Professional Documents
Culture Documents
Chairperson
Usec. Mario C. Villaverde, MD, MPH, MPM, CESO I
Co-Chairperson
Dir. Maylene M. Beltran, MPA
Members
i
TABLE OF CONTENTS
Foreword 1
Acknowledgements 2
Bibliography 55
ii
FOREWORD
To implement health reforms, the DOH engages the cooperation of its various
partners under the Sector Development Approach for Health in planning,
organizing, coordinating, and evaluating national and international support and
assistance under a common sector policy and investments program led by the DOH.
Related to this, there is a need to inform all stakeholders including all Filipinos of
F1 strategies as guiding principle and strategic approach in health planning, policy
and program development, implementation and for monitoring and evaluation.
Together, we can overcome any roadblocks that will impede our progress toward
health reforms so that we can triumphantly share the fruits of a healthy,
productive and progressive nation for all generations of Filipinos.
1
ACKNOWLEDGEMENTS
The F1 Technical Working Group led by the technical staff of the Health Policy
Development and Planning Bureau (HPDPB) which directed the preparation of this
document are grateful to a pool of writers, technical experts, resource persons which are
enumerated below:
A. Department of Health
Dir. Juanito D. Taleon, Dir. Angelina K. Sebial, Dir. Yolanda E. Oliveros, Dir. Criselda G.
Abesamis, Dir. Enrique A. Tayag, Dir. Carmencita Banatin, Dir. Leticia Barbara Gutierrez,
Dir. Nicolas B. Lutero III, Dir. Agnette P. Peralta, Dir. Edgardo Sabitsana, Dir. Joshua
Ramos, Dr. Shirley Domingo, Mr. Ruben John Basa, Dir. Kenneth G. Ronquillo, Dr. Ma.
Virginia G. Ala, Dir. Crispinita A. Valdez, Dr. Julito Sabornido, Dr. Lakshmi Legaspi, Dr.
Ivanhoe Escartin, Ms. Edna Nito, Ms. Rose Aguirre, Ms. Luz Tagunicar, Mr. Adel Azuelo, Ms.
Rowena Bunoan, Dr. Mario Baquilod, Dr. Aleli Sudiacal, Dr. Melecio Dy, Dr. Victoria
Mandai, Dr. Agnes Segarra, Dr. Marilyn Go, Dr. Edna F. Red, Ms. Virginia Francia C. Laboy,
Mr. Manuel G. Guevarra, Dr. Ma. Theresa G. Vera, Dr. Ma. Brenda C. Pancho, Engr. Bayani
San Juan, Engr. Ma. Cecilia Matienzo, Dr. Robert dela Torre, Dr. Alwyn Asuncion, Dr.
Jennifer Celestino, Ms. Nona Asilom, Ms. Violeta Padilla, Ms. Mary Jean Lim, Dr. Agueda
Sunga, Dr. Regina Sobrepeña, Dr. Erlinda Guerrero, Ms. Erlinda Domingo, Dr. Dorie Lynn
Balanoba, Ms. Menchu Equia, Ms. Jean Bernas, Dr. Lilibeth C. David, Ms. Charity Tan, Ms.
Jovita Aragona, Mr. Laureano Cruz and Ms. Agnes D. Marfori.
2
OVERVIEW OF THE PHILIPPINE
HEALTH SYSTEM
According to the World Health Organization (WHO), “a health system is composed of all
activities whose primary purpose is to promote, restore or maintain health”. It is
composed of health care institutions, supporting human resources, financing
mechanisms, information systems, organizational structures that link them together
and collectively culminate in the delivery of health services to patients.”
The Philippines has a dual health system consisting of a public sector and a private sector.
The former is largely financed through taxes, allowing services to be given for free or
following socialized user charges; while the latter is largely market-oriented and utilizes
user fees to finance health services. Hence, the poor obtains health services from health
facilities operated by the government while the rich opt for health services from private
facilities.
Since the devolution of health services under the Local Government Code of 1991, health
services provided by the public sector became shared by the Department of Health (DOH) and
the local government units (LGUs). The DOH, as the lead agency for health, became
responsible for the development and implementation of national policies and plans,
regulations, standards and guidelines on health, as well as the innovation of strategies in health
to improve the effectiveness of health programs. It also acts as the administrator of national
health facilities, and sub-national health facilities. Moreover, it provides services for emergent
health concerns that require complicated new technologies deemed necessary for public
welfare upon the direction of the President of the Philippines and in consultation with the LGUs
concerned. On the other hand, the LGUs shall assume primary responsibility over the delivery
of health services and the provision of health facilities devolved to them. The DOH shall in
coordination with LGUs shall design and instill mechanisms providing for an integrated and
comprehensive approach to health care delivery among LGUs, through the referral system and
the networking of local health agencies.
The DOH has adopted the sector-wide approach as the means to manage the implementation of
FOURmula ONE for Health (F1) to be known as Sector Development Approach for Health
(SDAH). The DOH and SDAH partners shall stimulate LGU participation to adopt F1 and national
priorities in their respective localities such as advocacy on the economic and socio-political
advantages of instituting health reforms, provision of incentives and forging performance-based
agreements between the national and local governments among others.
3
Goals of the Philippine System
The Philippine health system has three primary goals that correspond to the goals of health systems as
defined by the WHO. These goals are: better health outcomes, more responsive health system and
equitable health care financing.
The health system needs to meet the expectations of the population it is serving. Responsiveness is
a measure of the adequacy on how the health system is attending to the people’s expectation of
how they should be treated by the health service providers. It is focused on the client centeredness
of health care and encourages better performance towards it. This includes the patients’ and their
families’ right for choice, respect, dignity, confidentiality and quality health care. Satisfaction
with the health system on the other hand reflects the people’s evaluation of how their expectations
were met by health care providers. The health system should provide patients and their families
greater public satisfaction in the overall performance of the health system.
Equitable health care financing means that financial risks are distributed in a population based on an
individual’s capacity to pay rather than his or her risk of illness. The health system should ensure that an
individual or family will not be forced into poverty due to the payment of health care or prohibited to
avail of health care because of costs. Financial risk protection is provided by risk spreading strategy
wherein revenues from people are pooled and utilized for the payment of those who get sick.
4
Health Status of the Filipinos
The health status of Filipinos is improving but the rate of improvement is not as good as the health
status of other countries in South-East Asia.
.08
74
.78
73
.48
72
72
.18
may be attributed to the improving health status of the
72
.08
.88
72
.78
.58
73
71
.48
.28
72
71
72
.18
.98
72
71
.88
.68
72
70
.58
.4
71
70
70
.28
.08
70
71
people and other socio-economic factors.
.98
71
70
.68
70
.4
70
70
.08
70
70
68
Life in Years
.83
.53
67
.23
68
67
Life in Years
.93
67
.83
.63
66
.53
.33
66
67
66
.23
.03
67
66
.93
.73
67
66
.63
.43
Between the years 1980 to 2004, crude birth rate
66
65
.33
.13
66
66
65
.03
66
65
.73
66
.43
64
65
.13
65
.49
65
decreased from 30.2 to 20.5 births per 1,000
64
63
.49
62
63
62
population, while crude death rate decreased from 6.2 60
60
to 4.8 deaths per 1,000 population (Philippine Health 58
58 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
5
Other infectious diseases such as rabies, filariasis, schistosomiasis, leprosy and human
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) remain relevant public
health problems even though they are not leading causes of illness and death. Rabies incidence in
the Philippines is the 6th highest in the world. Filariasis is the second leading cause of permanent
disability among infectious diseases. Schistosomiasis remains endemic in the country although it has
been eliminated in most South East Asian countries. And while the leprosy has been considered as
eliminated based on national prevalence levels, certain areas still have prevalence rates above the
elimination target. Dengue fever is known to have sudden increases in the number of outbreaks
within a year. There is no vaccine or specific drug regimen to cure it. HIV/AIDS prevalence is
estimated to be low in the Philippines but, high risk behaviors appear to be increasing and could
lead to high incidence over time.
