MDGs on health and the need for partnerships

Forging National-Local Partnerships to attain Health MDGs Public Private Partnerships in Health Blueprint for the National Health Information System Creating Impact: Improving MMR in ZFF Partner Municipalities Undevolved Health in ARMM: An Issue in Attaining MDGs?
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table of contents
MDGs on health: Where are we now? Forging National - Local Partnerships to attain Health MDGs Philippine Health Outlook Forum: Responding to Health Inequities through Multi-stakeholder Partnerships Public - Private Partnerships in Health Blueprint for the National Health Information System Technical ICT Group for Health Provincial Health Partnership Program: Converging Priorities Governors and Partners towards MDGs Creating Impact: Improving MMR in ZFF Partner - Municipalities Undevolved Health in ARMM: An Issue in Attaining MDGs? SLAM wins Galing Pook Award 3 14 17 19 20 22 23 25 26 29 34

Message froM the President

It has been three years since the Zuellig Family Foundation decided to recast its strategy in an effort to help speed-up reforms in the local public health systems. By improving government health service delivery in local communities, more poor people receive what they rightfully deserve - proper healthcare. We use the Millennium Development Goals in health as objective measurements of our programs success (or failure). If our programs have been effective, then our partner-municipalities must show improved health indicators relating to maternal health, child health and infectious diseases. We are pleased to say that our first batch of nine partner-municipalities did not fail us. We owe the success to our very rewarding partnerships with
ISSN 2243-7126

Editorial Board
Ernesto D. Garilao Executive Editor-in-Chief Maricar D. Tolosa Editor-in-Chief Ana Katrina A. Go Managing Editor Juan A. Villamor Anthony Rosendo G. Faraon, MD Contributing Editors Eddie G. Dorotan, MD Jaime Z. Galvez-Tan, MD Undersecretary Teodoro J. Herbosa, MD Alvin B. Marcelo, MD Contributors Jovito M. Dy Mike U. Juan Wesley T. Villanueva Staff Writers Alberto G. Romualdez, MD

our contributors
Eddie Dorotan, MD
Dr. Dorotan is the Executive Director of Galing Pook Foundation, a resource institution that promotes innovation, sustainability, citizen empowerment and excellence in local governance. Having witnessed poverty across the country and seeing how local governments responded through innovations, Dr. Dorotan knows only too well that public-private collaborations are critical, particularly in health. In this issue, he shares what these partnerships are.

these rural municipalities - now numbering 30 - and with various government agencies and private organizations. We have experienced efficient sharing and deployment of resources, an expansion in influence and reach, and an increase in knowledge. These benefits strengthened our resolve to actively promote the formation of various multi-stakeholder partnerships for health, which is aligned with the Aquino administrations call for public - private partnerships (PPPs) and agenda of Universal Health Care for all Filipinos. Already, our Foundation has five groups composed of private and public individuals and organizations working on five different pertinent health issues - Localizing MDGs, Autonomous Region in Muslim Mindanao, information and communications technology, health financing and capability-building for municipal mayors. We also have the Zamboanga Health Alliance, a partnership with the Department of Health and the Department of Social Welfare and Development, working to improve the lives of residents in the Zamboanga Peninsula. In this issue of the Health Intel, we try to give readers a better appreciation of PPPs on health by presenting successful experiences on partnerships and arguments for PPPs. We hope that like us, you will start increasing your participation in endeavours that work towards improving the lives of poor Filipinos.

Undersecretary Gerardo Bayugo, MD

Ernesto Domingo, MD Benny Reverente, MD Advisory Board Members

Undersecretary Teodoro Herbosa, MD

Dr. Teodoro Herbosa is the chairman of the Public-Private Partnership Taskforce of the Department of Health, one of the first government agencies to form such a group to fast-track PPP programs and thus, bring much needed improvements in the countrys health sector. In his article, one will find a model that worked abroad and that could very much succeed in our country.

about the health intel

A publication of Zuellig Family Foundation, Health Intel intends to provide relevant information, insights and analyses for incisive policy discussions on critical health issues. The publication also serves as an advocacy mechanism for more responsive health leadership that can transform the Philippine healthcare system to be more equitable. The views and opinions expressed in this publication do not necessarily reflect those of the Foundation or the Zuellig subsidiaries and affiliates. No article in this publication may be reproduced or reprinted without prior written permission from Zuellig Family Foundation. Please send your comments, suggestions and contributions to communications@zuelligfoundation.org.

