceeded PhP 660 The NG, through the Bureau of Treasury (BTr), releases billion in each year during the period FY2016–2018. The IRA directly to LGU local treasurers appointed by the amounts of locally generated taxes and other revenue Department of Finance (DoF). The LGUs independently were significantly lower in ARMM than other Mindanao control their respective IRA and revenue from all regions. For example, Region XI obtained almost 20 times sources. This is not expected to change following the the amount of revenue from local taxes and charges as establishment of BARMM. The provisions of the 1991 Local the ARMM LGUs. Government Code (LGC) regarding the use of internal 67 Article IX, Sections 1, 8. 175 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT TABLE 8.4. 2016 LGU IRA DEPENDENCY 68 (IN PESOS MILLIONS) Department Region IX Region X Region XI Region XII Region XIII ARMM Mindanao Philippines CARAGA Total Total Locally sourced revenue 2.606 5,952 6,380 3,283 2,608 334 21,163 175,610 Internal revenue allotment (IRA) 14.305 19,120 17,346 16,034 14,474 16,019 97,298 343,777 Annual regular income (ARI) 16,946 25,262 23,764 19,332 17,870 16,643 119,817 536,767 IRA Dependency 84% 76% 73% 83% 81% 96% 81% 64% TABLE 8.5. 2016 LGU EXTERNAL REVENUE 69 (IN PESOS MILLIONS) Department Region IX Region X Region XI Region XII Region XIII ARMM Mindanao Philippines CARAGA Total Total EXTERNAL SOURCES 14,585 19,577 17,598 16,216 15,312 16,473 99,762 369,227 Revenue Allotment 14.305 19,120 17,346 16,034 14,474 16,019 97,298 343,777 Other Shares from National Tax 35 190 39 14 787 290 1,356 17,380 Collections Inter-Local Transfer 30 163 98 104 31 12 440 2,057 Extraordinary Receipts/ Grants/ 214 104 115 64 19 152 668 6,013 Donations/ Aids FISCAL AND BUDGETARY TRENDS DPWH were the main reasons for the fall between 2015 and 2016. In contrast, transfers from the Department of Appropriations to ARMM between 2015 and 2019 Social Welfare and Development (DSWD) increased during gradually increased. There has been greater volatility the period. Although new appropriations are by far the in other categories of appropriations during the period. largest category of funding, accounting for more than 80 For example, continuing appropriations displayed a percent of total appropriations, the significant volatility significant drop between 2015 and 2016 from PhP 389 of other appropriations created challenges for ARMM, million to PhP 97 million respectively. This was followed and will have a similar impact on BARMM. Changes in by a substantial increase to PhP 3,009 million in 2017 sectoral transfers can be particularly challenging in both due to a large amount of unused capital and MOOE upward and downward directions as the agencies have appropriations from 2016. It is understood that the to adapt to large increases or decreases in workload. unused appropriations were largely attributable to long These changes are often unpredictable and in the past delays in approval of capital and maintenance projects the ARMM agencies could not plan in preparation for the within ARMM. changes, and were therefore obliged to react as quickly as possible. Adjustments in ARMM allocations to affected Transfers from national government agencies (NGAs) agencies were difficult when late notice of changes also experienced volatility between 2015 and 2018. Total was received (because budget allocations are locked transfers fell from PhP 4,866 million in 2015 to PhP 2,619 in before the start of each year as part of the national in 2016 and continued to shrink in 2017. Cessation of budget process). certain transfers from the Department of Agriculture and 68 Computed from the Statement of Receipts and Expenditures consolidated by the BLGF-DOF 69 Computed from the Statement of Receipts and Expenditures consolidated by the BLGF-DOF 176 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M ARMM has been unable to obligate all available the relatively low disbursement rate in 2017 to address appropriations during the period. In 2015 they performed any unavoidable payment delays. This will ensure very well in being able to obligate 98.6 percent of efficient cash management and avoid a build-up of available appropriations. The following year, however, payment arrears. ARMM was only able to obligate 87.1 percent of available appropriations. The ratio of obligated to available It will be important for BARMM to maintain control of all appropriations increased again in 2017 to 93.3 percent. funds coming into and going out of the government. The This volatility in obligation ratios is a signal that there many sources of funds and the different ways that they may be problems in reaching timely decisions, difficulties enter the region have not been centrally managed in arising in maintaining progress on major capital ARMM. Funds provided through appropriations to ARMM investments or variations in absorption capacity due to and from NGAs have entered the region in a variety of institutional or operational factors. BARMM will need to ways in the past, though most have been channeled examine the reasons for volatility in the appropriation through either the ARMM treasury or Office of the utilization rates to determine the underlying causes and Regional Governor (ORG). BARMM should consider having address them where possible. a single agency responsible for managing funds from all sources and disbursement of those funds to agencies BUDGET EXECUTION as needed. This will facilitate good practices in cash management, financial control, recording and reporting on those funds. Cash management Operational and program expenditure Considering that BARMM ‘shall partake the nature of’ an LGU, it is not required to maintain a bank account The BG will have authority over several areas critical to within the Treasury Single Account. However, the basic service delivery such as budgeting, administration management of funds release and cash will be a much of justice, agriculture, environment, natural resources, bigger responsibility for BARMM than ARMM. There will be civil service, education, disaster risk reduction and substantially more funds available to BARMM than ARMM management, health, human rights, public works, social and the timing of transfer from the BTr to BARMM, and services, tourism, and trade and industry. This will be from the BARMM treasury to authorized users will need different to other sub-national governments and different to be carefully managed by the Treasury. This will require to ARMM. the establishment of cash management rules, consistent with laws, national rules and procedures, and rigorous Resources for the region will increase with funding application of those rules by the BARMM treasury. This coming from the IRA, locally generated revenue, annual should be a priority concern for the BG because cash block grants and the ten-year PhP 5 billion annual management has been a consistent focus for Commission allocation from the Special Development Fund for on Audit (COA) qualifications and observations in conflict-affected communities. This will be weighed recent years. against an expanded scope of responsibilities and obligations to establish new and expanded agencies One warning sign that cash management arrangements to comply with the BOL and to cope with the increased may need to be tightened is the significant gap between administration, accountability and service obligation and disbursement rates for ARMM. In 2016 delivery requirements. disbursements were 87 percent of obligations while in 2017 the rate fell to 65.7. Obligations are incurred from ARMM appropriations under the GAA were authorized appropriations at a higher rate than disbursements, on a line-item basis but BARMM will receive lump-sum suggesting that payment for goods and services appropriations and will have the flexibility to change contracted by ARMM was significantly slower than the basis for appropriations, subject to alignment with intended. BARMM will need to examine the reasons for national laws and regulations, to other forms that may 177 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT be more appropriate such as functional, program or to the specific purposes for which they should be spent. other groupings based on development plans. Such These grants can come from a) lump sum allocations in changes may provide more focus on development the GAA, b) allocations from NGAs from their own budget, priorities, but would require robust monitoring and or c) other sources such as donations, grants, and local accountability arrangements to ensure that funds are development assistance. properly controlled and used for the purposes intended. This will be a challenge considering the absence of such Health and Social Services mechanisms under ARMM, and considering the lack of control over LGUs that may receive funding from BARMM. The national budget places substantial resources with NGAs for the provision of local level services and Under the AOL, funds allocated for ARMM were released investments. Since there are several vertical programs directly to the treasurer of the RG (regional government). budgeted under NGAs which are implemented at the In the same way, the BOL states that annual block grants local government level, this has led to numerous parallel will be automatically appropriated and will be released funding flows, resulting in fragmentation of planning, directly and comprehensively to the BG without any lien budgeting, service delivery, and accounting leading to or holdback that may be imposed by the NG for whatever diffused lines of accountability. This was the case prior purpose. Funds received from NG through BTr to BARMM to BARMM and will continue unless a formal mechanism will be transferred to the regional agencies based on is established to simplify and monitor various funds and the approved budget by the BG. National programs and in-kind flows and accountability reporting. projects shall continue to be funded by the NG, such as the Pantawid Pamilyang Pilipino Program (Bridging DOH and DSWD have been particularly involved with Program for the Filipino Family—under DSWD), Health LGUs under the local government code due to activities Facility Enhancement Program, School Building Program, that have been devolved to LGUs. However, many health retained hospitals at DOH, PhilHealth, social pension for and social services programs continue to be funded senior citizens and Taskforce Marawi. by the central government under the budget of the DOH and DSWD. These include the Pantawid Pamilyang The involvement of NGAs in BARMM will continue to Pilipino Program, Health Facility Enhancement Program, entail a complex range of approaches and procedures retained hospitals at DOH, PhilHealth, social pension for with varying degrees of consultation and engagement senior citizens, immunization, control of communicable with BG, as has occurred under ARMM. This will maintain diseases, provision of drugs and medicines to devolved the challenging environment for the region in which the facilities, and operation of hospitals in the NCR. DOH- BG will need to draw up policies, plans and budgets on ARMM had a memorandum of agreement (MOA) with the the basis of partial information on government activity national DOH on funding, programs and services. Funds and investment in each sector. This makes it very difficult for national health programs were channeled through for agencies at all levels of government to ensure the Office of the Regional Governor (ORG) to DOH-ARMM. complementarity or efficient alignment of actions and Planning is done at the national program level and it thereby achieve their ends. appears that there was no involvement by DOH-ARMM in planning or decisions on those programs. LGU funding from NG transfers is received in two ways: formula-based block grants (or IRA); and ad hoc One of the many challenges of the complex funding grants. IRA is allocated to the different levels of local and administration arrangements is the multiple sets government and to specific LGUs within each level of guidelines for eligibility and fund release. Funds according to a pre-determined formula. LGUs have flow from the national budget to LGUs through several almost full discretion in the utilization of their IRA channels, each with its own set of requirements on after considering national guidelines on spending for eligibility, utilization and reporting. This includes funds development plans, debt servicing, gender programs, under overseas development assistance (ODA) as well as and so forth. On the other hand, ad hoc grants are tied locally funded programs. The parallel fund flows create 178 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M an extensive compliance burden on the limited capacity need strengthening: 1) competitiveness of the bidding of the LGUs by requiring different business processes and process; 2) procurement planning and implementation; administrative arrangements. 