deaths. Meanwhile, deaths due to accidents doubled Source: Philippine Health Statistics, 2004
600
90
100
80
500
Diseases)
and
Diseases of the Heart
population
per 100,000 population
80
of the Heart)
(Communicable Diseases)
and
400
Diseases of the Heart
Neoplasm
70
Neoplasm
Statistics, 2004). Deaths caused by communicable 300 50
60
(Communicable
Malignant Neoplasm
per 100,000
300 50
Malignant Neoplasm
Diseases
( Malignant
200 40
30
( Malignant
200
Communicable Diseases
decrease of pneumonia deaths from 86.4 per 100,000
20
10
Deaths
Deaths
100
10
0 0
1962 1964
1968 1970
1976 1978
1980 1982
1982 1984
1988 1990
1996 1998
2000 2002
1954
1954 1956
1958 1960
1960 1962
1964 1966
1966 1968
1970 1972
1972 1974
1974 1976
1978 1980
1984 1986
1986 1988
1990 1992
1992 1994
1994 1996
1998 2000
2002 2004
0 0
2004
2004, a 55.5% reduction (Philippine Health Statistics,
Communicable
Diseases
Communicable
Malignant Neoplasm
Years
Diseases
The infant mortality rate (IMR) and under-five Figure 3. Trends in Infant and Under-Five Mortality Rates
mortality rate (UFMR) per 1,000 livebirths in the Figure 3. Trends in Infant and
Philippines, Under-Five Mortality Rates
1993-2006
Philippines, 1993-2006
Source: National Demographic Survey, 1993; National Demographic and Health Survey, 1998 and 2003 and
rate of decline has slowed down during the 1990s. The 70 IMR 64
Mortality Rate per 1,000 live births
70 64
Mortality Rate per 1,000 live births
weight. On the other hand, UFMR was estimated at 64 Under-Five Mortality Rate Infant Mortality Rate
deaths per 1,000 livebirths in 1993 then declined to 24 per 1,000 livebirths in 2006. The most common
causes of under-five mortality are pneumonia, accidents, and diarrhea (refer to Figure 3).
6
Figure 4. Trends in Maternal Mortality Ratio
Fourteen percent of all deaths in women aged 15- Figure 4.Philippines,
Trends in Maternal1993-2006 Mortality Ratio
49 years are maternal deaths. The country’s Philippines,
Source: National Demographic 1993-2006
and Health Survey, 1993 and 1998 and
Source: NationalFamily Planning
Demographic Survey,
and Health2006
Survey, 1993 and 1998 and
maternal mortality ratio (MMR) was estimated at Family Planning Survey, 2006
50
50
0
There is regional variation in the attainment of 0 1993 NDHS
1993 NDHS
1998 NDHS
1998 NDHS
2006 FPS
2006 FPS
health outcomes such as infant and maternal Year
Year
mortality rates. Some regions are performing better
than the national average while the others are performing poorer than the national average.
Problems in administrative reporting are also aggravating the situation (refer to Figure 5 and 6).
Figure 6. Maternal Mortality Rates, Philippines Figure 5. Infant Mortality Rates, Philippines
Figure 6. Maternal Mortality Rates, Philippines Figure 5. Infant Mortality Rates, Philippines
and Regions, 2006 and Regions, 2006
and Regions,
Source: Field Health Service Information 2006of Health, Philippines, 2006
System 2006, Department and Regions,
Source: Field Health Service Information 2006of Health, Philippines, 2006
System 2006, Department
Source: Field Health Service Information System 2006, Department of Health, Philippines, 2006
Source: Field Health Service Information System 2006, Department of Health, Philippines, 2006
Philippines 0.63
NCR
Philippines 0.37 0.63
Philip 10
CARNCR 0.37 0.63
NCRPhilip 10 21.7
I
CAR 0.38 0.63
CARNCR 10.1 21.7
II I 0.38 0.62
I
CAR 10.6
10.1
III II 0.22 0.62
II I 6.5 10.6
IV-A III 0.220.32
III II 5.1 6.5
IV-BIV-A 0.32 0.96
IV-A III 5.1 7.5
VIV-B 0.96 1.19
IV-BIV-A 7.5 11.5
VI V 0.89 1.19
VIV-B 10.6 11.5
VII VI 0.47 0.89
VI V 10.6
11.2
VIII VII 0.47 0.93 VII VI 6.7 11.2
IX VIII 0.69 0.93 VIII VII 6.7 11.5
X IX 0.75
0.69
IX VIII 8.9 11.5
XI X 0.75 1.04 X IX 8.2 8.9
XII XI 0.6 1.04 XI X 8.2 12.9
Caraga XII 0.6 1.18 XII XI 5.2 12.9
ARMM
Caraga 1.18 1.31 Carag XII 5.2 7.4
ARMM 1.31 ARMMCarag 4.4 7.4
0 0.2 0.4 0.6 0.8 1 1.2 1.4 ARMM 4.4
0 0.2 0.4 0.6 0.8 1 1.2 1.4 0 5 10 15 20 25
0 5 10 15 20 25
The Philippines, being in the so-called Circum-Pacific belt of fire and typhoon, has always been
subjected to constant disasters and calamities such as floods, typhoons, tornadoes, earthquakes,
tsunamis, volcanic eruptions, drought, and flashfloods. Man-made disasters such as land, air and
sea disasters, civil and armed conflict also take their toll in lives and properties.
The country is also threatened by emerging and resurgent diseases. Emerging infectious diseases
are newly identified or previously unknown infections, such as severe acute respiratory syndrome
(SARS), while re-emerging infections are secondary to the reappearance of a previously eliminated
infection or an unexpected increase in the number of a previously known infectious disease, such as
avian influenza, mad cow disease and meningococcemia. Both types can cause serious public health
problems if not contained as close as possible to its source.
7
Responsiveness of the Philippine Health System
The availability of data for the overall responsiveness and satisfaction of the Philippine health
system is very limited and there is a need to improve its process of collection. The level of public
responsiveness and satisfaction with the health products, facilities and services are cited below:
The responsiveness of the hospital inpatient and ambulatory health care services in the Philippines
is generally acceptable as shown by the result of the World Health Survey in 2000. There were less
than half of the clients who rated with poor responsiveness the hospital in-patient care and
ambulatory health services in the domains of being provided prompt attention, respect for dignity,
autonomy, privacy and confidentiality of records and availability of basic amenities and social support.
However, the choice of health care provider and availability of adequate space have been rated poorly by
more than half of the respondents for hospital in-patient care (refer to Table 2). There is limited or no
data on the responsiveness of primary health care facilities.
8
In 2000, the Filipino Report Card on Pro-Poor Services showed that there was a high level of overall
satisfaction with health facilities. Satisfaction was significantly higher for private facilities than
government facilities. For profit hospitals were rated +96, while the government hospitals were
rated +79, rural health units (RHUs) were rated +82 and barangay health stations (BHS) were given
a rating of +74. Although in the same survey, government hospitals got higher ratings from the
rural households and those from the lower socio-economic class.
In the same report, private facilities when compared to government facilities ranked superior on
quality aspects, at par on convenience of location but inferior on cost aspects. In other words, cost
was the only categorical advantage of government facilities over private facilities. Health services
provided by public facilities were used mainly by those who could not afford the widely preferred
private services.
In 2005, a total of P180.8 billion was spent on health related expenditures which is equivalent to
3.1% of the Gross National Product (GNP) in 2005. Of this, 59.1% or P106.9 billion was taken from
private sources which include out-of-pocket, private insurance, health maintenance organizations,
employee-based plans and private schools. Around
48.4% or P87.5 billion is primarily from out-of Figure 7. Distribution of Health Expenditure
Figure 7. Distribution
by Source ofofFunds Health Expenditure
pocket which means that the burden of paying for by Source
Philippines, 2005 of Funds
health care is still predominantly shouldered by Philippines,
Source: Philippine 2005 2005
National Health Accounts,
Source: Philippine National Health Accounts, 2005
individual families instead of the government or
Local
insurance. National and local governments spent a Local
Government Others
Others
1.2%
total of P51.9 billion, or 28.7% of total health Government
12.87%
12.87% 1.2%
ability to pool resources and spread health risk. The individual family, through direct out-of-pocket
expenditure, is the least effective and most inefficient health insurance institution. A family’s
income and size limit the resources that can be pooled for health expenses. And since members are
often exposed to similar health risks, the family has limited risk-pooling capacity.
Until now, there has been limited progress made in expanding social risk pools which includes
government budget and social insurance funds for health. In 1994, social risk pools financed only as
much as 44% of total health spending and decreased to 42% in 2005 (Philippine National Health
Accounts, 2005).