Alvin Marcelo, MD
Technology has dramatically changed the business and communication landscape. Should the right information and communication technology be in place in the health sector, Filipinos can expect similar immeasurable benefits. As director of the University of the Philippines Manila National Telehealth Center, Dr. Marcelo not only tells what these benefits are, he also gives us how we should go about building the proper information system for the whole country.

Jimmy Galvez-Tan, MD
As former health secretary and now, as president of a foundation assisting local governments in healthcare management, Dr. Galvez-Tan knows the complications in the health system of the Autonomous Region in Muslim Mindanao. In his piece here, he shares what strategies can be adopted in ARMM where, unlike in the rest of the country, health is not devolved to local government units.

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Table 1. Philippine status in terms of attaining the MDGs on health targets

MDGs on HEAlTH:
WHErE ArE WE noW?
s
ince adopting the Millennium Development Goals in 2000, the Philippines has made significant improvements in the general health of the population. Despite the gains, though, the country will still likely miss some of the MDGs. These include targets in reducing the maternal mortality ratio, achieving universal access to reproductive health services and stopping the spread of HIV/AIDS. The present administration, however, stressed that its priority is to meet the MDGs. In fact, President Benigno Aquino III, in his speech during the 65th United Nations General Assembly in September 2010, reiterated his administrations focus on ensuring the achievement of the MDGs. The same was pronounced by Health Secretary Enrique Ona during the Second Health Outlook Forum when he said, I dont intend to miss the (MDG) targets. During his speech, Aquino said that his government will ensure that private businesses, while allowed to grow unimpeded, must recognize and fulfill their social responsibilities. Our administrations pledge: To channel the gains we might reap from Public - Private Partnerships into social services, like those in health, education, and poverty alleviation. At the rate things are going, the country will likely attain the targets of reducing child mortality and halting malaria and other diseases. There is also medium probability of attaining universal access to treatment for HIV/AIDS (see Table 1).

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MDG 4: reduce by two-thirds between 1990 and 2015 the under-five mortality rate

MDG 5: reduce by three-quarters, between 1990-2015, the maternal mortality ratio and achieve universal access to reproductive health by 2015

ignificant strides have been made in reducing child

mortality for the past two decades. The country will likely attain its 2015 infant (IMR) and under-5 (U5MR) mortality targets of 1.17 and 1.20, respectively, given the pace by which the rates have been decreasing. In 1990, IMR and U5MR stood at 57 and 80, respectively. The same indicators stood at 34 and 25, respectively, in 2008. The IMR of 34, however, translates to 80,000 children dying annually of preventable causes. The figure also masks the great disparity between children from rich and poor families. Among the lowest quintile, U5MR is 59 and IMR is 40 while among the highest quintile, the figures are 17 and 15, respectively. In rural areas U5MR is 46 and IMR is 35 but in urban areas, the same indicators are 28 and 20, respectively. Among the regions, the ARMM had the highest U5MR at 94, followed by Eastern Visayas at 64. NCR had the lowest at 24. This reflects the inequity in access to child health programs and services. The poor and more vulnerable segment of the population have low to medium access to healthcare. During a lecture that former Health Secretary Alberto Romualdez delivered at the University of the Philippines, Manila on September 2008, he said that 83% of children from top quintile homes get the Expanded Program on Immunization vaccines while only half of those from the low quintile families get the vaccines. Based on the 2008 National Demographic Health Survey (NDHS), a mothers educational attainment plays a crucial role in reducing early childhood mortality rates. Children whose mothers have attained relatively higher education have higher chances of survival. Children whose mothers had elementary education are three times more likely to survive than those whose mothers had no education. Likewise, child mortality rate is seven times higher and U5MR four times higher for uneducated mothers than

ased on the Philippines Fourth Progress Report-2010, the rate of

decline of maternal mortality, at 0.47%, is very low such that the country is unlikely to meet its target on maternal health. According to Romualdez, inequities plague the delivery of maternal and reproductive health services, leading to 3,000 Filipino women dying unnecessarily every year. Rich urban communities and those in the upper wealth quintile have greater access to maternal and reproductive health services. Mothers in poor rural communities, particularly the geographically isolated and depressed areas, have to endure home deliveries by hilots (traditional birth attendants), dilapidated health facilities, inadequate and incompetent health providers, and lack of access to essential medicines and reproductive health products.

levels of income and natal care

The NDHS report showed that 98% of pregnant women in the highest quintile receive antenatal care compared to 77% in the lowest quintile. Romualdez said that while less than half of the poor pregnant women in the country receive iron supplementation, 80% of pregnant women from the top quintile get this vital supplement. He added that among poor women giving birth, less than two percent undergo caesarian sections compared to 20% among their rich counterparts. (see also Figure 1)

Child mortality is seven times higher for uneducated mothers.