3) use of Philippine Government Electronic Procurement System (PhilGEPS) in announcing bidding opportunities Delivery on the ground is complicated by each agency and results; 4) efficiency and timeliness of the interacting with LGUs in various ways. The NGAs set procurement process; 5) capacity building; 6) internal their own guidelines for LGUs regarding each of the audit; and 7) the procurement complaint system. programs they administer. The local governments shared their frustrations regarding conflicting policies on fund Under BARMM, procurement implementation should be releases during interviews for this project. When the implemented in coordination with overall public financial NG releases funds to LGUs, it issues corresponding management activities, with an emphasis on guidelines such as compliance with RA No. 9184. However, the following: specific provisions of the guidelines may require LGUs to do otherwise. Furthermore, LGUs noted that the new • Strengthen collaboration with the private sector rules or guidelines are not disseminated to them in a in determining the appropriate procurement timely manner. NGAs place on LGUs the responsibility for arrangement in the region; awareness of applicable rules, which are often posted on websites. However, some LGUs, especially those without • More transparency, including publication of reliable internet connectivity, are unable to check the investment priorities and budgets; NGAs’ websites regularly to stay abreast of new rules • Institute procurement planning linked with the or guidelines. budgetary process; Procurement • Mandatory use of PhilGEPS in announcing bidding All NG procurement—for departments, bureaus, offices opportunities and results; and agencies, including state universities and colleges, • Ensure appropriate use and reference of government-owned or controlled corporations, procurement plan; government financial institutions and LGUs—is covered by the procurement law, RA No. 9184, Government • Build capacity within the agencies/LGUs through Procurement Reform Act (GPRA), and its implementing professionalization of procurement practitioners, rules and regulations (with latest revision as of tapping the Government Procurement Policy Board- 2016). BARMM will likewise adhere to the GPRA in its accredited State Universities and Colleges for procurement processes. In all cases, the procurement training and making them a procurement resource of the government should be governed by the following for BARMM instrumentalities; 24 BOL Article XII, principles: transparency, competitiveness, efficiency, Section 19; accountability and public monitoring of the process. The government uses a tool to monitor and focus • Establish an internal audit system in line with strengthening measures in the Procurement Entities. the greater requirements for public financial The Agency Procurement Compliance and Performance management; and Indicator (APCPI) self-assessment is widely supported in the government, and it is an important instrument in the • Together with the national government, enhance the performance-based incentive mechanism. In the sample current procurement complaint system making it APCPI provided by three ARMM LGUs, the following areas more independent from the Procuring Entity. 179 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT Controls on budget execution INTERNAL AUDIT In 2020, BARMM will have access to the block grant There was no internal audit across most of the ARMM and other revenues according to its own budget Government and LGUs. COA is relied upon to verify management rules, however those rules must comply compliance with required procedures and practices. with the BOL provisions requiring budget preparation and Among the ARMM line agencies, DPWH-ARMM and allocation to conform to national laws and budgeting DOH-ARMM have internal audit units that report to the rules and regulations implemented by DBM and DILG respective Regional Secretaries. The DBM has been for allocations from the block grant.70 The BOL also responsible for monitoring internal audit of NGAs and imposes additional constraints on the content and LGUs. There is a recent COA Circular No. 2018-003 that prioritization of expenditure within the BARMM budget prescribes the use of the Internal Auditing Standards that are not applied to the national budget. These for the Philippine Public Sector (IASPPS) and Internal include: priority to health, education and social services; Control Standards for the Philippine Public Sector no expenditure permitted for firearms; and annual (ICSPPS) effective November 21, 2018. The new circular appropriations for personnel services, including salaries aims to update the existing rules and regulations on and allowances, must be less than 45 percent of annual the internal control system and keep abreast of recent revenues. The ARMM budget proposed for 2019 included developments in the internal auditing profession and personnel services expenditure of around 49 percent related internal control systems. The BOL requires the of appropriations, which would need to be trimmed BG to establish an auditing body that will have internal to comply with the required limit. In addition are the auditing responsibility across the regional government. agencies and institutions that will need to be established An internal audit charter will need to be enacted by the and maintained under the BOL. The additional funding Parliament in order to ensure that this body functions as available to BARMM from 2020 will reduce the pressure intended and enhances transparency and accountability imposed by the ceiling on expenditure types, but this will as required by the BOL. need to be managed carefully through structures, staffing levels and plantilla71 approvals to ensure that they LGUs within BARMM must also have internal audit remain under the ceilings. functions coherent with the objectives of the BG. The BARMM internal audit body will need to coordinate The ARMM budget submitted to Congress is with LGU internal audit units to allow for effective supplemented by performance indicators that measure assessment of risks and the robustness of arrangements the quantity, quality or timeliness of outputs and for managing resources across the region. The outcomes of the agency’s programs, activities and implementation of internal controls across BARMM would projects. This is in line with the DBM’s Performance benefit from central coordination to enable a more Informed Budgeting (PIB) whereby agencies are required systematic review of compliance and a clear process for to identify quantified targets against which their enforcing any sanctions or penalties. performance can be measured in terms of economy, efficiency and effectiveness. The performance is assessed in three specified areas: (i) education, science and technology; (ii) road network and other public infrastructure facilities; and (iii) health services. The BARMM budget is also required to be performance based and must adhere to national budget preparation rules. 70 BOL, Article XII, Section 19. 71 Plantilla - a government approved listing of positions in any govermental institution or agency 180 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M ACCOUNTING AND FINANCIAL by COA to the legislature (in the case of the ARMM, the RLA), there was no formal scrutiny process. There was no REPORTING Public Accounts Committee or a similar one created at the RLA to examine and follow up on the implementation ARMM was required to comply with national accounting of audit recommendations for improvement by the ARMM and financial reporting requirements in the same way government. Instead, scrutiny and response to audit as national government agencies. The BOL makes no reports was left to the individual agency or LGU heads mention of accounting policies and standards but being audited. states that BG must implement transparency and accountability mechanisms consistent with open ARMM produced unqualified reports in only one of government practices and generally accepted financial the last six years based on COA audits—2014. In 2013 management principles.72 This suggests that BARMM will COA issued a management letter with no opinion and also be expected to follow the Philippine Public Sector financial statements for all other years have been Accounting Standards (PPSAS) and financial reporting qualified. In addition to opinions, COA has provided requirements applicable to other levels of government. recommendations for matters requiring attention from The PPSAS are broadly consistent with the International the authorities. All government agencies are required Public Sector Accounting Standards 25 Article XII, Section to comply with COA recommendations on their audits. 2 (IPSAS) and are set by the Commission on Audit ARMM received 216 COA recommendations in 2017, through its Public Sector Accounting Standards Board fully implemented 111, and partially implemented 84. to harmonize the existing public sector accounting The number of recommendations (and the number standards to the prevailing international standards. of recommendations not implemented) increased between 2015 and 2017, the latest year for which EXTERNAL AUDIT AND OVERSIGHT audit reports are available. The main reasons for COA recommendations were unliquidated cash advances, COA is the designated auditor for BARMM and its inaccurate and unreliable accounts, weak compliance constituent LGUs. There is a Regional COA office based in with COA regulations, non-settlement of obligations, the ARMM Government compound that has been tasked late submission of financial documents, weak financial to oversee the audit of the ARMM government offices controls, failure to impose obligations on defaulting including the constituent LGUs. COA assigned auditors contractors and improper program beneficiaries to each ARMM agency and resident auditors at province for scholarships. and city levels of ARMM LGUs. There was no consolidated audit report for the whole of ARMM. Separate audit It is of some concern that the number of partially reports are issued for the ARMM RG, RLA and each LGU. implemented and unimplemented recommendations The RG audit report covers the 26 RG agencies funded by has increased in recent years. The frequency of qualified the NG, 20 locally-created offices attached to the Office audit opinions on financial statements is also a concern. of the Regional Governor (ORG), and other Regional This indicates that financial reporting and internal Government Agencies (RGAs) which are funded out of the control need to be strengthened in the region and ARMM local budget. require sustained attention. Strengthening the internal control framework and financial reporting is essential to The audit reports were submitted to the corresponding ensure that BG and BP have reliable financial reports to head of agency (ORG, RLA and LGUs). In the absence of a use for decision making, providing a strong foundation legal requirement for submission of audit reports for accountability in the use of resources. 72 BOL, Article XII, Section 2. 181 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT CROSS-CUTTING ISSUES ARMM legislation suffered from the absence of authority to regulate the affairs of LGUs within its territorial Cohesion and integration within and across tiers jurisdiction. That is now provided for the BG to a of government limited extent in the BOL through the requirement for a Bangsamoro Local Government Code. The Code The BG will be under the President’s general supervision is expected to be a priority to be enacted by the BP in its exercise of its powers, as was the case for ARMM. but it needs to be constructed without diminishing This includes authority over budgeting, creation the privileges of LGUs as provided for in the Local of sources of revenues, grants and donations, and Government Code of 1991 and other existing laws. There Islamic banking and finance. Intergovernmental may also be scope within the intergovernmental agencies relations mechanisms were lacking under the AOL. This to be established for relationships between BARMM and contributed to prolonged unsettled issues in the exercise LGUs to be addressed. of ARMM’s powers and functions, particularly matters related to fiscal autonomy. This was highlighted in a Capacity and capability case study on ARMM by the Congressional Policy and Budget Research Department (CPBRD) which presented The BOL provides greater autonomy for BG in managing key issues on intergovernmental relations pertaining resources available to it, but there are also many to fragmented national-regional, and regional-local additional obligations, controls, limitations and government relations, and weak representation in requirements for establishing specific institutions within national policymaking. BARMM to deal with fiscal and financial management matters. This will require the acquisition of new Under the BOL, a NG-BG Intergovernmental Relations skills, staff, systems, laws and regulations as soon as Body will be created as a means by which overlapping practicable by the BTA to create the arrangements and concerns can be raised and addressed by the national meet its obligations under the BOL. This would be a and regional government through regular and continuing major task for any government, but will be particularly consultation or negotiation. Any unresolved issues difficult for the BTA because of the limits on available can be elevated to the President. The creation of an professionally qualified and experienced staff in the Intergovernmental Fiscal Policy Board is a crucial region and the previous reliance by ARMM on national