On the average, families spend only 1.9% of their Figure 8. Family Expenditure on Health by Category
Figure 8. FamilyPhilippines,
Expenditure 2000on Health by Category
annual family expenditures on health care, based on a Source: Family Philippines, 2000
Income and Expenditure Survey, 2000
Source:Expenses for dental
survey conducted in 2000. The average health Family Income
Expenses
and Expenditure Survey, 2000
charges,for dental
Other medical
expenditure amount of a family then was roughly charges
Other medical
charges,
contraceptives and
othercontraceptives
health servicesand
charges
3.5%
P2,660 and ranged from P572 to P4,430. Of this Medical charges
3.5%
other4.3%
health services
4.3%
9
Challenges of the Philippine Health System
Given the scenarios presented in the previous sections, it is evident that the Philippine health
system is confronted with challenges in achieving its three goals: improving the health status of the
population, developing a health system that is more responsive to the health needs of the people
and ensuring equity in financing health care.
Medicine Generic Name Medicine Medicine Brand Manufacturer Philippines India Pakistan
Preparation Name
Mefenamic Acid tab 300 mg tablet Ponstan Pfizer 20.98 2.80 1.46
Hyoscine-N-butylbromide 10 mg tablet Buscopan Boehringer 9.26 2.45 0.60
Cotrimoxazole 400/80 mg tablet Bactrim Roche 14.80 0.75 1.09
Nifedipine 20 mg tablet Adalat Retard Bayer 37.56 1.50 3.85
Gemfibrosil 300 mg capsule Lopid Pfizer 34.66 13.17 2.89
Furosemide 40 mg tablet Lasix Aventis 8.56 0.53 1.28
Enalapril maleate 5 mg tablet Plendil ER AstraZeneca 35.94 5.95 8.25
Gliclazide 80 mg tablet Diamicron Servier 11.00 7.57 5.00
Salbutamol 50 mg Ventolin Glaxo 315.00 132.38 65.88
Diclofenac 50 mg tab Voltaren Novartis 17.98 0.92 3.92
Isosorbide dinitrate 5 mg SL tab Isordil Wyeth 10.29 0.26 0.23
Loperamide 2 mg cap Imodium Janssen 10.70 3.27 1.94
Ceftazidime pentahydrate 1g vial inj. Fortum Glaxo 980.00 418.72 322.75
There are also problems in the accessibility and quality of health products, facilities and services.
The access to cheaper but quality drugs and medicine is poor. In 2003, the Philippine
pharmaceutical market was estimated to be P65 to 70 billion and accounted for roughly 45% of
health spending. Despite the large pharmaceutical market, local drug prices are 2 to 30 times
higher than in Canada or neighboring Asian countries. This situation exists partly because low cost
quality generic medicines comprise only 15 to 20 percent of the market while the rest are
dominated by high-priced branded medicines (See Table 4). Furthermore, drug distribution is
controlled by a few big distributors, mostly private drugstores; 85% of all drugs sold in the country
are dispensed from these private pharmacies.
The access to health facilities and health professional is also poor. In 2003, around 60% of all births were
attended by a trained health professional in a health facility but the rest were delivered by hilots or
unlicensed midwives and other untrained attendants (NDHS 2003). In the same year, around 34 out of
100 deaths from all causes and around 65% of deaths from certain conditions originating in the perinatal
period were attended by a medical or health professional (PHS 2003).
Government primary health facilities are conveniently located as 94% of households are within 15-
minute walking distance to a Rural Health Unit (RHU) or Barangay Health Station (BHS). However,
these facilities were frequently bypassed resulting in overcrowding of higher level facilities that are
supposed to be reserved for more specialized care.
On health facility utilization, the Filipino Report Card on Pro-Poor Services in 2000 showed that 77%
of households surveyed used health facilities of one type or another (See Table 5). Urban
households tend to use health facility services more compared to rural households. Government
facilities were more frequented than private facilities due to the cheaper cost of health services
being offered. Those who used the private facilities were predominantly rich households and urban
respondents, although poor respondents reported using private facilities as well.
10
Table 5. Utilization of Health Facilities by Area
Philippines 2000
Source: Filipino Report Card on Pro-Poor Services, World Bank, 2000
These challenges have been in the forefront of major reform initiatives in the health sector and
remain as the focus of the implementation framework for health reforms that will be discussed in
the next section.
11
IMPLEMENTATION FRAMEWORK FOR
HEALTH REFORMS: FOURMULA ONE
FOR HEALTH
To respond to the major challenges in the health sector there is a need for more
aggressive health reforms to be implemented across all levels of the health sector. Thus,
an implementation framework for health sector reforms was developed - the FOURmula
ONE for Health (F1). This approach is designed to implement critical and concrete health
interventions as a single package, and incorporates effective management infrastructure
and financing arrangements. It shall be implemented throughout the medium term, from
2005 to 2010.
F1 engages the entire health sector to include the public and private agencies, national
agencies and local government units, external development agencies, and civil society in
the implementation of health reforms. Everyone is invited to join the collective race
against fragmentation of the health system of the country, against the inequity of
healthcare and the impoverishing effects of ill-health. With a robust and united health
sector, the race towards better health and a brighter future can be won.
12
Starting the Race with the End Goal in Mind:
FOURmula ONE for Health Goals and
Objectives
Over-all Goals
FOURmula ONE for Health objectives
The implementation of FOURmula ONE
for Health (F1) is directed towards and the health system goals
achieving the end goals of the Philippine Reform Mechanisms
Health System --- better health Objectives
outcomes, a more responsive health Health Systems Goals
system, and more equitable healthcare 1. Financing (higher, better
• Better health
financing. These goals are in consonance and sustained)
2. Regulation (assured outcomes
with the Millennium Development Goals
(MDGs) and Medium Term Philippine quality and affordability)
3. Service Delivery • More responsive
Development Plan (MTPDP), and are health system
(ensured access and
articulated in more detail in the National availability)
Objectives for Health 2005 -2010. 4. Governance (improved • Equitable health
health system care financing
performance)
General Objective
FOURmula ONE for Health (F1) is aimed at achieving critical reforms with speed, precision and
effective coordination directed at improving the quality, effectiveness, equity, and efficiency of
the Philippine health system in a manner that is felt and appreciated by all Filipinos.
General objective
FOURmula ONE for Health (F1) will strive within the medium term to:
Secure higher, better and sustained financing for health;
Assure the quality and affordability of health goods and services;
Ensure access to and availability of essential and basic health packages; and
Improve performance of the Philippine health system
13
The F1 Objectives and Strategies
Health Financing
Objective: Secure higher, better and sustained financing for health
Strategies
1. Mobilizing resources from extra-budgetary sources
2. Coordinating local and national health spending
3. Focusing direct subsidies to priority programs
4. Adopting a performance-based financing system
5. Expanding the national health insurance program
Health Regulation
Objective: Assure the quality and affordability of health goods and services
Strategies
1. Harmonizing licensing, accreditation and certification
2. Developing a “seal of approval” for quality assurance
3. Pursuing revenue enhancement with income retention for health
regulatory agencies
4. Ensuring access of the poor to essential health products, specifically
drugs and medicines
Strategies
1. Making available basic and essential health service packages by
designated providers in strategic locations
2. Assuring the quality of both basic and specialized health services
3. Intensifying current efforts to reduce public health threats
Good Governance
Objective: Improve performance of the health system
Strategies
1. Improving governance in local health systems
2. Improving national capacities to manage and steward the health
sector
3. Pursuing the development of rationalized and more efficient national
and local health systems
14
Building Gains of Previous Health Reforms:
Drawing Impetus for FOURmula ONE for
Health Implementation
The current implementation of health reforms builds upon the lessons and experiences from the
major health reform initiatives undertaken in the last 30 years -- from the Primary Health Care
approach in the late 1970s, the Generics Act in the late 1980s, the devolution of public health
system in the early 1990s, the National Health Insurance Act of 1995, to the Health Sector Reform
Agenda (HSRA) conceptualized in the late 1990s.
Since the inception of the HSRA in 1999, health reforms have made inroads in at least 30 provinces.
In health governance, municipalities have joined together to form Inter-Local Health Zones (ILHZs)
to optimize sharing of resources and maximize joint benefits from local health initiatives. A total of
151 out of 183 organized ILHZ (82%) became functional in 2005.
Under health regulation, the parallel drug importation of drugs and medicines lowered the cost of
ten therapeutic classes of their local counterpart by at least 50% from their 2000 prices. Access for
cheaper but quality drugs were promoted through the establishment of Botika ng Bayan and Botika
ng Barangay as well as the promotion of generic pharmaceutical products.