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those whose mothers reached high school. The gap is even bigger for those whose mothers have college education.

3,000 Filipino women die unnecessarily every year.

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Education and maternal care

Contraceptive prevalence rate (CPR) over the years has remained Educational attainment also affects a womans health-seeking behavior. The NDHS showed that mothers with no education were two times more unlikely to seek antenatal care from skilled health providers. The same correlation goes for the likelihood that mothers will get iron supplementation, protection against neonatal tetanus, facility-based delivery, and delivery by skilled provider. Among the countrys regions, only 46.7% of pregnant women in the ARMM receive antenatal care from skilled health providers compared to the 85-97% of women in majority of the regions. tract infections including STDs, HIV, and AIDS; prevention and appropriate treatment of sexual disorders; prevention and treatment of breast cancers, and other gynecological conditions; counseling and education on sexual health; adolescent reproductive health; male reproductive health; and prevention and management of violence against women. Figure 2 shows that family planning and birth spacing is critical to reducing child mortality rates. Despite the significance in curbing maternal and early child mortality rates, ensuring access to reproductive health services remain a low priority, particularly in poor rural areas. The survey showed that the country is likely to miss the target for ensuring universal access to reproductive health by 2015. low (see Figure 3). Data showed that total fertility rate (TFR) and CPR is shaped by socio-economic and geographic factors. According to Romualdez, recent fertility rate figures showed that rich women on average have only two children, while poor women at the bottom quintile of income groups have 6 or 7 during their reproductive years. The NDHS report also showed that women with college or higher education have TFR of 2.3 and CPR of 53.1 in contrast to the 4.5 TFR and 18.5 CPR of women with only elementary education. Among the regions, the ARMM had the highest fertility rate at 4.3 and lowest CPR at 15.1 compared to TFR of 2.3 and CPR of 54.1 in NCR.

reproductive health
Limited access to reproductive health services also impedes the reduction of maternal and early child mortality rates. Reproductive health services include family planning; maternal and child health and nutrition; prevention and treatment of reproductive

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Target: Have halted, by 2015, and begun to reverse the incidence of malaria and other major diseases
The rate of progress towards eradicating malaria incidence indicates from 1990 to 2009. In 2008, the DOH declared 22 provinces as malaria-free, leaving local governments of the 58 other provinces to work towards totally being malaria-free (see Figure 7).

MDG 6: Have halted, by 2015, and begun to reverse the spread of HIV/AIDs; and achieve, by 2010, universal access to treatment for HIV/AIDs for all those who need it
Experts expressed alarm over the rapid increase in the number of new HIV/AIDS positive cases during the past two years. From an average of one new case a day in 2007, it rose to an average of two new cases a day in 2009 and then to four new cases a day in 2010 (see Figure 5). Although considered to have low-HIV-prevalence, the current rate of increases in new cases coupled with the slow rate of progress indicates that the country may not meet its 2015 target. In February 2011, the National Epidemiology Center reported 159 new cases, 22% higher than Data from the 2009 Integrated HIV Behavioral and Serologic Surveillance revealed that only 38% of the most-at-risk populations were reached by the HIV prevention programs. Access of those with HIV infection to anti-retroviral therapy was only 82% according to the 2010 report of the Philippine National AIDS Council. the previous year. This rapid increase was attributed to increased risky behavior and low coverage of HIV interventions.

a high probability of attaining the target by 2015. Figures 6a and 6b show the continuous decline of malaria morbidity and mortality rate

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TB remains a major concern

While there were gains in the detection and cure of tuberculosis, TB prevalence and mortality remain a concern. According to the 2010-2016 Philippine Plan of Action to Control Tuberculosis of the DOH, the country was still at the 9th place among the 22 high-burden countries. The countrys TB prevalence, incidence and mortality rates remained higher than the average global and regional levels (see Figure 8). There have also been increasing new cases of Multi-drug Resistant TB (MDR-TB) from 2005-2009 and varying MDR-TB that developed from previously treated cases.