improvement in the BOL to promulgate implementing agencies and their systems. rules and address any disputes related to fiscal autonomy with concerned NG counterparts. However, Fiscal management capacity and framework is a critical the relevant mechanisms still need to be elaborated in area that will need to be addressed by BG immediately. sufficient detail to ensure the intergovernmental bodies Prior to the block grants, ARMM government functioned meet the needs of BARMM and other like a national government agency and did not produce government institutions. its own macro-fiscal estimates for revenue or expenditure over the medium term, and it had limited opportunity ARMM had no control over LGUs within its territorial to make strategic cross-sectoral allocation decisions jurisdiction especially over the latter’s use of their own within its boundaries. With the increase in the amount financial resources in performing devolved functions or and flexibility of revenue under BARMM control, these programs. LGUs are accountable to the NG as the source functions will become much more important. Hence, the of their IRA and other available government funding. institutionalization of regional macro-fiscal and cross- It was noted by the Regional Secretary of Interior and sectoral strategic planning capacity will be a key priority. Local Government (DILG-ARMM) that IRA utilization has been mostly on infrastructure, which should have Under the BOL, BARMM will have greater fiscal autonomy been entrusted to the ARMM, with very little on health, in generating and budgeting its revenues. However, education, and other basic services. exercising fiscal autonomy and organizational capacity in revenue collection will remain a challenge. Addressing 182 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M the current constraints in organizational capacity will made more difficult for information on national activities be a critical aspect of the creation of the Bangsamoro because BARMM extends across three regions for which Revenue Office (Article XII, Section 11 of BOL). data would require separation and recalculation, which is not always done. Local government information is The enactment of a civil service law for BARMM as not always available to BARMM and even when it is provided for in Article VII, Section 39 of BOL will facilitate available, it may not be timely for decision making on the hiring of civil servants in the BARMM government budgetary planning, allocation and review. This is not on a merit based system, while protecting appropriate solely the problem of BARMM, although it would be existing government officials. This process will need to the main beneficiary of such information. It would be a be under way early in the life of BARMM because hiring useful initiative for intergovernmental bodies to consider of appropriate staff will be crucial. The staff of ARMM will options for developing a consolidated database and provide a valuable source of experienced and qualified reporting framework for BARMM. people but this will not be sufficient to meet the needs of BARMM for new and expanded functions. Moreover, Autonomy and accountability the provisions for redundancy and severance available to ARMM staff may provide an attractive alternative and The constraints on BARMM render the extent of could limit the numbers of people available to stay on its autonomy somewhat limited compared with an under the new administration. independent provincial government within a federal system such as the United States or Australia. This is Transparency not to suggest that the level of autonomy in BARMM is unimportant, because many of the provisions within BARMM can be expected to continue to achieve a the BOL permit BARMM to act in ways that are not high level of transparency with respect to its financial available to other Philippine regions, recognizing the information because it will be subject to the same characteristics and preferences of citizens of BARMM. general requirements as ARMM in addition to broad However, the constraints on BARMM through the transparency requirements under Article XII, Section Constitution and other means should be recognized 40 of BOL, which states, “The BG adopts a policy when accountability for outcomes in the region of full disclosure of its budget finances, bids and is assessed. public offerings, and shall provide protocols for the guidance of local authorities in the implementation BARMM should not be held accountable for actions of said policy which shall include, among others, the and results that are outside its control or substantive posting of the Summary of Income and Expenditures, influence. For example, if resources are insufficient for and the participation of representatives from civil the Bangsamoro Government to reasonably achieve the society in the budget process. The same policy shall obligations set for it—despite its best efforts—then the apply to its constituent LGUs.” Other provisions of BOL ultimate responsibility for this state of affairs must at include requirements for transparency, reporting and the very least be a shared one. Similarly, if LGUs within engagement in relation to intergovernmental matters, BARMM underperform, the Bangsamoro Government inclusion of women and minorities, and can only begin to remedy any failings to the extent sustainable development. that centrally imposed administrative and institutional controls allow it to do so. BARMM can neither adapt One area where transparency has been a challenge for nor ignore the obligations placed on it by national ARMM, and will continue to be so for BARMM, is the laws, regulations and procedures. These constraints need to obtain, consolidate and report information on need to be recognized in any assessment of BARMM all public activities within the region. The multiplicity of performance, and understood as limits to its autonomy. sources of funding, delivery of programs and support The relationship between the BARMM government and its services by a variety of Philippine and international constituent LGUs must therefore be carefully elaborated, agencies and tiers of government is not reported. This is to establish a clear framework of responsibilities, 183 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT accountability and reporting. To date, LGUs receive Development Fund for BARMM which will provide an direct fiscal transfers from the NG and are subject to additional PhP 5 billion over ten years to address few responsibilities and very little accountability vis-a- particular areas of need. BARMM is required to focus on vis ARMM. LGUs should be given a role in planning and education, infrastructure and health as three of its main budgeting, and made more accountable to BARMM in the budget priorities under the BOL. stewardship of public funds. ARMM has scored well below average on every indicator Health service delivery impact in Table 8.6 except the percentage of unpaved roads. Less than half of households have access to a water Mindanao and BARMM in particular are among the supply. Many small water utilities operated by LGUs have poorest and least well served areas of the country in difficulty sustaining operations and generating capital for most respects, including economic activity, education, expansion due to low tariffs (and consumers’ reluctance health, social services and environmental management. to pay). The number of health facilities is also low This adds an extra layer of difficulty for the BG and compared with other regions. LGUs are unable to provide constituent LGUs because they are starting this new adequate financial support, human resources and phase of development from a low base, both individually equipment necessary for the operation and maintenance and relative to the rest of the country. The NG has of local health infrastructure facilities, thus rendering recognized this with the establishment of the Special them non-functional or underutilized. TABLE 8.6. INFRASTRUCTURE DEVELOPMENT INDICATORS BY REGION Region Unpaved Access to water supply Access Energy Irrigation Number of Number of Teledensity5 provincial source for drinking and/ to toilet connections4 development hospitals Barangay Health (2014) roads1 or cooking2 facilities3 (2016) (2016) (2015) Stations (2015) % % % % % NCR - 63 95 - - 160 477 30.68 CAR 71.3 56 74 90 86 23 639 3.76 I 27.0 65 85 96 71 86 1,160 1.89 II 56.8 65 77 93 64 59 1,240 0.90 III 27.3 71 90 97 65 168 1,969 2.79 IV-A 19.4 64 90 96 71 208 2,248 3.80 IV-B 81.2 64 66 84 64 23 836 3.80 V 38.4 69 68 91 58 51 1,158 1.75 VI 74.8 57 69 96 64 62 2,059 1.50 VII 49.7 53 72 97 91 57 1,877 2.47 VIII 74.8 74 69 90 78 43 831 0.65 IX 89.4 64 62 74 54 44 702 1.11 X 90.3 72 73 86 58 65 1,085 3.69 XI 64.0 69 78 80 39 54 1,023 4.44 XII 88.4 69 63 68 42 56 1,115 1.98 XIII 87.6 70 78 96 43 17 782 4.65 ARMM 82.7 45 26 38 30 19 421 0.44 1 Data lifted from CPBRD 2017, drawing lessons for the creation of regional government under a federal setup, Case study on ARMM, p.8 2 Stated in terms of percentage of households by source of water supply for drinking and/or cooking (use of faucet or shared faucet), community water system, own use tubed/ piped deep well, shared tubed/ piped deep well (Table 1.23, page 1-39) 3 Stated in terms of percentage of households by kind of toilet facility they use (water-sealed sewer septic tank either used exclusively or shared with other households, water-sealed other depository used exclusively by household) Table 1.27, page 1-40. 4 Date includes on the electric cooperative areas (Table 14.17, page 14-15). 5 Teledensity per 100 population (Table 13, 15, pages 13-25). Source: 2017 Philippines Statistical Yearbook, CPBRD 2017, Drawing lessons for the creation of regional government under a federal setup. 184 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M The results achieved by ARMM against its performance CONCLUSIONS AND RECOMMENDATIONS targets, and against realistic and reasonable targets (in view of its starting point) have been mixed. Although There are high expectations for BARMM to perform better ARMM achieved most of the health targets it set for 2016 for the people of the region than did ARMM. This will and 2017, many of the targets are below national averages require concerted effort to implement the requirements and have not increased over time. Also, it is questionable of BOL, which are substantial, and to operate within whether the targets set are the most important areas the fragile social, economic and political context. This of focus. Most are activity or output targets relating report identifies three basic challenges and associated to the number of services provided for hospitals and recommendations in relation to PFM in BARMM. health services but not relating to health outcomes. As discussed previously in this report, many of the Firstly, the BTA needs to keep government in the region important health indicators from a national perspective functioning efficiently and effectively while initiating are worse in BARMM than other regions in the the necessary transformation. In other words, it must Philippines, and substantially below those of many low- continue to do what was done by ARMM and implement income countries. Health programmatic and surveillance major change at the same time. It will be crucial to the data are weak and unreliable, meaning that these credibility of the BTA to ensure that existing activities inequities are likely to be more persistent and intractable and services are delivered to the people of BARMM than is apparent. In addition to dealing with issues efficiently and effectively. Any transformation required such as infectious diseases and maternal and child should be considered in the context of its likely impact health, BARMM now needs to face a set of challenges on the delivery of the BTA’s obligations as a government. characteristic of more developed parts of the country The need to keep government functioning effectively will and other economies, namely chronic noncommunicable have to be a high priority. The transition plan will provide conditions such as heart disease, diabetes and cancer, all the mechanism for setting out how the Bangsamoro of which contribute increasingly to the overall burden Parliament (BP) and Bangsamoro Government (BG) will of disease. achieve both continuation of sound government and the change required. A coherent health strategy and significant investments are needed for the health system to adapt and Secondly, the BTA needs to establish key institutions and improve outcomes. It will be important for BARMM to agencies to ensure that the basic financial management consider refocusing its efforts in health on improving functions in the governance framework are in place outcomes and setting challenging targets in relevant and operating when needed. Important among these indicators that are needed to close the gap between institutions and agencies are the transitional BP and core BARMM and other regions. This overview suggests that financial agencies responsible for revenue management, BARMM will face considerable challenges in achieving budget planning and preparation, treasury, legislation improvements in service delivery outcomes in the areas and internal audit. The BG will also need to adopt a identified as priorities