In health service delivery, key LGU facilities have been upgraded to meet accreditation
requirements and be entitled for capitation or reimbursements from PhilHealth. All DOH hospitals
underwent income retention and utilized their income to improve health care services. Four
specialty hospitals were rationalized into corporate hospitals wherein they started to be managed
by autonomous governing boards. Such hospitals include the Philippine Heart Center, Lung Center
of the Philippines, National Kidney and Transplant Institute and the Philippine Children’s Medical
Center.
For health financing, LGUs have increased contributions needed to enroll indigents into the social
health insurance program. Not only is the coverage of health services being improved in these
localities, invaluable lessons are also being learned to bolster confidence in the implementation of
these reforms nationwide.
15
Defining the Rules of Engagement: Seven (7)
General Guidelines for Health Reform
Implementation
F1 Rule No.1
FOURmula ONE for Health (F1) will organize the critical reform initiatives into four
implementation components, namely: Health Financing, Health Service Delivery,
Health Regulation and Good Governance.
F1 Rule No. 2:
The implementation of FOURmula ONE for Health (F1) will focus on a few manageable
and critical interventions. Such interventions will be identified using the following
criteria:
Doable given available resources - Critical interventions identified for each
component must be deemed doable given the available time, human and financial
resources.
Sufficient groundwork and buy-in - The chosen interventions must be backed by
sufficient groundwork and buy-in from implementation partners, especially in the
development of reform packages for local implementation.
Triggers a reform chain reaction - These critical interventions must be able to
trigger a chain of reaction that will spur the implementation of other FOURmula ONE
for Health (F1) interventions, within and across the four components.
Produces tangible results and generates public support - These critical
interventions must be able to show tangible results within the immediate and medium
terms, which in turn generate support and cooperation from the public.
F1 Rule No. 3
F1 Rule No. 4
The National Health Insurance Program (NHIP) will serve as the main lever to effect
desired changes and outcomes in each of the four implementation components, where
the main functions of the NHIP including enrollment, accreditation, benefit delivery,
provider payment and investment are employed to leverage the attainment of the
targets for each of the reform components.
16
F1 Rule No. 5
F1 Rule No. 6
The functional clustering of teams and assignment of specific Team Leaders shall
facilitate implementation, monitoring and supervision in a coordinative manner and
shall not, in any way, prejudice the corporate nature of the DOH-attached agencies
or the autonomy of Local Government Units.
F1 Rule No. 7
17
Carrying Out the Game Plan: Winning
Strategies to Attain FOURmula ONE for
Health Component Specific Objectives
Critical interventions under F1 are packaged under the four reform components: Health Service
Delivery, Health Regulation, Health Financing, and Good Governance. It is envisioned that all the
reform components shall be implemented as a single package in areas which shall be called as the
FOUR-in-One sites. Greater investments, more technical assistance and more intensive
implementation processes and arrangements shall be focused in the FOUR-in-One sites. As such,
16 provincial LGUs were selected as initial implementation sites for F1 and additional provinces if
not all provinces in the country shall be selected as roll-out sites.
The provinces that are not selected as F1 sites are encouraged to implement the different F1
programs, projects and activities (PPAs) within their means even without the support from other
partners. However, it is recognized that the implementation of many F1 PPAs shall be done at
national scale such as the different priority public health programs and projects for maternal and
child health, tuberculosis, HIV/AIDS and enrollment of indigent families to the Sponsored Program
of PhilHealth among others.
To better operationalize each reform component, flagship PPAs has been defined. The said PPAs
shall be implemented at the national and local levels.
The PPAs at the national level shall focus on health policy formulation and program development;
capability building for LGUs and other stakeholders; leveraging services for priority public health
programs; regulation of services, products and facilities, health promotion and advocacy;
improvement of management systems and processes; tertiary care development; and monitoring
and evaluation among others.
The PPAs at the LGU level focus on the adoption and implementation of health policies and
programs. The LGUs shall also strive for the improvement of their management systems and
processes. The preceding section shall focus on the details of the PPAs for the national and LGU
levels.
18
F1 Programs, Projects and Activities
National Level LGU Level
I. Health Financing I. Health Financing
1. Expansion of the National Health Insurance Program (NHIP) 1. Support to the Expansion of National Health Insurance
a. Attainment of Universal Coverage for Social Health Insurance Program (NHIP)
b. Assurance of National Government Premium Counterpart a. Support to the Attainment of Universal Coverage for Social
c. Development and Implementation of Tool/s to Identify the Indigent Families for Health Insurance
PhilHealth Sponsored Program Enrolment b. Assurance of Local Government Premium Counterpart
d. Accreditation of Health Care Providers c. Adoption of PhilHealth Approved Tool for Identifying
e. Expansion of PhilHealth Benefit Packages Indigent Families and Ensure their Enrolment to PhilHealth
d. Compliance to PhilHealth Accreditation Standards
e. Rational Use of PhilHealth Capitation and Reimbursements
2. Budget Reforms in DOH and Attached Agencies 2. Increasing LGU Investment for Health
a. Development of the Health Sector Expenditure Framework (HSEF) a. Increasing Budget Allocation for Health
b. Establishment of a System for Budget Allocation, Utilization and Performance b. Revenue Generation and Mobilization of Extra-Budgetary
Monitoring Resources
c. Mobilization of Extra-Budgetary Resources c. Income Retention of Health Facilities
d. Coordination of National and Local Health Spending
2. Development of Quality Seals for Health Products, Food, Devices, Drug 2. Legislation and Localization of Health Regulatory Policies
Establishments, Facilities and Services
4. Improving the Availability and Access to Low-Cost and Quality Essential 3. Improving the Availability and Access to Low-Cost Quality
Medicines and Other Health Commodities Essential Medicines and Other Health Commodities
a. Promotion of High Quality Generic Pharmaceutical Products a. Promotion of High Quality Generic Pharmaceutical Products
b. Expansion of Pharmaceutical Distribution Networks b. Establishment and Operation of Pharmaceutical Distribution
c. Identification of Alternative Local and Foreign Sources of Low-Priced Quality Networks
Drugs and Medicines c. Implementation of Pooled Procurement among Health Facilities
d. Development of Mechanisms for Pooled Procurement Among Health Facilities across LGUs
Across LGUs
19
F1 Projects Programs and Activities
National Level LGU Level
III. Service Delivery III. Service Delivery
1. Public Health Development Program 1. Public Health Development Program
a. Establishment of Disease-Free Zones a. Establishment of Disease-Free Zones
Filariasis Elimination Services Filariasis Elimination Services
Schistosomiasis Elimination Services Schistosomiasis Elimination Services
Rabies Elimination Services Rabies Elimination Services
Leprosy Elimination Services Leprosy Elimination Services
Malaria Control Services Malaria Control Services
b. Intensifying Disease Prevention and Control b. Intensifying Disease Prevention and Control
Tuberculosis Control Services Tuberculosis Control Services
HIV/AIDS Control Services HIV/AIDS Control Services
Dengue Control Services Dengue Control Services
Emerging and Reemerging Infection Prevention and Control Services Emerging and Reemerging Infection Prevention and Control
Services
c. Improving Reproductive Health Outcomes c. Improving Reproductive Health Outcomes
i. Enhancement of the Child Health Programs i. Implementation of Child Health Programs
Expanded Program on Immunization Expanded Program on Immunization
Breastfeeding Program Breastfeeding Program
Integrated Management of Childhood Illnesses (IMCI) Integrated Management of Childhood Illnesses (IMCI)
Nutrition Services Nutrition Services
ii. Enhancement of the Maternal Health Programs ii. Implementation of Maternal Health Programs
Safe Motherhood Policy Safe Motherhood Policy
Reproductive Health to Include Family Planning and Adolescent Reproductive Health to Include Family Planning and Adolescent
Health Health
Maternal Nutrition Maternal Nutrition
d. Intensifying Healthy Lifestyle and Management of Health d. Intensify Healthy Lifestyle and Management of Health Risks
Risks Advocacy campaigns for risk behaviors
Advocacy Campaigns for Risk Behaviors Water and Sanitation Programs
Water and Sanitation Programs Risk factor screening
Risk Factor Screening
e. Strengthening the Surveillance and Epidemic Management e. Strengthening the Surveillance and Epidemic Management
System System
Creation and Strengthening of Epidemic and Surveillance Units Creation and Strengthening of Epidemic and Surveillance Units
Creation of Regional Epidemic Management Committee (REMC) Creation of Provincial Epidemic Management Committee (PEMC)
Set up Surveillance Systems Set up Surveillance Systems
Linkage with Private Sector Linkage with Private Sector