Breaking down the data into regions show that 11 out of 17 regions are below the national average cure rate of 82%. Central Luzon, at 69%, had the lowest cure rate. Of the 11 regions, five are in Luzon, including the National Capital Region, one is in the Visayas and five are in Mindanao.

Figure 7. Distribution of malaria cases in the Philippines, 6-year average (2003-2008)

58 provinces still have to strengthen efforts to address Malaria.

source: Philippine Progress report on Millennium Development Goals 2010 11

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Forging national-local Partnerships to attain Health MDGs

by: Eddie Dorotan, MD, MPA

urrently, the country is still lagging behind in reducing infant

units. It further delineated the task of hospital care to the provincial governments, while that of preventive care to the municipalities and cities. This set-up led to difficulties in the coordination and integration of the delivery of health services. Confusion on the roles played by regional DOH officials and local elected officials ensued. Centers of Health Development (DOH Regional Health Offices) personnel were accustomed to a vertical health implementation for years. Governors and mayors, on the other hand, were new to the task of health given to them. Worse, for some local officials, health was not a priority. Through the years, the country has seen slow progress in the

mortality and maternal mortality. Infant mortality rate (IMR) is still at 25 per 1,000 live births while maternal mortality ratio (MMR) is at 162 per 100,000 live births (2005 FPSA and 2008 NDHS). The targets, by 2015, are 19 for IMR and 52 for MMR. AIDS/HIV, tuberculosis and other diseases still pose threats to the population. Across geographic and income groups particularly the poor, there are significant differences in outcomes and program performances in these three health Millennium Development Goals (MDGs 4, 5 and 6). So the question is: can we attain the MDGs in health by 2015? My optimistic answer is yes we can but only if national and

integration and coordination of health services. The DOH has been slowly implementing health sector reforms at the local level. The Philippine Health Insurance Corporation has devised a sponsored program giving capitations and reimbursements to local government units. And local governments are working together through interlocal health alliances and zones. The challenge now is how to make our health system work better, given the mandate of devolution. Specifically, how do we forge national and local partnerships in health so that we can achieve our health targets by 2015? What are the most important areas for forging partnerships?

Pursuing 2015 MDG targets through Partnerships A

s the country continues to struggle in meeting some of the By having the Center, countries can benefit from the advice and support of experts and gain the professional capability to successfully implement PPPs. According to Public - Private Partnership Center Executive Director Last April, Ona announced that the United Nations Economic Commission for Europe (UNECE) approved the establishment of an International Public - Private Partnership (PPP) Specialist Center for Health in Manila. The Center will, among others, fund the development and updating of specific best practice guides under the direction by the UN PPP Secretariat; manage the sector specific PPP Research Program; and manage the Specialist Centre Membership. The Center is part of UNECEs program of establishing an International Center for Excellence on PPP in Geneva and then various sectoral specialist centers in different countries. Other PPPs for health include the formation of the Zamboanga Alliance between the Zuellig Family Foundation, Department of Health and Department of Social Welfare and Development. The Alliance will work to improve the health situation in 51 Zamboanga Peninsula municipalities that are also recipients of DSWDs conditional cash transfer program. Philamer Torio, the establishment of the Center can lead to more infrastructure projects in the countrys health sector. targets, there is a need for greater private participation not just to help the country meet its targets, but to alleviate the conditions of poor Filipinos as well.

local governments can forge effective, efficient and empowering partnerships.

Fragmented Health system

One of the problems confronting the health system is the fragmentation as a consequence of the Local Government Code of 1991. The Code devolved the functions of health service delivery from the Department of Health to the local government

Dr. Eddie Dorotan facilitates the Health Leaders for the Poor training program participated by mayors and health leaders from ZFF partner-municipalities.

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entire population. By concentrating on primary health, we do not only hit MDGs in health but the rest of the MDGs as well. In the same manner, by tackling activities on other non-health MDGs, we improve further the attainment of MDGs in health (as these non-health MDGs are part of the social determinants of health outcomes). Health programs and projects, at all levels, should concentrate on what matters most: the ELEMENTS of Primary Healthcare.

Nutrition

Malnutrition in this country should be minimized if not eliminated. It can be done through a tripartite partnership among government, non-government and private sectors.

Treatment and management of Common and Chronic Diseases

Malaria, Tuberculosis, Schistosomiasis are still with us. These must be controlled significantly and the same must be done with HIV/AIDS and other emerging diseases. The chronic diseases of diabetes, hypertension, arthritis and the concerns of the elderly must also be addressed.