for its budget. This is complicated Bangsamoro Development Plan so that it can access by the multiple sources of activity from all tiers of allocations from the Special Development Fund as soon government that contribute to outcomes, making it as practicable. This will need to be achieved while the difficult to establish a unified strategy and to ensure BTA is limited to a large extent by the resources and rules complementarity and effective accountability for results. applied to ARMM. 185 C H A P T E R E I G H T: P R E P A R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A L T H I N B A R M M - FINANCIAL MANAGEMENT Thirdly, it is essential that change is managed carefully to procedures unless there is an overwhelming net benefit make the best use of existing financial resources, skilled from change. This includes national and local systems, and experienced staff, local and national systems while key professional and experienced staff, structures and considering the potential to transform them or adopt operating arrangements. This does not preclude plans alternatives in the time available. The BG will need to for change in the medium to long term, but it will avoid make tradeoffs as it weighs up major changes envisaged unnecessary disruption during the transition if the against the realistic choices available. In that context, a inherited resources can be used effectively as proven approach to adopt in the short term (the first year the foundation. at least) is to retain existing staff, resources, systems and 186 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M CHAPTER NINE: PREPARING FOR EFFECTIVE AND ROBUST GOVERNANCE OF HEALTH IN BARMM - ORGANIZATIONAL DEVELOPMENT SUMMARY realities, and distribute workload more efficiently throughout different specializations (bureaus) and • The newly-formed BARMM Ministry of Health lines of authorities (Office of the Minister; Office (MOH) is in a unique position to reorganize itself of the Secretary General) while integrating highly for enhanced efficiency and to better achieve inter-dependent work processes within the same its outcomes. The BOL stipulates that BARMM functional groupings to create greater efficiency. as a political entity shall establish its own basic These actions would help to ensure that MOH governance structure that reflects the aspirations strategies expressed in plans, policies, programs and and secures the identity and posterity of the projects are reflected and operationalized in the Bangsamoro people. It is important therefore to organizational structure. ensure that the structure of BARMM government ministries like MOH supports this same purpose. BACKGROUND & RATIONALE • Critical elements and principles in organizational BARMM was formed through the ratification of the design must be incorporated and enhanced in the BOL for BARMM in February 2019. The BOL (Sec. 8, Art. MOH structure, including specialization, span of XVI) provides for a BTA interim cabinet composed of 15 control, coordination and efficiency, and balance and primary ministries, including a Ministry of Health (MOH) functional integrity. Specifically, an organizational replacing the previous DOH-ARMM. structure should efficiently cluster functions and deliverables, reduce unnecessary bureaucracy Upon transfer to the new regional government, the between decision makers and units that provide Ministry of Health (MOH) preserved the organizational strategic support, and balance the span of control arrangement of the DOH-ARMM in order to maintain such that those with complex work functions have uninterrupted health services to the BARMM population. fewer direct reports (narrower control) and those With that structure, the MOH managed simultaneous with focused or routine functions have more reports challenges resulting from the need to maintain services (wider control). while transitioning into a new government with its own organic laws and new leadership, while at the same time • In 2019, the World Bank Group partnered with MOH incorporating new programs and services mandated by leadership to design a functional organizational the Universal Health Care (UHC) law, and adapting to structure that addresses key deficiencies in the DOH- the structural changes due to a parliamentary system. ARMM structure. This transitional structure requires These challenges required the Ministry and its leadership cross-functional groups (bureaus, divisions, units) to develop a strategic vision and a set of institutional to convene and ensures that mission-critical and strategies that can rally the different stakeholders to strategic decisions are made by pertinent leaders continue the current services while building a best-fit yet and technical experts within directly concerned agile organization for the BARMM Ministry of Health. offices. Future strengthening of the MOH organization is recommended. A more robust structure would At the request of the Ministry of Health, the World incorporate important key result areas of the Bank Group undertook an analysis and provided BARMM health sector and its geographical recommendations for organizational restructuring for 187 C H A P T E R N I N E : P R E PA R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A LT H I N B A R M M - O R G A N I Z AT I O N A L D E V E L O P M E N T the new Ministry to deliver on sustainably financed 2. Benchmarking against the organizational structure UHC. The analysis provided inputs using organizational of health ministries in other countries, specifically development (OD) technical frameworks and proposed Australia and Malaysia, as well as the Philippines processes to enable the Ministry to develop a best-fit DOH national and regional offices. organizational structure to translate the BTA’s and the Ministry’s health priorities within the realities of the 3. Review of pertinent national laws and guidelines current transition context. including the BOL and guidelines provided by the Department of Budget and Management (DBM) A FUNCTIONAL STRUCTURE FOR and the Civil Service Commission (CSC) to aid in designing the details of the functional structure. THE MOH As a result, an interim functional structure to best Designing a functional structure for the MOH involved respond to the changing needs in the health sector is using the following standard critical elements and presented in Figure 9.1. principles in organization design: specialization, span of control, coordination and efficiency, balance, and Key features of the organogram include: functional integrity. Specialization is clustering those • Placement of the Office of the Minister to directly with related competencies, functions and services, supervise the units providing strategic support deliverables and outputs together. The span of control services or requiring ease of response. denotes the number of personnel directly reporting to a single leader; the more complex the functions, the • The creation of four bureaus organized by key smaller the span of control should be. Coordination and result area and major functions and deliverables, efficiency, on the other hand, is considered by grouping specifically: offices that have closely interrelated processes and thus require constant communication and collaboration to 1. Public Health Bureau responsible for health deliver services and achieve target outcomes. Putting program development and monitoring; them directly under one leader will help ensure efficiency, cohesiveness, and responsiveness. Balance 2. Health Systems Bureau for developing, is important to ensure that the size of the units— maintaining, and continuously improving and concomitant authority that managers wield—is policies, processes, and standards for health commensurate with the scope of work and deliverables, planning, research, facility development and such that the span of control allows for leaders and regulation, and health performance M&E; employees to meaningfully interact and work together. Functional integrity entails ensuring that appropriate 3. Field Operations Bureau to provide oversight checks and balances are in place across the structure supervision to implementing units, ensuring whenever there is a clear split in lines of accountability that they are provided technical assistance between units implementing programs and those that and capacity building for effective program monitor and regulate them. implementation and service delivery; and Grounded in the above elements, the process of 4. Finance and Administration Bureau to provide developing the structure involved the following: critical support services to all MOH units to ensure smooth operation. 1. Consultation and design validation with internal stakeholders including the Minister and all heads of • Balancing of the span of control: narrower (lesser offices of the MOH including their senior direct reports) for those with complex functions, and technical staff. wider (more direct reports) for those with focused or routine functions. 188 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M The BOL provided important context which guided the d. Assist and cooperate with the NG in the proposed structure, including: provision of quarantine services to prevent and control entry to the country of 1. The BARMM and National Government relationship. communicable diseases. Based on the BOL, BARMM as a political entity shall establish its own basic government structure The forthcoming BARMM Administrative Code and Health that reflects the aspirations, secures the identity Code are expected to further clarify and refine the and posterity of Bangsamoro people and Muslim relationship of the National Government, via DOH, with Filipinos. It is important therefore to ensure that the Ministry of Health. the overall BARMM structure, and consequently the structure of BARMM Ministries such as MOH, support The proposed MOH functional structure involves a this same purpose. number of changes from the DOH-ARMM structure. First, new offices were created to carry out functions poorly 2. The BTA is tasked to prepare the mandated Codes represented in the prior structure or entirely absent for BARMM to guide its operations. These codes from it. Next, office names were changed to better align include Administrative, Civil Service, Education, Local with their roles and responsibilities. Finally, four offices Government and Revenue. were reorganized from one position in the organizational structure to another in order to better reflect their 3. In the BOL, specific provisions relating to health are reporting and functional relationships with other offices. expressed in broad terms under Article VI Section The rationale for these changes is described in Annex K. 13, which emphasized the continuous funding from the National Government for National Programs In addition, the proposed functional structure will and Projects such as operations of the DOH- require three major cross-functional groups to enforce retained hospitals and PhilHealth. The Bangsamoro coordination and create synergy between and among Government may at its discretion provide offices. Without the presence of cross-functional groups, supplemental funding. a functional structure like that of MOH may create silos (or highly independent offices) within the organization 4. The main BOL provision on health is under Article and perpetuate a culture of non-cooperation that will 9, Basic Right Section 22, which mandates the result in duplication of activities and outputs, bottlenecks Bangsamoro Government, presumably through the in work processes, and delayed services, among other MOH, to: undesirable outcomes. The major cross-functional structures include the Executive Committee, Management a. Adopt a policy on health that shall provide a Committee, and Mission-Critical Subcommittees or comprehensive and integrated health Technical Working Groups. Each of these structures and service delivery; their members are presented in Annex L. b. Establish a general hospital system that shall The proposed functional structure comprises 363 provide excellent and affordable personnel,73 290 of which are new positions in addition medical services; to 73 positions inherited from DOH-ARMM (Annex M). The proposed staffing pattern subscribes to the staffing c. Promote rights to health and access to essential guidelines recommended by the Department of Budget goods, health and other services; and and Management.74 73 At the time of publication, there were only 111 positions approved and budgeted by the BTA. 74 DBM’s Resolution No. 1 Series of 2006, Rationalization Program’s Organization and Staffing Standards and Guidelines. 