f. Strengthening the Disaster Preparedness and Response System f. Strengthening the Disaster Preparedness and Response System
g. Intensifying Health Promotion and Advocacy g. Intensifying Health Promotion and Advocacy
Review of Health Promotion Interventions and Technology Upgrade Localization of Health Promotion and Advocacy Materials
Strengthening Health Promotion in Service Packages Behavior Change Communication (BCC)
Integration of Patient Education in Clinical Practice Guidelines Intensification of Patient Education in Clinical Practice
Creation of Health Promotion Foundation
2. Health Facilities Development Program 2. Health Facilities Development Program
a. Rationalization of Health Facilities and Services Including the Provision a. Rationalization of Local Health Facilities to Include BEmOC/ CEmOC
and Capacity Building of Human Resources for Health and the Provision and Capacity Building of Human Resource for
b. Integration of Wellness Services in Hospitals Health
c. Hospital Development Planning b. Integration of Wellness Services in Hospitals
c. Compliance to PhilHealth Accreditation Standards for Health Facilities
d. Compliance to DOH Licensing Standards for Health Facilities
IV. Good Governance IV. Good Governance
1. National and LGU Sectoral Management 1. LGU Sectoral Management
a. Strengthening the Stewardship of National and Local Health Systems a. Strengthening the Local Health Systems Development
b. Strengthening the National Human Resources for Health Program b. Strengthening the Local Human Resource Management System
c. Sector Development Approach for Health (SDAH) Implementation c. Sector Development Approach for Health (SDAH) Implementation
d. Institutionalization of the Monitoring and Evaluation of Health Reforms d. Support to the LGU Scorecard Implementation
e. Strengthening the Philippine Health Information System e. Strengthen Local Health Information System Development and
Utilization
2. DOH Internal Management 2. LGU Internal Management
a. Strengthening the Public Finance Management a. Strengthening the Public Finance Management
b. Strengthening the Procurement and Logistics Management b. Strengthening the Procurement and Logistics Management
c. Asset Management c. Asset Management
d. Strengthening the Internal Audit d. Strengthening the Internal Audit
20
Health Financing
I. STRATEGIES
The objective of health financing reforms is to secure higher, better and sustained investments in
health to provide equity and improve health outcomes, especially for the poor. The key strategies
for attaining this objective are as follows:
21
II. PROGRAMS, PROJECTS AND ACTIVITIES
A. National Level
1. Expansion of the National Health Insurance Program
a. Attainment of Universal Coverage for Social Health Insurance
The Philippine Health Insurance Corporation or PhilHealth shall continuously conduct advocacy to
increase membership and collection for the National Health Insurance Program (NHIP) to achieve
its goal of universal social health insurance coverage. This shall include social marketing
mechanisms to increase and sustain coverage as well as ensuring timely and accurate premium
remittance for the following: a) indigent families under the Sponsored Program; b) Overseas
Filipino Workers (OFWs); c) voluntary and self-employed individuals under the Individually Paying
Program (IPP); and d) government and private employees under the formal sector. In order to
establish a truly equitable social health insurance program, PhilHealth shall develop a more
responsive contribution structure such that those who have more resources bear the bigger
burden compared to that of the poor.
Steps shall also be taken to ensure that benefits remain within the range of targeted support
value. Clinical Practice Guidelines (CPGs) or treatment protocols for the proper management of
patients shall also be developed to ensure rational use of drugs, medicines and services and to
prevent excessive claims of health providers from the purchasers of health services such as
PhilHealth and the general population.
22
2. Budget Reforms in DOH and Attached Agencies
a. Development of the Health Sector Expenditure Framework
A medium term Health Sector Expenditure Framework (HSEF) will be developed to facilitate
linking budget allocation to performance. This will be the basis for planning, budgeting, utilizing
funds and monitoring other project components, harmonized with DOH’s own management
processes.
23
B. LGU Level
24
2. Increasing LGU Investments for Health
Advocacy for the increased health budget allocation for capital outlay, maintenance and other
operating expenses and personal services from the IRA shall be conducted among municipal, city and
provincial LGUs.
25
Health Regulation
I. STRATEGIES
Health regulation reforms aim to assure access to quality and affordable health products, devices,
facilities and services, especially those commonly used by the poor. Strategies under this reform
component include the following:
Consistent with the over-all financing strategy for health reforms, cost recovery and
income retention for health regulatory agencies and other revenue-generating mechanisms
shall be pursued to ensure financial sustainability. However, use of retained revenues shall
be backed by a rational and approved expenditure plan.
The availability of low-priced quality essential medicines commonly used by the poor shall
be assured through the following mechanisms: (1) promoting high quality generic
pharmaceutical products; (2) expanding pharmaceutical distribution networks; (3)
identifying alternative local and foreign sources of low-priced pharmaceutical products;
and (4) developing mechanisms for pooled procurement among health facilities and across
LGUs to realize economies of scale.
26
II. PROGRAMS, PROJECTS AND ACTIVITIES
A. National Level
The regulatory systems and processes of the DOH need to be upgraded, harmonized,
streamlined and simplified. In the process, personnel and manpower implements would be
rationalized and dedicated to more productive activities. On the side of the regulated, this
agenda would derive customer trust in the system and, ultimately, satisfaction on the
regulatory services provided.
In the One-Stop Shop Licensure System, a single license to operate shall be issued to the health
facility which would cover all services provided within the premises of the health facility,
including diagnostic and other ancillary services. There shall be a single license application
process and unified inspection of the health facility that shall be conducted by a composite
team of professionals with the technical expertise to determine compliance to regulatory
standards.
Another important feature of the One-Stop Shop Licensure System shall be the automatic
renewal of license. With this feature, the license to operate shall be renewed upon submission
of required documents without prior inspection of the health facility. Compliance to regulatory
standards shall be determined during intensified monitoring visits by the regulatory officers
from the CHDs and DOH regulatory bureaus. Automatic renewal of license shall necessitate a
more intensive, less frequent regulatory procedures that focus more on providing incentives for
timely submission of applications such as discounts on license fees.
The implementation of the One-Stop Shop Licensure System shall be evaluated by 2009-2010.
The system is expected to promote efficiency in health regulation, which shall in turn lead to
the achievement of the F1 goals of responsiveness and client satisfaction.
The Bureau of Quarantine (BoQ) shall set up a One-Stop Shop for the issuance of Certificate of
Compliance to Criteria for Establishments’ Sanitation and Employees’ Hygiene for all
establishments located inside the perimeter of airports and seaports nationwide.
27
b. Automation of Regulatory Systems and Processes
Upgrading of regulatory systems and processes shall be realized through the establishment of a
“central regulatory hub” that will facilitate transactions in the regulatory bureaus and
improve their information management system. This shall entail software development for the
automation of systems and procedures for the regulation of health products, food, devices,
drug establishments and facilities. Automation will increase efficiency in the regulatory
bureaus as well as client satisfaction through better, faster and more convenient public
service.
For the Bureau of Health Facilities and Services (BHFS), there is the ongoing development and
implementation of the computer-based Integrated Drug Test Operations and Management
Information System (IDTOMIS). Its objective is to make efficient and effective the current
systems and procedures for accreditation of drug testing laboratories and drug abuse treatment
and rehabilitation centers through on-line application and payment systems, registration of
clients, and verification and confirmation of drug test results through the development and
implementation of computer-based systems.
The Bureau of Food and Drugs (BFAD) is currently undergoing automation of its regulatory
systems and processes. Likewise, automation of its systems and processes is being proposed by
the Bureau of Health Devices and Technology (BHDT) as well as the BoQ.
Decentralization to the CHDs shall initially be undertaken for the licensing process for hospitals
and clinical laboratories. Other health facilities and other health regulatory functions shall be
targeted later on, based on the evaluation of initial decentralization efforts. Similarly, the
decentralization of selected regulatory functions to LGUs shall be based on the experience with
decentralization to CHDs. In addition, a research study on the capacity of LGUs to undertake
health regulatory functions shall be conducted. The data that will be obtained shall serve as
basis for policy decisions on decentralization of regulatory functions to LGUs.