Education
Greater emphasis should be made on educating the public about healthy lifestyles, preventing diseases, managing
Dao Mayor Joselito Escutin (middle) together with his municipal health officer, Dr. Humblelyn Horneja and Vice Mayor Lorie Eslaban, rallies his townmates to support governments various health programs

illnesses, and where and when to get medical assistance. Information and dissemination of health programs and projects should be popularized so that people will be more aware, are more health conscious, will have choices and be empowered to take care of their familys health needs.

Community-based health initiatives have to be reinvigorated. The number of community health workers and parents and community organizations must be increased so they can be mobilized for preventive care in the countryside.

Self-Reliance/Community Initiatives

Areas for Partnerships

President Aquinos program of Universal Health Care for All Filipinos aptly affirms that health is a basic human right. As such, every Filipino can demand basic health services from the government. But health is also a responsibility of every citizen; therefore, everyone should contribute to the well-being of all. This encompassing principle all the more gives impetus to the need for more effective partnerships between national and local stakeholders in healthcare.

On the other hand, the PHIC, being the biggest purchaser of healthcare, should craft incremental upgrading of quality benefit packages to its members and make sure these benefits (preventive and curative, including catastrophic) are delivered by accredited government and private providers across the land in the most effective and efficient manner. Together, the DOH and PHIC, as the main players in health reforms, should partner in a seamless way so that innovations and implementation are done better and faster. It is essential that DOH and PHIC work very closely with local government units in localizing these health reforms.

Livelihood
Providing the poor with income generating activities and livelihood opportunities should be a component of any comprehensive health program as this will increase the purchasing power of the family.

5.

Health human resource

The people who deliver the health services must be appreciated and be given incentives in performing their noble task of uplifting the health of our people. The benefits under the Magna Carta for Public Health Workers must be given right away. We must also incentivize the work in the countryside and minimize brain drain and maximize brain gain. Given the challenges and

Environmental Sanitation
Every family should have access to potable water and safe sanitation facilities. Water and sanitation are very important determinants of health. Less people will get sick from water-fecal-borne diseases if only people have these basic necessities in life.

Here are the areas where partnerships have to be forged: 1. social Health Insurance

3.

Inter-lGU Cooperation

Securing health insurance coverage for all is a must. This can be done by having the national government enroll all the poor (50% of the population) to the National Health Insurance Program (NHIP) of the Philippine Health Insurance Corporation (PHIC) through the DOH. Twenty-five percent of the population (the employed sector) is currently covered by government and private agencies. The remaining 25% should be sponsored by local governments. This would entail a total cost of just about P10-11 billion a year from the national government! Everybody then, even the poor, can demand basic preventive and curative health services from accredited government and private providers.

Provinces, cities, municipalities and barangays have to work together in delivering, financing and coordinating a continuum of services from preventive to hospital care within a province. Inter-local health zones and alliances have to be further incentivized to improve performance. This may be in the form of performance-based grants or awards and recognition. Improving accountability relationships among politicians, health providers and the community should help in making health services work by having more access to information, feedback mechanisms, functional local health boards, and performance monitoring and evaluation.

opportunities ahead, the way forward is universal healthcare through efficient, effective and empowering stakeholders. partnerships In this among national and local way, I am optimistic we can attain MDGs not only in health but in all MDGs as well by 2015. There is no other way.

Maternal and Child Care

Mothers and children should not die without being attended to by appropriate health personnel. Maternal and child care should include responsible parenthood, family planning, immunization and birthing facilities, among others.

Essential Drugs
Essential quality medicines should be accessible to all. Bringing down the cost of medicines should be a priority. Ensuring the quality and the right utilization of these medicines is also very important. A strong regulation of medical and medical products should secure efficacy and safety of these products.

4.

Primary Healthcare

2.