189 Commission on Office of the Legal and Legislative PhilHealth Population (8) Minister (12) Liason Unit (4) 190 Food and Drug Regional Nutrition Internal Control Unit (3) Administration Council (8) Media and Public Quarantine Relations Unit (4) Legend: Health International Cooperation Unit (4) New unit Health Emergency Change in position within the structure O R G A N I Z AT I O N A L D E V E L O P M E N T Management Service (20) Chnage in name Health Information Change in scope Technology Service (8) Pending/For further discussion Bangsamoro Bid and Awards Secretary General (5) BAC Secretariat Committee Health Systems Bureau (4) Public Health Bureau (4) Field Operations Bureau (4) Administration and Finance Bureau (4) Policy Health Disease Hospital Provincial Supply Chain Epidemiology Finance Division Administration Development Performance Prevention and Monitoring Health Management Division (2) (2) Division (2) and Planning Monitoring Control Division Service (5) Offices Division (2) Division (2) Division (12) (2) Health Human Field Health Provincial General Inventory Communicable Local Health Budget Planning Resources Service and Epidemiology Services Management Disease System Division Section (8) Section (6) Development System Section Surveillance Section (8) Section (5) Section (16) (6) Division (18) (3) Section FIGURE 9.1. THE MOH PROPOSED FUNCTIONAL STRUCTURE ORGANOGRAM Pharmacy Procurement Health Family Health Surveillance Research Quality Rural Health Accounting Records and Logistics Regulation Section (16) Section (5) Section (6) Assurance Units Section (8) Section (8) Support Section Division (2) Division (6) (9) Policy Non- Licensing and Management Personnel Development Communicable Hospitals Accreditation Barangay Health Section (4) Section (4) Section (4) Disease Section (16) Stations Section (16) C H A P T E R N I N E : P R E PA R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A LT H I N B A R M M - Health Facilities Quality Institutional and Development Assurance and Mental Health City Health Cashier Development and Division (2) Monitoring Section (10) Offices Section (7) Human Resource Section (6) Management Section (7) Planning and Environment City Design Section and Occupational Epidemiology (10) Health Section Surveillance (7) Section Infrastructure Health Staff Staff Information Barangay Health Recruitment, Quality and Equipment Health Units Stations Performance Management Section (10) and Promotion Management Selection, and Section (4) Promotions F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M CONSIDERATIONS FOR FURTHER Environmental health must therefore be articulated in the functional statement of the existing offices in STRENGTHENING OF BARMM-MOH the approved structure, rather than given the priority FUNCTIONAL STRUCTURE status that a section designation would bring. Moreover, the structure effectively de-emphasizes The above organizational models and recommendations health systems by assigning it as a division (Policy are presented on the understanding that any new Systems) under the Public Health Bureau instead structure may require further revisions and strengthening of as a separate bureau. Finally, the MOH may wish in the future, especially as BARMM moves beyond the to revise the staff complement for these offices transition period, and in the context of ongoing regional given the high demand of work vis-à-vis the health and national discussions. priorities and agenda. The BTA approved a transition structure for the MOH 2. Need to function as a ministry, not a regional office in mid-2020. The approved structure is in some ways of an NGA. Under the ARMM structure, DOH-ARMM similar to the proposed functional structure described served as the DOH regional office, with the staff above, but it differs significantly in the following areas: therein implementing plans and programs mostly 1) required functions of a Ministry under an autonomous from National DOH. However, as an autonomous government, 2) size of staffing complement, and 3) region with a parliamentary form of government, the the major functions in health governance and service ministry must be able to fulfill the functions of an delivery (from four critical bureaus to three). The autonomous government. The table below presents allocations of supervisory and technical positions are the difference between a regional arm of the NG and lacking in some offices. a ministry of an autonomous region. The MOH has since then drafted its vision and mission Regional Office of a national Ministry under an statements and identified priority high-impact programs government agency (NGA)* autonomous government** for the medium term. These priorities will require an • Implement laws, policies, • Develop and implement appropriate structure that will implement the strategic plans, programs, rules its own programs and operational priorities of MOH for BARMM during and regulations of the department or agency in the and after the transition period. The structure must also regional area be able to address any changes brought about by the • Provide economical, •Design, install and pandemic that constitute the emerging “new normal”. efficient and effective service enforce systems and to the people in the area standards Given the gaps between the MOH priorities and the * From Executive Order 292 also known as The Revised Administrative Code approved transition structure, it is recommended that of 1987 (Book IV, Chapter 5, Section 26 – Field Offices) ** Functions of national agencies presumed to be appropriated to the the following structural improvements are addressed BARMM government by virtue of their autonomy within the next two years at most (some may need to be addressed sooner). This change from a regional office to a full ministry 1. Need to strengthen offices under Public Health and entails: 1) establishing structures of offices to enable Health Systems. The Public Health Bureau is crucial MOH to fulfill the mandates of the BOL and the in intensifying directions, policies and programs functions required of a ministry; 2) providing the on the MOH agenda and priorities. In the approved necessary competencies in the organization to fulfill transition structure, there are five sections within the new functions; and 3) installing the necessary the Public Health Bureau that cover all identified processes, systems, and technology to make the priority programs except environmental health. structure work. 191 C H A P T E R N I N E : P R E PA R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A LT H I N B A R M M - O R G A N I Z AT I O N A L D E V E L O P M E N T 3. Need to emphasize and intensify governance role of the Ministry. The MOH strategically formulates STRUCTURE REFINEMENTS: OPTIONS policies, sets directions and standards, and FOR THE FUTURE develops the programs to guide the field offices in their operations and program implementation. In light of possible changes and opportunities to shift This governance function of the MOH requires: 1) the MOH’s organizational design in the near future, strategic and systems thinking to set direction and further refinements to the functional structure may lead all actors in the health system of BARMM; 2) become necessary. These refinements are presented partnership building and network strengthening; 3) in the alternative structure in Figure 9.2 below. The framing and influencing policies in BARMM that are alternative design aims to further strengthen the way related to public health; and 4) extensive technical the ministry can deliver its results. It provides features competencies to provide standards and quality that incorporate key result areas (such as quarantine) measures, among other requirements. Hence, the needed by the BARMM health sector, taking account MOH structure and organizational competencies of inescapable geographical factors. It also distributes must be designed and strengthened along these workload more efficiently in different specializations major governance functions. The Office of the (bureaus) and lines of authorities (Office of the Minister Minister, for example, must focus on strategic issues and Office of the Secretary General), while bringing while the middle level management focuses on together highly inter-dependent work processes operational management. Policy development and within the same functional groupings to create greater performance management-related structures must efficiency. Specific features include: be in place, from planning and budgeting, to policy analysis, formulation and execution, to monitoring, a. Inclusion of Food and Drug Administration (FDA) evaluation and quality assurance. and PhilHealth as attached agencies. The proposed interim functional structure created a Pharmacy 4. Need to refine the structure in the pandemic Quality Assurance Division that derives its standards context and the “New Normal.” The COVID-19 from the FDA. As an attached agency, the functional pandemic has presented immense challenges for relationship of this Division is clearly established. the health sector, especially in the Philippines. With PhilHealth provides important inputs for the MOH the growing number of cases in the region, the MOH while relying on the MOH for the delivery of health as the public health leader will have to put in place services. The interdependencies of these two structures and mechanisms to implement health organizations are formally recognized if PhilHealth is strategies in the light of the emerging new normal in an attached agency of the MOH. the country, in BARMM and in the global community. The adaptation of the structure will require sufficient b. The Office of the Minister has fewer units requiring staffing with necessary skills for alternative health day-to-day operational supervision. These offices delivery modes, such as telemedicine, allocation of provide strategic and independent analysis and resources from traditional cost items like on-site inputs for the Minister and support the requirements training to on-line training, and new functions for of governance and external relations: Legislative multi-sector cooperation to ensure wider health Liaison Unit, Media and Public Relations Unit, and access for vulnerable groups, especially the elderly. the Internal Control Unit. This also maintains a The pandemic brings an opportunity to gain valuable manageable number of direct reports to the Minister. lessons for the health sector and governance in c. Project Management Unit (called International general. MOH may very well reflect on its experience Health Cooperation Unit in the proposed and prepare to make the organization proactive and interim functional structure), Health Emergency responsive to the expectations of the health systems Management Service (HEMS), and Bids and Awards of the future. Committee (BAC) are located under the Office of the 192 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Bangsamoro Secretary General. These units require h. The Procurement Section is created to act as close supervision, given the sensitive nature of their secretariat to the BAC, among others. This is roles. Reporting directly to the Secretary General, answerable to the Supply Chain moreover, these units will be able to faster and more Management Division. easily coordinate and cooperate with other units—an imperative for successful delivery of their i. Institutional Development and Human Resource respective functions. Management is elevated from a section to a Division. This major function will implement various d. Health Information and Promotion, previously a important systems for the entire MOH: performance section under the Disease Prevention and Control management, recruitment and selection, reward and Division, is located in Figure 9.2 as a division directly recognition, employee welfare, among others. As a reporting to the Director of the Public Health Bureau. section, it will be limited in capacity and therefore Making this a division underscores the premium in its ability to perform major services. A unit has given to health promotion and education as vital specific limitations under the DBM regulations; underpinnings of disease prevention. This would increasing its staff beyond prescribed limits implies mean higher capacity and at the same time greater the creation of a division. accountability for the unit. In adopting any further revisions to the functional e. The Surveillance Section under the Epidemiology structure, a further structural review may be undertaken Division is renamed Epidemiological Analysis Section to assess functional efficiency, identify the need for to distinguish its work from offices performing adjustments to the structure and to the roles and data collection in the field. The Analysis Section responsibilities of the different functions. At the same consolidates and analyzes various data from the time, frequent and relatively minor changes in the field, and presents these in a meaningful form to structure can have a negative impact on organizational guide management action. performance and staff morale. It is suggested, therefore, that for an initial period at least, any changes in the f. A Quarantine Division is created and placed under structure are implemented on a ‘clustered’ basis or by the Field Operations Bureau. This arrangement will related functional groups, such as changes within related allow for easier coordination of the Division with divisions in a bureau. other health facilities should an immediate response be needed. Annexes Annex K: Rationale for Proposed Changes in the Ministry g. The Health Information Technology Section (HITS), of Health Functional Structure located directly under the Office of the Minister Annex L: Cross-Functional Groups for Decision Making in the proposed interim functional structure, is and Coordination in the Ministry of Health envisaged as a unit under the Administrative Annex M: Number of Positions in the Proposed Division (Figure 9.2). The nature of HITS is to MOH Structure provide support services to all offices in MOH by maintaining information technology infrastructure. http://bit.ly/BARMMHFSAAnnexes As such, it must be consolidated under the Administrative Division. 