The BoQ shall decentralize appropriate regulatory functions to major quarantine stations
nationwide.
In the background of decentralization, the DOH regulatory bureaus shall re-orient their
organizational goals and functions, focusing more on regulatory standards development,
supervision and monitoring, surveillance and oversight. They shall endeavor to build up the
capacity of CHDs, other field units (i.e. quarantine stations) and LGUs to perform decentralized
regulatory functions, particularly the training of personnel.
28
d. Upgrading of the Critical Capacity of Regulatory Agencies
The regulatory bureaus shall develop and implement their master plans to upgrade laboratory
equipment, services, systems and processes including the retooling and retraining of their health
human resource.
Outsourcing is the contracting out or buying in of goods or services from external sources, whether
government or private, instead of the regulatory bureaus providing such services themselves. This
can take the form of a regulatory bureau transferring the operation of a certain regulatory service to
a private firm.
Initial efforts on outsourcing or contracting out of selected regulatory services to other government
agencies or the private sector shall be evaluated for efficiency and effectiveness, particularly in
terms of strengthening enforcement and promoting compliance to regulatory standards. The
regulatory bureaus shall also determine which among their remaining regulatory functions may be
outsourced or contracted out.
The presence of specialized service support systems and expert services is needed to assure
continuous compliance with the technical requirements of the regulatory bureaus. There should be a
regulatory mechanism to recognize or deputize specialized or expert service providers through
accreditation or certification systems.
In order to promote geographic access to hospital facilities and to maximize the use of limited health
resources, the DOH shall expand the scope of hospital regulation by controlling the establishment of
new hospitals through the institution of the Certificate of Need as a requirement for the issuance of
a permit to construct and license to operate a hospital. Similarly, there is a need to promote access
to medical equipment to where they are needed most by coming up with a list of essential health
technologies for each level of health care systems.
The BoQ has integrated all accreditation into a Unified Seal of Approval by subscription to the
Hazard Analysis Critical Control Point and the Good Manufacturing Practice since 2004. BoQ also
developed the Quality Seals for Food Service Establishments within the perimeter of airports and
seaports.
29
The DOH and PhilHealth shall harmonize the Sentrong Sigla Certification (Phase II level 1) and the
PhilHealth accreditation of RHUs and BHSs by integrating PhilHealth accreditation standards for
RHUs/BHSs into the basic certification standards of the Sentrong Sigla.
The BoQ has a long standing coordination and cooperation with other ASEAN countries: Brunei
Darussalam, Indonesia, Malaysia and the Philippines East Asia Growth Area. There is a continuous
quarterly meeting in each country by rotation attended by representatives from their Customs,
Immigration, Quarantine and Security since 1994.
For medical devices and equipment, the ASEAN countries are looking for integration measures on
the regulatory systems and processes such as:
A common submission dossier for product approval;
An abridged approval process for medical devices which Regulatory Authorities of
benchmarked counties or regional RAs have already approved;
A harmonized placement of medical devices into the ASEAN market based on common
product approval process; and
A formalized post marketing alert for defective or unsafe medical devices and equipment
Along these activities, the Philippine DOH joined the ASEAN Harmonization Working Party and
worked in parallel with Global Harmonization Task Force on technical harmonization efforts.
Access to essential life-saving drugs depends on the availability and affordability of such,
especially in areas of high morbidity and mortality. Moreover, other factors also influence and
have direct or indirect effects to access to essential drugs and medicines namely: rational
selection and use of medicines, tailored procurement, sustainable financing and reliable health
and supply systems.
In line and espoused within the National Objectives for Health to achieve the Medium Term
Philippine Development Plan and Millennium Development Goals, the following interventions
have been prioritized to achieve our envisioned goal of better health outcomes through the
provision of essential drugs and medicines, especially for the poor and underserved.
30
a. Promotion of High Quality Generic Pharmaceutical Products
Promotion of high quality generic pharmaceutical products shall be pursued among producers,
distributors, retailers, medical and dental practitioners and consumers. BFAD shall ensure that
generic pharmaceutical products are of high quality through their regulatory systems and
processes. Rational prescribing of drugs and medicines among medical and dental practitioners
shall be enforced according to the Pharmacy Law (RA 5921) and Generics Act (RA 6675). Rational
drug use shall be promoted among patients and consumers of drugs and medicines to ensure safety
and attainment of desired therapeutic effects. The advocacy for the establishment of functional
therapeutic committees in government and private hospitals shall be strengthened. Another
strategy is the P100 program which is being implemented by the DOH. This program has the main
objective of ensuring access to drugs and medicines which are packaged within an affordability
parameter of 100 pesos or below. This program shall be piloted in 100 hospitals (DOH and LGUs).
i. Botika ng Barangay (BnB). The BnB program seeks to make quality essential drugs and
medicines more affordable and available to the Filipino people down to the Barangay level
among the poorest of the poor. Regulatory requirements for establishing BnB were
streamlined for facility and seed capital investments were planned and provided for from
the DOH to assist LGUs in pushing for and realizing the objectives of the Program. The
current target is to establish one BnB to serve three adjacent barangays. To date, there are
more than 11,000 BnBs all over situated even in the most far flung areas of the country.
ii. Botika ng Bayan (BNB).The DOH together with the Philippine International Trading
Corporation (PITC) launched in December 2004 the BNB project to set up a nationwide
network of privately-owned and operated accredited pharmacies that sell low-priced
parallel imported or generic drugs with the aim of competing with commercially priced
drugs and medicines in the market. At least 1,500 outlets have been opened so far.
31
d. Development of Mechanism for Pooled Procurement among Health Facilities
across LGUs
Mechanisms for pooled procurement among health facilities across LGUs shall be developed to
capture the benefits of economies of scale through the execution of Memorandum of Agreements
(MOAs) or Memorandum of Understanding (MOUs).
The BoQ has restructured its regulatory fees in 2005. This was followed by the BHFS in 2006, when
it started to implement a rationalized schedule of fees for the regulation of health facilities. BFAD
and BHDT shall also re-structure their own regulatory fees based on actual administrative costs.
The BoQ is mandated to retain and utilize at least fifty percent (50%) of its income by virtue of
Republic Act 9271 of 2004.
DOH shall continue to push for the approval of the special provision on income retention and
utilization by BFAD, BHDT and BHFS under the General Appropriations Act or its enactment in a
Republic Act (RA).
The BHFS shall continue to propose the implementation of the provision in Section 17 of the
Hospital Licensure Act or Republic Act 4226 that allows the hospital licensing agency to retain
funds collected from permit to construct, registration and license to operate fees for hospitals and
other health facilities covered by the RA.
Income retention and fiscal autonomy, with appropriate control and auditing systems, is expected
to result in better performance of the health regulatory bureaus.
32
B. LGU Level
33
Health Service Delivery
I. STRATEGIES
The objective of service delivery reforms is to improve the accessibility and availability of
basic and essential health care for all, particularly the poor. The following strategies are
utilized to attain this objective:
Basic and essential health service packages shall be made available in all localities
while specific and specialized health services shall be made available by designated
providers in strategic locations. This will ensure the continuity of health services
from the primary, secondary up to tertiary levels of care.
34
II. PROGRAMS, PROJECTS AND ACTIVITIES
A. National Level
35
ii. Maternal Health Programs. The improvement of reproductive health outcomes such as
the Maternal Mortality Ratio (MMR),Total Fertility Rate (TFR), Contraceptive Prevalence
Rate (CPR) depend on the strengthening of maternal health programs, development and
implementation of new policies and standards, and ensuring availability and
accessibility of public health commodities and services. This includes provision of
ferrous sulfate, Vitamin A, and tetanus toxoid; conduct of prenatal and postnatal
check-ups and assistance during delivery by skilled health professionals and delivery in
health facilities capable of providing Basic or Comprehensive Emergency Obstetric Care
(BEmOC or CEmOC); family planning; Contraceptive Self Reliance (CSR); adolescent
health and other reproductive health initiatives as well as maternal nutrition among
others.
The promotion of Safe Motherhood Policy, in which all pregnancies are treated as high
risk, and maternal death reviews shall be considered for all maternal deaths. BEmOC
and CEmOC facility mapping and upgrading shall be advocated by the DOH including the
creation of Women’s Health Team, implementation of CSR and other Reproductive
Health (RH) programs among LGUs.