DoH-PHIC-lGU Collaboration

The universal healthcare strategy has to put primary healthcare into its core thrust so that people from different sectors - government, private, non-government and civil society - work hand in hand in securing the health welfare of the

The DOH must exert its technical-political leadership in public health, hospital care and regulations, so that the most effective, efficient and empowering health interventions are carried out nationwide.
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the current social health financing scheme, the poor subsidizes the rich. The richest quintile benefit the most from PhilHealth reimbursements at P5.2 billion compared to P1.4 billion among the poorest quintile, noted Dr. Leizel Lagrada, officer-in-charge of the Health Policy Development and Planning Bureau in the Department of Health. Dr. Rosette Vergeire, Medical Officer IV of the Health Policy Development and Planning Bureau of the DOH, also reiterated in the second Health Outlook Forum the need for advocacy support to pursue the Healthcare Financing Strategy 2010-2020 that would include mobilizing resources for healthcare spending that will be effectively allocated and utilized to ensure improved financial risk protection. Dr. Suzette Lazo, Director of the Food and Drug Administration, presented the inability of regulatory bodies to ensure availability of quality, effective, and affordable essential medicines. According to her, Drug prices in the Philippines is among the highest in the world. Recent evidence documents that procurement costs are higher than international reference standards and mark-ups from distribution to the retailer vary widely reaching up to 355%. Aside from the factors mentioned, the poors health seeking behavior also contributes to the poor health indicators. Poverty, coupled with inequity in the current health system, drives the poor out of the healthcare system. It is not surprising that the poor have

the worst health outcomes and are most vulnerable to infectious and communicable diseases, said Dr. Eric Tayag, Director of the National Epidemiology Center of the DOH. They either have limited or no access at all to basic health services that are readily available to people with financial means. Faced with this scenario, the poor continues to suffer as a result of an inequitable health system. Revisions of policies and programs, however, should have effective implementation strategies especially because experiences have shown that past and even present efforts have not been benefitting the poor. For instance, lowering the prices of medicines by 50 percent has not addressed the poors problem on access to medicines. To begin with, the poor are so poor that they do not even have pockets, much less money for medicines, explained by Mr. Emmanuel Leyco, Executive Director of the Center for Legislative Development. Presented with these issues, the Zuellig Family Foundation urged the government to step up its efforts and start engaging the private sector. According to the ZFF President Ernesto Garilao, there is a need to mend the current set-up although there is no one fix. He stressed the need for stronger public-private partnership toward shared understanding and collaborative action to ensure sustainable gains in the health sector.

Health Secretary Enrique Ona emphasizes the advantage of harnessing public-private partnerships during the Second Philippine Health Outlook Forum.

PHIlIPPInE HEAlTH oUTlook ForUM:

rEsPonDInG To HEAlTH InEQUITIEs THroUGH MUlTI-sTAkEHolDEr PArTnErsHIPs

n the countrys health system, the poor are placed at a great disadvantage as the number of health workers is disproportionately employed in the private sector. According to former Health Secretary Alberto Romualdez, Seventy percent of the countrys health workers are employed in the private sector serving only 30 percent of the population; the remaining 30 percent of workers are in the government services catering to majority of the Filipinos. He added that for a country that produces a good number of the worlds health professionals, almost 60% of Filipinos die without seeing one. Recognizing the depth of the problem in the countrys health situation, the Zuellig Family Foundation (ZFF) provided an avenue to raise the level of discussions on national health issues as common concerns. More than being a platform for discussion, the Philippine Health Outlook Forum also emphasizes the need for public-private collaboration to jumpstart improvements in programs, and ensures the sustainability of gains. Two Forums held last year (January and October) tackled challenges in the health sector and the response of the new Aquino administration through its health agenda of Universal Health Care. The root cause of the countrys poor health system is the prevalence of inequities. During the Forums, contributing factors such as the fragmented healthcare delivery system, inefficient social health financing scheme, high costs of medicines, poor governance structure and regulatory mechanisms were presented and analyzed.

Policies and programs in the past have failed to target the areas and vulnerable groups of the population that need the assistance most. Data shows that the poor, who have the greatest need for healthcare, namely, pregnant women, the newborn, infants, and children, are underserved. The former Health Secretarys report also showed that while rich urban communities with access to modern facilities like those in Metro Manila, Cebu, and Davao have outcomes comparable to those of developed countries i.e., Life Expectancy at Birth (LEB) of over 80 years, Infant Mortality Rate (IMR) of less than 10, and Maternal Mortality Ratio (MMR) of less than 15, poor rural communities, such as those in Bicol, the Samar provinces and ARMM, have results that approach those of the least developed countries i.e., LEB under 60 years, IMR over 90, and MMR over 150. The fragmentation of healthcare service delivery has resulted to discrimination against the poor. The poor has to go to hilots or traditional healers for medical attention since these are widely available, accessible, and affordable, noted Clinical Epidemiologist and Senior Management Officer of Medical City, Dr. Joselito Acuin, during the Forum. Even the social health financing scheme in the country contributed to the wide disparity between the rich and poor income quintiles. Contrary to the intention of the law, studies showed that under