193 Commission on Office of the Legal and Legislative Population Minister Liason Unit 194 Regional Nutrition Internal Control Unit Council Food and Drug Media and Public Administration Relations Unit Bangsamoro Bid and Awards PhilHealth Secretary General Committee Project Management Unit O R G A N I Z AT I O N A L D E V E L O P M E N T Health Emergency Management Service Health Systems Bureau Public Health Bureau Field Operations Bureau Administration and Finance Bureau Policy Development Health Disease Prevention Provincial Epidemiology City Health Finance Division Administration and Planning Performance and Control Health Division Offices Division Division Monitoring Division Division Offices Health Human Communicable Field Health General Planning Resources Service and City Provincial Budget Disease Services Section Development Division System Section Hospitals Hospitals Section Section Section FIGURE 9.2. ALTERNATIVE FUNCTIONAL STRUCTURE FOR MOH City Provincial Research Health Family Health Epidemiological Health Epidemiology Epidemiology Accounting Information Section Regulation Division Section Analysis Unit Surveillance Section Surveillance Section Section Technology Section Policy Licensing and Non- Health Information and Promotion City Health Provincial Health Management Records Development Accreditation Communicable Division Units Units Section Section Section Section Disease Section Health Quality Facilities and Assurance and Mental Health Cashier Personnel Barangay Health Barangay Health Development Division Monitoring Section Section Section Section Stations Stations Environment Institutional Planning and Supply Chain Development and and Occupational Management Design Section Local Health Human Resource Health Section Division Management Section System Division C H A P T E R N I N E : P R E PA R I N G F O R E F F E C T I V E A N D R O B U S T G O V E R N A N C E O F H E A LT H I N B A R M M - Infrastructure and Quarantine Division Inventory Staff Equipment Pharmacy Management Performance Section Quality Section Management Assurance Division Facilities and Asset Staff Recruitment, Management Section Selection, and Promotions Section Quality Logistics Management Support Section Section Procurement Section F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M DISCUSSION AND POLICY OPTIONS SUMMARY • It is essential that the BG and its agencies and institutions continue to function during the political • MOH should undertake a comprehensive and transition period. The BG is advised to retain key inclusive strategic planning process that explicitly staff, systems, and resources in the short-term unless articulates funding and service delivery priorities, there is an overwhelming benefit to change, and to partner responsibilities (especially provincial and use them as a foundation for implementing reforms. municipal LGUs and other local stakeholders), and quantitative mechanisms for tracking progress. An • Devolution of health service delivery to LGUs is not associated medium-term health financing strategy recommended in BARMM at this time, considering should be developed in tandem. MOH should ensure the persistent under-funding of primary health that, as much as possible, regional priorities align care by BARMM LGUs and the overall fragile state with or reflect national priorities. of health service delivery throughout the region. Instead, MOH should strengthen regional oversight • MOH is advised to give a high priority to while encouraging LGUs to increase their financial strengthening the building blocks of health service support for public primary care facilities like RHUs, delivery in its regional planning efforts, specifically and engaging them in regional planning efforts. considering the unique supply-side and health care access constraints facing each province. MOH should • Building regional capacity for vaccine delivery is work to ensure a minimum capacity for health an MOH priority, but rather than devoting block service delivery (including staffing) throughout the grant funds to the purchase of vaccine antigens, provinces, addressing equity differentials which are currently supplied by national DOH, MOH as evidenced. should first build local capacity for vaccine storage and management, and ensure thorough and timely • All existing health-related funding streams should training of staff throughout the BARMM provinces in be consolidated under the MOH umbrella in order all aspects of vaccine delivery. to increase the resource pool for meeting identified health needs throughout the region. Such a pooling This Health Financing System Assessment (HFSA) mechanism should be able to integrate future was undertaken at the request of the Government of funding streams, including LGU funds, as may be the Philippines and the regional Government of the required by national law. Autonomous Region of Muslim Mindanao (now the Bangsamoro Autonomous Region of Muslim Mindanao) in • The BARMM government (BG) should work to recognition of a unique set of needs and opportunities. maximize current and future access to PhilHealth Regional health outcomes and service delivery capacity reimbursements by strengthening information lag behind the rest of the country; low public financing systems and monitoring use of this financing stream for health, a challenge for all regions in the Philippines, as a key performance indicator of health facility cannot entirely account for this discrepancy. A severe lack managers. A regional effort is required to ensure of data—in health service delivery capacity, governance, maximum rates of accreditation of health facilities at health financing and health outcomes—has hindered all tiers in the health system. the development of responsive policy reforms. However, 195 DISCUSSION AND POLICY OPTIONS the new political and financial autonomy of the region service providers (that is, hospitals, RHUs) that disbursed presents a watershed moment for reconsideration of them in accordance with funding requirements and the entire public health sector; the current analysis was program priorities. However, funding was insufficient to designed to provide evidence and recommendations meet the health care needs of the population, primarily to inform this process. Furthermore, linked with this due to the lack of investment in the building blocks of new autonomy, the regional peace and development service provision: staff, equipment, utilities like electricity processes—in which the World Bank has been a long- and IT capacity, and medicines and commodities. ARMM term partner—provides a positive, forward-looking LGUs contributed little of their budgets to health care, strategy framework for fundamental reform. further constraining the delivery of services. The regional government served mainly as a conduit of funds from This HFSA has looked broadly at the public health the NG to end-point providers, and lacked the authority sector, from inputs (notably financing), process capacity to make allocation decisions or ensure that regional (including governance and supply side readiness), and priorities were being addressed through outputs (through the most comprehensive household local programming. survey yet undertaken in the region). Each of these elements is presented and discussed in depth in National government appropriations to BARMM increased the preceding chapters. In this section, some of the dramatically in 2020, along with BARMM independent key findings and policy recommendations are briefly authority to allocate funds according to regional summarized and discussed. priorities via the block grant funding mechanism. Funding to BARMM-MOH also increased dramatically in 2020. In The current COVID-19 pandemic has dramatically addition to block grant funding, there are a number of accentuated the findings and recommendations of this additional funding streams that could be consolidated report. From its position as one of Asia’s fastest growing under the MOH umbrella and planned for accordingly, economies, the Philippines now faces fiscal challenges in an integrated way, with other MOH programs. from the impact of the disease – and the efficiency Consolidating existing health-related funding streams of expenditures in the health sector, both public and within MOH will give it a greater pool from which to private, now must be more critically examined than ever. allocate resources to meet identified needs. Formalizing Stress has been placed on health service delivery by the a pooling mechanism during this time of regional direct morbidity of the disease, and the displacement transition will also make it easier for future funding of capacity needed to address usual health priorities. streams to be seamlessly integrated. The pandemic has highlighted the weaknesses in the Philippines health system and the immediate and For example, as part of the BOL, BARMM is set to receive devastating situation that can emerge when public health PhP 5 billion per year for 10 years as part of a Special and primary care services are persistently underfunded. Development Fund, which is to be used for rebuilding, It is hoped that the recommendations in this report will rehabilitation and development of conflict-affected inform the efforts of the national and regional levels of communities. In addition, ARMM-HELPS funding often government to strengthen especially primary health care supports health activities but is a separate budget line financing and delivery. item provided directly by the national government. MOH should ensure that health-specific activities within these HEALTH FINANCING FOR UHC – REVENUE POOLING larger initiatives be programmed with MOH input and AND INTEGRATION integrated into MOH’s own yearly plan. In addition, as external sources of funding become available to BARMM, Financing of the ARMM health system was characterized MOH should look to integrate them into existing program by a varied and complex flow of funds into the region priorities and activities to ensure they do not appear as with little coordination or integration and minimal add-ons that disappear if the funding streams cease. regional oversight. Funding streams originated from many sources and were directed to many end-point 196 EXECUTIVE SUMMARY F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M PRIORITY ACTION ITEMS AND FUTURE CONSIDERATIONS PRIORITY ACTION ITEMS FOR BARMM MOH Immediate 1. Begin a comprehensive strategic planning process with LGU participation. • Prioritize funding building blocks of service delivery as a way to target supply- side limitations and more effectively address immunization and nutrition program weaknesses and primary care access constraints. • Build (or strengthen) regional oversight mechanisms towards a goal of improving efficiency and equity in service delivery throughout BARMM provinces. • Ensure regional funding priorities are aligned with national funding priorities, as a substantial proportion of health funding in BARMM still flows from the National Government. • Work to increase regional resources for health by leveraging additional resources from existing funding streams, and spending more efficiently in order to gain value for money. • Engage local executives and health boards as well as hospitals as important stakeholders in service delivery. • Build monitoring and evaluation (M&E) into planning process by defining quantitative measures and assigning responsibility for ongoing plan implementation and refinement to a high-level office within MOH. Consider linking a portion of LGU health budgets to performance in key areas. 2. Develop a health financing strategy that integrates all current health-related funding streams in BARMM within MOH in order to increase the resource pool for addressing priority health needs, with a goal of reducing out of pocket expenditure for health among the population. 3. Initiate planning to address recommendations within the BARMM Regional Action Plan for Nutrition as well as the Effective Vaccine Management Assessment, recently conducted by UNICEF. Couch both of these efforts within the broader MOH regional planning initiative. 4. During transition period, maintain key staff, systems and resources from the ARMM administration in order to ensure government functioning. Major changes in these areas must be carefully managed in order to avoid disrupting continuity of services. Medium-term following plan development Make use of findings from the 2019 BARMM Household Survey to develop targeted interventions to address the most pressing access issues, especially for immunization and nutrition services. Utilize local talent to develop and implement creative public education campaigns on a variety of health-promotion messages, including accessing PhilHealth benefits and entitlements. Specifically gear messages to women as primary caregivers. 197 DISCUSSION AND POLICY OPTIONS Ongoing 1. (with special attention before 2022) Make a targeted effort to engage LGUs in increasing local funding for health service delivery, for example through focused education efforts and incentive mechanisms. Consider (and build support for) the future possibility of a regional Special Health Fund that includes LGU contributions and supports services throughout BARMM with an aim to ensure geographic and socioeconomic equity. 