Threats of emerging and re-emerging infections such as Severe Acute Respiratory Syndrome
(SARS) and avian influenza necessitates the creation and strengthening of the disease
epidemiology and surveillance network through enhancing the Epidemiology and Surveillance
Units (ESU) at all levels of government units – municipal level (Municipal Epidemiologic and
Surveillance Unit or MESU), city level (City Epidemiologic and Surveillance Unit or CESU) and at
the level of the province (Provincial Epidemiologic and Surveillance Unit or PESU). Tracking of
disease incidence as well as the development and implementation of prompt response shall be
greatly facilitated by the institutionalization of ESU networks in all LGUs. Regional Epidemic
Management Committee (REMC) shall be created at the regional level. In line with these
initiatives, linkages with private sector practitioners who serve a significant part of the
population shall be strengthened and be made more efficient.
36
f. Strengthening the Disaster Management System
Prevention of loss of lives during emergencies and disasters requires strengthening of health
emergency and disaster preparedness, response, recovery and rehabilitation including poison control
across all levels. This shall be done through the organization, integration and coordination of the
entire health sector for emergency and disaster preparedness and response and by providing and
augmenting the necessary logistic resources for effective and efficient response to the same. The
National Disaster Coordinating Council (NDCC) Memorandum Order No. 5, s. 2007 has institutionalized
the cluster approach in the Philippine Disaster Management System from the national to the
provincial level where the DOH is the main interlocutor or lead agency in the four clusters (Health;
Nutrition; Water, Sanitation and Hygiene (WaSH) and Psychosocial Services) with the counterpart
Inter-Agency Standing Committee Country Team as support, with defined roles and responsibilities.
The DOH, as the national policy institution, shall formulate, disseminate and implement the policy on
health emergency management from which the local government, non-government organizations and
other members of the health sector will anchor their thrusts and directions for health emergency
management. The DOH shall take the lead in the development and advocacy of the all–hazard
approach in health emergency preparedness, response and recovery (HEPRR) plan in all DOH health
facilities (CHDs and DOH Retained Hospitals). The development of the plan defines in advance the
arrangements, procedures, advocacy awareness, health emergency response coordination and
monitoring, logistics pre-positioning and donations tracking and other related activities that will
enable these health facilities to effectively prepare for, response to and recover from emergencies
and disasters.
The CHDs and the DOH Retained Hospitals shall continue to serve as the regional front liners to
any emergencies and disasters in their respective area. The CHDs take care of the
institutionalization and coordination of health emergency preparedness and response at the
local level, while the DOH Retained Hospitals provide the needed pre-hospital care (first aid
care, ambulance transfer and referral) and hospital care. The Regional and Hospital Emergency
Operation Centers shall be established or sustained in order to report and update the DOH
Central Monitoring Center all the emergencies and disasters in their respective jurisdiction.
The Regional Health Emergency Network (RHEN) shall be established at the regional level
through a MOA with different stakeholders. Policy formulation, advocacy, networking,
coordination and monitoring shall also be implemented for the promotion of Safe Community
and Safe Hospitals assisting in building awareness to effect changes and improve disaster risk
reduction capacity in emergency management.
ii. Strengthening Health Promotion in Health Service Packages. Health promotion shall be
strengthened and incorporated into health service packages. Aggressive promotion of
F1 adoption to stakeholders, especially the LGUs and the public, will be undertaken.
37
2. Health Facilities Development Program
a. Rationalization of Health Facilities and Services Including the Provision and
Capacity Building of Human Resources for Health
Rationalization of the health facilities and services guarantees the delivery of quality health care
services by providing appropriate access to the right facilities in the right places and with the right
professionals. It also drastically limits the rapid rise in cost of the health care system by reducing
excess capacity; removing wasteful duplication of services and ensuring a continuity of care from
primary or home based care to specialized care.
Health care facilities and health providers operating within a health care delivery system of a
specific area shall follow a set of guidelines that would enable them to rationalize their facilities and
services based on the health needs of the community they serve. This covers public and private
health care providers, national and local health facilities such as health centers and RHUs, BEmOC
and CEmOC, drug outlets, laboratories and hospitals. DOH shall pursue facility mapping for public
and private facilities for all these facilities to ensure access of the population to health care
services.
Assistance for the rationalization of facilities and services shall be provided to include critical
upgrading of facility and equipment. The DOH shall also ensure health human resource capability
building and venue for professional enrichment.
38
B. LGU Level
ii. Implementation of Maternal Health Programs. The LGUs shall ensure the implementation of
maternal health programs such as the delivery of pregnant mothers in BEmOC and CEmOC
facilities by skilled health professionals; conduct maternal death reviews; tetanus toxoid
immunization; prenatal and post-natal check-ups; distribution of iron supplements to pregnant
mothers and distribution of iron and Vitamin A to lactating mothers among others. The LGUs
shall develop Women’s Health Teams consisting of physicians, nurses, midwives, trained
traditional birth attendants and volunteer health workers. The Women’s Health Team will
attend to deliveries and implement family planning and other RH programs. The LGUs may
develop family planning, contraceptive self reliance and reproductive health ordinances among
others to ensure the improvement of maternal health.
39
d. Intensifying Healthy Lifestyle and Management of Health Risks
The LGUs shall intensify programs and activities that promote healthy lifestyle to prevent
cardiovascular diseases, diabetes mellitus, chronic obstructive pulmonary disease, breast and
cervical cancers. This shall include promotion of smoking cessation, right diet, exercise, stress
management, safe water, and sanitation among others. The LGUs shall network with
professional and other private groups in setting local support and advocacy teams for healthy
lifestyle. The LGUs may develop health ordinances such as a Tobacco Control Ordinance to
support the implementation of healthy lifestyle and the management of health risks.
i. Behavior Change Communication. The promotion of behavior change for health shall be
intensified to improve the health seeking behavior, attitude and values of the local
population towards health and health related matters.
ii. Localization of Health Promotion and Advocacy Materials. Health promotion and
advocacy materials shall be localized using the vernacular or dialect for easier
understanding of the population in a particular area.
40
2. Health Facilities Development Program
a. Rationalization of Local Health Facilities to Include BEmOC / CEmOC and
the Provision and Capacity Building of Human Resources for Health
Rationalization plan of LGU health facilities shall be developed and implemented to ensure that there
is a continuity of care from primary, secondary and tertiary level. This shall cover the BHSs, RHUs,
BEmOC and CEmOC facilities. The LGUs should ensure that core referral hospitals and CEmOC
facilities are offering regular and emergency services on a 24-hour basis. This shall entail the
merging of adjacent facilities and their health human resource, facility level adjustment and
reconfiguration including facility and equipment development. Facility mapping shall be
conducted among LGUs to serve as basis for the rationalization plan. The LGUs may develop local
ordinances to ensure the implementation of rationalization plans to optimize the utilization of
health facilities.
LGUs which are lacking in HRH shall be encouraged to develop mechanism to ensure the
application, hiring and retention of necessary HRH to include legislation, executive issuances and
memorandum of agreements for salaries and benefits. The DOH shall also assist in the training
and professional development of LGU HRH.
41
Good Governance
I. STRATEGIES
The objective of good governance in health is to improve health systems performance at the
national and local levels. This involves interventions that cut across all areas of health reform and
employs these key strategies:
42
II. PROGRAMS, PROJECTS AND ACTIVITIES
A. National Level
The DOH shall lead the LGUs towards effective stewardship of their local health systems through
the institution of health reforms at the local level. This shall be done through the establishment
of FOUR-in–ONE convergence sites where all four reforms - health financing, health regulation,
health service delivery and good governance are implemented initially in 16 provinces then
eventually in the rest of the country. The key elements in the implementation of these FOUR-in-
ONE sites are: investment planning; service delivery flow and referral network in a province-wide
system; formation of inter-local health zones leading to province-wide governance mechanisms
and institutions for the health system; and rationalization of central support to F1 convergence
sites. A roll-out framework and plan shall be developed and implemented for the expansion of F1
convergence sites to other areas based on lessons learned from pilot convergence sites.
LGUs that may not yet have the capacity to adopt a convergence approach to implement health
reforms shall be assisted in the development of functional inter-local health systems based on
learning derived from best practices. Improvement in the capacity of local health authority to
manage and coordinate the functions of the local health system shall be pursued.
Promotion and advocacy for increased inter-LGU cooperation and coordination as well as public-
private partnership shall also be intensified.
Technical leadership and management capability at the central and regional levels will be
strengthened through retooling and retraining of central office and CHD personnel as well as
tapping DOH representatives to serve as vital links to the LGUs.
i. Human Resource for Health Planning and Production. HRH Planning shall be done by
getting the total workforce requirements and corresponding costs based on parameters
like current population and population growth, current stock of HRH category and
attrition rate, and preferred health worker to population ratio. It should then follow
that the production of health manpower shall be based on the actual and projected
requirements of the health delivery system.
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ii. Human Resource for Health Utilization and Placement. A recruitment and selection system
shall be developed based on actual job competencies. At the same time, rewards and
incentive mechanism through a performance management system shall be developed to
motivate health professionals to continue personal development and improve job
performance. Actual career development and management shall be conducted to support
health manpower through retention planning, individual career planning, career pathing and
succession management. These processes shall also ensure that a qualified professional will be
ready to continue the service of a vacated position.
The DOH shall continue to augment necessary HRH at the local level when necessary through
the implementation of the Doctors to the Barrios and Rural Health Practice Program, provision
of a pool of Medical Specialist and provision of Medical Officers.
iii. Human Resource for Health Learning and Development. Strategy driven, competency-based
training and development interventions shall be aggressively pursued to equip HRH at the
national, regional and local levels with knowledge, attitudes and skills required to carry out
reforms in the country’s health care system.
iv. Human Resource for Health Information System. Different HRH Information Systems shall be
installed to capture employee information, support HRH Management and Development
systems, announce job vacancies in the health sector and generate baseline HRH data for use
in planning. There is a need to communicate these health human resource thrusts and
resources to both the health workers and the communities.
To maximize the use of the monitoring and evaluation system and keep it responsive to changes during
the medium term, there is a need to develop the monitoring and evaluation capabilities, including
research skills of DOH central office and CHD personnel.
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e. Strengthening the Philippine Health Information System
Health information should be managed, disseminated and utilized effectively. In line with this, a
Philippine Health Information Network (PHIN) shall be institutionalized which shall serve as the “data
portal” or a search engine for all health information. Easily accessible data shall make not only
health planning easier but also support cooperative efforts with partners. With both public and
private sector using the same information source to monitor and plan, efforts and interventions shall
become more complementary.
Efforts in this regard shall include harmonization of information systems of different stakeholders in
health. This will include information systems on human resource, vital registries and health
statistics, disease surveillance, national and local health accounts, health regulations, and health
facilities. To maximize the use of the information system, the DOH as well as the other health sector
stakeholders shall develop systems on knowledge management which includes not only information
systems but also development of knowledge management oriented decision-makers, staff and
processes.
d. Asset Management
The DOH shall undertake a comprehensive and systematic process of effectively acquiring,
maintaining, upgrading, operating and disposing its assets to maximize the utilization and worth of
these assets.
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B. LGU Level
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2. LGU Internal Management
c. Asset Management
The LGUs shall undertake a comprehensive and systematic process of effectively acquiring,
maintaining, upgrading, operating and disposing its assets in the health facilities to maximize the
utilization and worth of these assets.
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Running the Health Reform Race: Operational
Framework for FOURmula ONE for Health
To ensure its effective and efficient implementation, FOURmula ONE for Health (F1) shall adopt
the following management approach:
Institutionalizing interagency steering committee
Designating implementation teams
Providing dedicated coordination teams
Integrating resource management and
Strengthening management of communications and advocacy.
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The relationship of the above teams to the National Steering Committee for Health, the attached
agencies and special concerns and to the Office of the Secretary shall be defined as shown in the
figure:
Secretary
National Steering Attached Agencies & Special
of Health
Committee on Health Concerns
Policy & Standards Development & Technical Assistance Field Implementation and Coordination
Regional Regional
Implementation Implementation
& Coordination & Coordination
Teams
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Roles and Responsibilities
The Executive Committee (ExeCom) – provides policy directions for implementing FOURmula ONE
for Health. The ExeCom is chaired by the Secretary of Health and is composed of all
undersecretaries, assistant secretaries and selected Directors in the DOH.
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The Policy and Standards Development Team for Health Service
Delivery (PSD Team for Service Delivery)
The PSD Team for Service Delivery ensures the development of policies, standards and guidelines
for health programs and the provision of technical assistance to health service providers. This
includes the development of disease surveillance systems, program design for essential health
packages and specialized health services, health promotion and advocacy, and upgrading of health
facilities, among others.
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Local Implementation and Coordination Teams (LIC Teams)
The LIC Teams are responsible for the over-all implementation of F1 activities in their respective
local government units or Four-in-One Convergence sites.
Chaired by the Local Chief Executives (LCEs) or their duly designated representatives, the LIC
Teams will ensure local health governance through the institutionalization of management
structures consistent with F1 implementation.
Civil Society
Civil society and other private sector partners are expected to assist the DOH and the LGUs in
achieving desired health objectives.
Civil society will help point out people’s health needs, particularly those of the vulnerable groups
and bring to the attention of the LCEs and/or LIC Teams such felt needs.
They will contribute towards enhancing the equity, accountability and transparency of F1
implementation at the Four-in-One Convergence sites.
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Pump-Priming Health Reform Implementation:
F1 Financing Mechanisms and Strategies
The financing of FOURmula ONE for Health or F1 implementation follows a two-pronged strategy:
1. The first one, described earlier in the section on financing, refers to the rational use of
public subsidies, both national and local, and the increasing role of social health insurance in
paying for the health services of Filipinos. This likewise requires aligning these resources to
sustain the strategic thrusts and programs of F1.
2. The other strategy entails using available resources, mainly those from the foreign
assistance pipeline to pump prime F1 implementation in the immediate term.
The financing portfolio for FOUR-in-One Convergence Sites consists of the following:
Grants will come from development agencies such as the European Union (EU), the German
Technical Cooperation (GTZ) and the Government of Belgium among others.
LGU Counterpart will come from the respective Internal Revenue Allotments (IRA) and other
revenue sources of the LGUs; or from loans that may be accessed from the Asian Development
Bank (ADB) or the Kreditanstalt für Wiederaufbau (KfW) through the Municipal Finance Corporation
(MFC), an attached agency of the Department of Finance, and other such development or
commercial banks.
National Government Counterpart will come in the form of technical assistance, training and
capability building, systems development support, logistics support or other non-cash assistance
from the Department of Health. One source identified for the national Government counterpart is
the World Bank (WB), in the form of a budget support loan.
Other Partners like the World Health Organization (WHO) and other United Nations-attached
agencies, the United States Agency for International Development (USAID), the Japan International
Cooperation Agency (JICA) and other funding agencies will also be tapped for technical assistance
and support.
Given the diversity of funding sources and priorities, F1 will offer a rational menu of interventions
to finance, organized in a way that individual donors can support, while reflecting their own
priorities and preferences.
This menu provides a venue where various donors, the DOH, the LGUs and other agencies can
dialogue and jointly answer how the full package of F1 implementation can be supported. The end
goal of this dialogue shall be an optimal foreign assistance portfolio that:
Ensures that the full package of F1 implementation is fully supported;
Ensures that there is a balance between loans and grants, between funds for project
preparation and funds for implementation in supporting targeted FOUR-in-ONE
convergence sites;
Ensures that funds are applied in a timely manner, i.e. present and future support for F1
are made available over a longer planning horizon;
Ensures that funds are applied in a manner compatible with improving the capacities to
manage the reforms, thus avoiding parallel funding agency operated agendas and
management infrastructures; and
Any health project that will be developed in the future shall as much as possible be
consistent with and brought into the F1 framework.
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Reaching the Finish Line: Setting New F1
Targets and Objectives
As previously emphasized, working on reforms for the health sector will never be
done in a single medium term. It is a long-term, dynamic and iterative process
such that reaching the F1 finish line means starting on a new track all over again.
It is the intention of F1 to put the building blocks in place now and trigger more
reforms in the future.
All stakeholders for health are encouraged to join the race against fragmentation,
inequity and ill-health to reach a brighter and healthier tomorrow for many
generations of Filipinos to come.
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BIBLIOGRAPHY
Administrative Order 2005-0023: Implementing Guidelines for FOURmula ONE for
Health as Framework for Health Reforms, Department of Health, Philippines
National Demographic and Health Survey 2003, National Statistics Office, Manila,
Philippines, and ORC Macro, Calverton, Maryland. 2004
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