2. Build BARMM data collection and analysis capacity in order to better track and measure health outcomes. Prioritize staff development in this area, or prioritize hiring for this skill set. MATTERS OF STRATEGIC ATTENTION FOR BTA AND MOH Medium-term Consider forming a management unit with dedicated technical staff to develop and implement a Special Health Fund and Regional Service Delivery Network. Action items for this unit would include: • Preparing partnership agreements that include definitions of roles and responsibilities of the different levels of health facilities, funding contributions, and payment mechanisms. • Preparing and implementing operational guidelines for referral systems, gatekeeping, and care management. • Designing and implementing unified records systems, care registries, and data collection and analysis systems. • Designing and implementing continuous quality improvement programs. Long-term Consider the possibility of regional purchasing of vaccine antigens, pending the following: • Supply-side limitations in vaccine service delivery have been adequately addressed throughout the provinces. • MOH has strong oversight mechanisms in place around inventory management, staff training and other vaccine delivery requirements. • Staff turnover rates are low or dropping, which would suggest the skill and experience levels of staff are improving. • MOH has strong data collection and analysis capacity to monitor immunization rates and target interventions to provinces, LGUs, and/or barangays with poor vaccine coverage. 198 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M Despite being autonomous, BARMM still receives a change. This does not preclude plans for change in significant amount of health care funding from the the medium to long term, but it will avoid unnecessary national government, therefore it should ensure disruption during transition if the inherited resources that regional priorities align with national priorities can be used effectively as the foundation. At the same and initiatives. Not only this, but MOH should also be time, core competencies in public financial management able to adapt to future changes at the national level should be strengthened within the new ministries. An (implementation of the UHC Law and the resulting outline of this process for the Ministry of Health is changes to PhilHealth). Any financing scheme should considered in Chapter 8 of this study. be linked to a regional plan for improving health care delivery and health outcomes for all BARMM citizens. HEALTH STRATEGIES AND PLANNING This plan should be conceived with stakeholder input and buy-in, based on a thorough needs assessment With the transition from ARMM to BARMM comes the and understanding of existing capacity issues in BARMM opportunity to re-envision the role of the Ministry of RHUs, ready for implementation with integrated M&E Health in the region and to create comprehensive, mechanisms, and achievable by existing stakeholders actionable regional plans and strategies to enhance with clear expectations, roles and accountability. service delivery and improve health outcomes. There are a number of plans that already exist; these should GOVERNANCE be a starting point for broader regional planning efforts. Recommendations from the 2018 Supply Side The BTA is currently balancing the dual goals of keeping Readiness Assessment, UNICEF-supported efforts to government in the region functioning effectively while improve vaccine delivery, and national-level guidance to initiating political transformation. The BTA notes that it address undernutrition could all be incorporated into a will be crucial to the credibility of the new regional entity comprehensive regional plan, and they all point to the to ensure that existing social services are seamlessly need to improve infrastructure and capacity development delivered to the people of BARMM throughout the in RHUs, for example in the areas of staffing, training, transition period. logistics, IT and equipment, in order to deliver services more effectively. Strengthening the building blocks of The BTA should quickly establish key institutions and service delivery should be a major priority for MOH agencies to ensure that the basic financial management planning efforts and initiatives. functions in the governance framework are in place and operating when needed. Important among SERVICE DELIVERY – STRENGTHENING PRIMARY HEALTH these institutions and agencies are the transitional CARE FOR IMPROVED HEALTH OUTCOMES Bangsamoro Parliament (BP) and core financial agencies responsible for revenue management, budget planning Results from the BARMM household survey provide and preparation, treasury, legislation, and internal important context for regional planning efforts. First, audit. The BG will also need to adopt a Bangsamoro the former ARMM provinces and the BARMM expansion Development Plan so that it can access allocations from areas are not a uniform group, although they share many the Special Development Fund as soon as practicable. of the same challenges. Any regional effort to address health outcomes and improve health service delivery It is essential that change is managed carefully to make must take into account the unique ethnic, economic the best use of existing financial resources, skilled and and health care access constraints facing households experienced staff, and local and national systems while in each province. The best way to achieve this is through considering the potential to transform them or adopt sustained involvement of LGUs and municipal health alternatives in the time available. A proven approach officers in MOH regional planning efforts. MOH should to adopt in the short term (the first year at least) is to consider building flexibility into its regional health retain existing staff, resources, systems and procedures plan so that it can be tailored to the needs of specific unless there is an overwhelming net benefit from provinces rather than being one-size-fits-all. 199 DISCUSSION AND POLICY OPTIONS In addition, it is important to keep in mind that the health function may result from deficiencies in any of former ARMM provinces have a different history than the necessary health system inputs, including financing, the BARMM expansion areas, in particular related to LGU management, supply chain, human resources and financing of health services. Former ARMM provinces, demand generation. The outcome itself—immunization which have had little consistent funding from LGUs for coverage—is readily quantified and monitored. BARMM a long period of time, may have worse health outcomes had suffered from persistently low immunization than those with more LGU involvement. MOH may have to coverage, despite receiving vaccine antigens from NG vary the approach it takes to engaging LGUs from these procurement. Recently, the region saw an outbreak distinct areas and delivering services to of polio among children. For these reasons, the HFSA constituents there. included a specific focus on immunization. Data collected as part of the BARMM household survey Investments in supply side readiness are essential if provide a much more comprehensive picture of regional the Philippines is to address poor health outcomes in performance and equity; linked with a parallel survey of BARMM. Some concrete recommendations arising from service delivery capacity in the RHUs, this chapter now the study are summarized as follows: provides the evidence base for a granular investment plan to improve immunization coverage in BARMM. • To increase health workforce density, the numbers By examining the BARMM health system from multiple in all cadres need to be increased, especially in rural perspectives – covering inputs, capacities and outputs, and remote areas. Better distribution of existing the report has ascribed the low rates of immunization health staff could be achieved through incentive coverage to multiple factors. Important amongst these mechanisms to promote deployment in was continuity in the central and regional supply of underserved areas. vaccines. Weaknesses in the cold chain also threaten the efficacy and availability of vaccine antigens and • Addressing critical shortcomings in the logistics and other essential medicines. The high rates of drop-out supply chain is an utmost priority. between first and third doses of routine infant vaccines indicate barriers to health service access, as well as gaps • Major improvement is needed to ensure the in service delivery readiness at the local facility level. availability of the basic amenities such as power, The report makes recommendations to address these emergency transportation, and communication challenges in BARMM, however the findings are also most channels, on which crucial clinical and associated relevant to national efforts to integrate primary health services depend. service delivery and focus health financing through • The use of real-time information systems using pooled reimbursement mechanisms. modern technology would greatly aid in monitoring In partnership with UNICEF, BARMM-MOH has already and decision making for service delivery. begun a planning process for the regional vaccine • Currently, there are no mechanisms to assess the delivery program. This process has clarified the need quality of care, and these should be instituted as for MOH to more effectively support infrastructure and part of the regular supervision process by districts capacity development in RHUs—for example in the areas and provinces. of staffing, training, logistics, IT and equipment—in order to improve vaccine delivery and coverage. MOH THE EXAMPLE OF IMMUNIZATION – A CORE PUBLIC should ensure a basic minimum capacity throughout HEALTH FUNCTION the region, as it is accountable to all BARMM citizens; however, a complete needs assessment and plan for how A country’s routine childhood immunization program may MOH will meet the vaccine needs of its citizens must be described as the “canary in the coalmine” during a include immediate and sustainable opportunities for health sector review. Poor outputs from this core public LGUs to provide funding and in-kind support. A planning 200 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M process to improve immunization service delivery can be primary health care needs of the population. Devolution extended to planning for other public health or primary in the near-term would aggravate this situation. care services that RHUs provide. MOH can use the lessons learned from the immunization planning process to If devolution is considered in the future, it would be inform future planning efforts. unwise for such a transition to occur in haste or all at once. Any transition would have to be measured, and It is especially important to include local stakeholders begin with a full inventory by LGUs of all the services from the beginning, in order to inform them of the provided by RHUs: who provides them, and who funds needs that exist throughout the region and the them. Then LGUs should determine how those services essential roles that primary care and public health play. would be taken over at the provincial or municipal level, Including LGUs and provincial, municipal and city health and who would manage them. Lessons learned from officers in regional health planning efforts can help to other countries’ experiences should be studied and ensure that everyone is educated about the value of applied, with effective monitoring by the BARMM regional prevention in building a healthier and more financially government. secure population. LGUs are set to see dramatic increases in IRAs beginning DEVOLUTION VS. REGIONAL INTEGRATION OF HEALTH in 2022, in accordance with the Mandanas v. Ochoa FINANCING AND SERVICE DELIVERY legal ruling. BARMM LGUs are highly dependent on IRA contributions for their local budgets, as they receive BARMM-MOH is in a period of planning and very little income from other sources. Because LGUs reorganization, determining how to spend the increased will receive more money, the NG may see this as an funding allocation in the block grant. BARMM itself is opportunity to shift more responsibility to LGUs by also in a period of transition, one element of which is explicitly or implicitly requiring them to use their funding to reconsider how the regional government and LGUs on activities previously paid for by NG. However, if this is should work together in the future. As stipulated in the not made explicit, a situation could arise whereby neither BOL, health is one of the priority areas for BARMM in this LGUs nor the NG fund some activities. transition period. In order to improve the financing and delivery of health services to better meet the needs of National government funds for BARMM health services the population, BARMM-MOH should engage provincial, often only cover a limited item, such as vaccine antigens municipal and city LGUs in its planning efforts, not only but not the equipment necessary to transport, store with a goal of encouraging them to increase funding but and manage vaccines or the staff to deliver them. also with an eye to the future. If LGUs can prove their LGUs are expected to provide this sort of financial or “ownership” of health care and their understanding of in-kind support, but they have not done so in BARMM. the tenets of UHC, devolving health service delivery to This undermines the ability of national programs to local LGUs might be a longer-term goal, once systems achieve their goals. The regional MOH should take have been set up to support the transition and provide responsibility for explicitly planning health service effective monitoring. provision throughout the region and include LGUs in this process from initiation to implementation, monitoring However, now is not the time to consider devolution. and refinement. A regional health plan should clearly BARMM is accountable is to the entire population— delineate each group’s responsibilities, including it should not diffuse this responsibility through funding roles of different stakeholders. This will make it devolution, not in this critical period of transition, easier for LGUs to see how their support is being used. especially considering BARMM LGUs have a history of An inclusive planning process at the regional level may poor local funding and low prioritization of health care. encourage LGUs to build assistance for the health sector Furthermore, years of limited funding for local service into their own planning and budgeting processes. delivery have left RHUs under-resourced to meet the 201 DISCUSSION AND POLICY OPTIONS BARMM LGUs have traditionally contributed a much lead to de-emphasis of priority services previously smaller share of their budgets to health programs supported by vertical programs – such as immunization. than non-BARMM LGUs. They are fiscally independent The scale of the investment needed to raise the health of the region and do not have to include the regional system’s readiness to deliver services should not be government in their budget planning or preparation underestimated, and a rigorous assessment of local processes, nor are they accountable to the regional capacities is required. government for how the funds are used. MOH could consider using some of its increased funding to create The UHC includes a national requirement for the performance-based grants or matching grant programs adoption of integrated province-wide and city-wide to engage LGUs in planning for and providing health health systems, which will comprise all local health services. It could make funding contingent on the LGUs systems, specifically the staff and offices within LGUs that including an MOH representative in their budget planning are most directly connected to health service delivery. process as it relates to health services, to ensure These integrated systems will set up Special Health regional goals are reflected in local plans. Similarly, Funds (SHF) to manage all health resources from DOH, MOH should include LGU representatives in its own PhilHealth and other sources, including from LGUs if they planning processes to help build trust, transparency, choose to transfer their local health budgets to the SHF and active participation. MOH might also designate for management. The UHC Law specifies that “the SHF regional positions tasked with overseeing particular can be allocated for population-based and individual- aspects of local service delivery, especially elements that based health services, capital investment, health system are newly funded by LGUs, which would help to ensure operating costs, remuneration of additional health consistency in delivery across provinces and LGUs while workers, and incentives for health workers…”. The BOL demonstrating ongoing regional support. includes a stipulation that BARMM set up an arrangement like this as well. FUTURE SCENARIOS - A SINGLE REGIONAL SERVICE DELIVERY NETWORK? Since it functions as a centralized government, BARMM is naturally positioned to set up an integrated health Block grant funding will give BARMM greater autonomy system and a pooled funding arrangement. The idea of to use government appropriations in a way that having LGUs contribute to a pooled fund directly would best meets the needs of the BARMM people. Funding make for a more streamlined funding mechanism, but priorities do not have to be negotiated with the NG, it could threaten local care delivery if funding is pooled allowing for greater localization and adaptability. and used across the region at the expense of the LGU’s Although focused on BARMM, the current HFSA analysis own local community. may also serve as a case study for challenges faced regionally across the Philippines - as the nation moves Without national-level requirements or guidance, towards unified financing for UHC and more integrated individual LGUs can determine how much to contribute health service delivery. As mandated in the UHC Law, to health services, making funding inconsistent across the institution of collectively financed Service Delivery provinces and municipalities. MOH could recommend Networks will do much to increase the efficiency of (and incentivize) that all LGUs give a certain amount (or service delivery. This HFSA draws out details of the percentage) to local health service delivery and also give BARMM experience that exemplify common challenges a portion to the regional SHF to be allocated throughout to instituting this mandate. In particular, the effective the region. Alternatively, MOH could recommend an pooling and management of public financial resources amount or percentage that LGUs should spend on health for health may not be straightforward – and will depend services; LGUs would then determine how to allocate heavily on local, provincial and regional governance that between a regional SHF and local service delivery. capacities. A focus on delivering integrated services Regional spending of the SHF should be reported in a coherent, person-centered framework must not accurately to the LGUs as a matter of routine, allowing them to see how their contributions are used. 202 F I N A N C I N G T H E T R A N S I T I O N T O U N I V E R S A L H E A LT H C O V E R A G E I N B A R M M It may be advisable for BARMM to adapt to the block should take stock of its hospital capacity, and in due grant mechanism first, and then use the lessons learned course determine if operating its own tertiary referral from that process to inform how to set up, manage hospital is a priority for the region; if not, what financing and utilize a Special Health Fund. In addition, BARMM arrangements can it make with the existing referral should set a new framework for working with LGUs in hospitals to ensure the availability of high-quality tertiary general as part of the transition process, with a focus care for its constituents without posing a substantial on accountability and transparency, and then use that financial burden? framework for managing health collectively through a pooled fund if the decision is made to do that in NUTRITION the future. The BARMM household survey describes severe Acting to some extent as a single, regional SDN, BARMM undernutrition among BARMM children. In view of the may work towards developing capacity for procurement intrinsic mortality risk, cases of Severe Acute Malnutrition of its own regional supply of medical commodities, and Moderate Acute Malnutrition require the most urgent including vaccine antigens. This may address some of the attention. The Philippine government has policy guidance issues with continuity of supply that have been noted. in place with the DOH Administrative Order (AO 2015-055) However, BARMM should not pursue this until national- on the Management of Acute Malnutrition in children level changes in vaccine financing and procurement under Five, National Guidelines for the Management of that result from implementation of the UHC Law are Severe Acute Malnutrition, and more recent National fully realized. Instead, MOH should prioritize using its Guidelines for the Management of Moderate Acute increased funding from the block grant appropriation Malnutrition (2016). Training on the implementation of to build local capacity to store and manage vaccines these guidelines has already been conducted at regional and other commodities and to capacitate staff with the and provincial levels under the ARMM government. needed training to deliver them, all of which are lacking The challenges now for the BARMM government are in BARMM RHUs. In the future, if MOH is in a position to in implementation of the nutrition program, ensuring purchase commodities, having addressed infrastructure the supply chain of commodities, linking the different requirements, a needs assessment should be conducted referral levels, and in the overall management, first, in order to determine the priorities for regional supervision and monitoring of the program. purchase and thereby avoid duplication with national DOH. This will involve MOH devising a strategy for A second priority for nutrition in BARMM is to focus working with IPHOs and RHUs to track requirements at on “Women First” as both an entry point and a focus the local level, especially in areas with either insufficient for nutrition interventions. Women often bear the or excess supplies. responsibility for keeping the household together and functioning, regardless of their situation; as such, any FUNDING OF HOSPITALS benefit from improving the lives of women—helping to align their beliefs and perceptions with their children’s Other decision points not directly addressed in this well-being—will likely benefit the entire household. report but important to include in a health financing A “Women First” approach makes sense in terms of strategy are those that relate to the medium- to long- improving breastfeeding and child feeding practices. It term financing arrangements for hospitals. BARMM- would also help with addressing the misconceptions MOH should consider whether or not to introduce regarding the causes and consequences of stunting performance measures in the allocation of annual that were elicited in the household survey. If mothers subsidies or budgets to hospitals, and also whether were made aware of the importance of child nurturance or not hospitals can be encouraged to show more factors—such as exclusive breastfeeding, followed by autonomy in the mobilization funds with a view complementary feeding at the right time and to the right towards a future goal of full self-sufficiency. BARMM extent—they might be motivated to try them out. 203 DISCUSSION AND POLICY OPTIONS ADDRESSING EQUITY – BARMM AS AN EXAMPLE In conclusion, the provisions included in the UHC Law show the Philippines’ commitment to ensuring access Despite overall national improvement in East Asian to affordable health care for its population. The goals countries, indices of maternal and child health continue of making care more integrated and localized and of to lag or decline in particular subnational regions. The strengthening the role of PhilHealth as a strategic health financing and delivery systems assessed in this purchaser of goods and services will help move the report show BARMM as an example of a regional, indeed country towards more inclusive, targeted and affordable global, challenge. The persistent low levels of routine health care service delivery. However, the success of the immunization in this region are comparable to those in UHC Law lies in implementation, in particular by LGUs. the poorest low-income countries. Consequent outbreaks In the case of BARMM, the most significant goals for UHC of vaccine-preventable illness, particularly measles, cannot be attained without investment in health logistics cause morbidity, mortality and increased household and infrastructure, the inescapable basic building blocks poverty. Of particular concern are the low levels of that must underpin health care service delivery. The polio vaccination, which compare unfavorably even Philippines will struggle to achieve its UHC goals unless it with global examples of extreme fragility and violence supports its subnational regions to move in that direction such as Iraq. In BARMM, the rate of complete polio themselves. Fortunately, BARMM is positioned to address immunization is a mere 33 percent, and for 44 percent these deficiencies and others in this period of planning of children no routine vaccination is reported at all. 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Philippines 2013 National Demographic and Health live births). Survey Final Report. Manila, Philippines, and Rockville, Maryland, USA: PSA and ICF International. UNICEF, WHO, World Bank. Joint child malnutrition estimates. Data accessed online at: https://data. PSA and ICF. 2018. Philippines National Demographic worldbank.org. Indicator: prevalence of underweight, and Health Survey 2017. Quezon City, Philippines, and weight for age (percent of children under 5). Rockville, Maryland, USA: PSA and ICF. UNICEF. 2019. State of the World’s Children 2019. Children, Philippines Statistics Authority - Poverty and Human Food and Nutrition. Growing well in a changing world. Development Statistics Division. 2016. Official Poverty New York, NY: UNICEF. Statistics of the Philippines Full Year 2015. Manila, Philippines: PSA. UNICEF. 2020. Effective Vaccine Management Assessment, BARMM 2020. Consultant Re