Pursuing strategic Partnerships

n a bid to help the country achieve the MDGs on health, pursuing strategic partnerships became imperative following the two forums. Follow through mechanisms for the Forum initiatives involve a series of roundtable discussions. These were conducted to pursue the recommendations and action plans taken up and aimed at building consensus on how to best move forward and create greater impacts that address gaps in the health sector. Currently, there are four technical working clusters, each focusing on a particular area: ARMM, ICT for health, Localizing MDGs, and Health Financing. The Foundation forged a partnership with the League of Provinces of the Philippines to scale up localization initiatives addressing MDGs for health. The partnership entails capability building for governors, provincial health officers, and health leaders, as well as technical support. The ARMM Cluster was formed to focus on and help address the health inequities in ARMM. As part of the cluster, the

Foundation gave its commitment to support the governments efforts to improve the health situation in the ARMM. Through its Community Health Partnership Program, the Foundation will provide eight towns in the region with leadership training, infrastructure and equipment grants, and other resources for health innovative programs. Four other municipalities in Maguindanao have received similar support from the ZFF. Cosette Realica, executive director of the Foundation for Sight, proposed the Sight for a Child Program of the Optometric Association of the Philippines. This entails early vision screening and visual impairment detection among elementary school children in the ARMM. Other RTD participants, including representatives of the University of Manila, Merck Sharp & Dohme Philippines and CARD-MRI, committed to support scholarships and long-term health human resource development programs, community mental health programs and health infrastructure plans. They will also call on other stakeholders to get involved in the development interventions for the ARMM.

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Public Private Partnerships in Health

Teodoro Herbosa, MD FPCS FACS Undersecretary, Chairman, Public-Private Partnership Taskforce, Department of Health

Blueprint for the national Health Information system

By Alvin Marcelo, MD

n November last year, inside a room packed with CEOs and

called Build Operate Transfer (BOT) scheme or joint venture. Among the early PPP projects involved power generation, tollways, airports and seaports. PPP is not privatization. In the United Kingdom, the Private Finance Initiative (PFI), a form of PPP has been used extensively since the 1990s. While PPPs used to largely involve power, roads and ports, these soon included social services. These were

executives of financial institutions, the Department of Health, headed by Secretary Enrique Ona, gave a well-received presentation on its ten priority public-private projects (PPPs). The encouraging response of the private sector led Ona to create the PPP taskforce within the DOH. The taskforces objectives are: 1. 2. Develop policies and appropriate approaches for engaging the private sector in attaining health goals Embark on advocacy, social marketing and capacity building activities for DOH and local government unit (LGU) health facilities in establishing PPPs 3. 4. 5. Promote sound contracts, memorandum of agreements, and memorandum of understanding Craft and implement monitoring and evaluation tools based on defined objectives and parameters for PPPs Act as a clearinghouse for collecting experiences, analysis and dissemination of best practices The DOH is also one of the first government agencies under the present administration to conduct an agency-wide seminar on PPP concepts and principles. It also engaged collaborative efforts with the Department of Finance and the PPP Center of the Philippines (PPP Center). Recently, the Jose Reyes Memorial Medical Center, a flagship hospital of the DOH, launched a PPP for a cancer treatment facility. In partnership with the Philippine Oncology and Cancer Center, it now offers the very first linear accelerator and high dose brachytherapy in a government hospital. The new facility also allows for the training program of radio oncologists. Previously, this training was only available abroad or in private or university hospitals. There are two projects included in the priority projects for 2011. These are the Vaccine Self Sufficiency Program (VSSP) of the Research Institute of Tropical Medicine (RITM) and the Modernization of the Philippine Orthopedic Center (POC). These two projects have technical specifications and are due for feasibility studies through an assistance fund from the PPP Center. The concept of PPP is not new to the Philippines. It was formerly

contracts for school buildings, hospitals and even prisons. The UKs PPPs included construction and operations of different social services, with responsibility remaining in the public sector. Coupled with transparency and good governance, the projects became successful. Now, most hospitals in UK were established through PPP and are run under its National Health Service trust. Through PPP, the Philippines can regain its competitiveness in the region. At present, the countrys DOH-retained hospitals vary from very modern ones like the specialty hospitals, to the very old and dilapidated hospitals with circa 1960s design and technology. Past administrations, instead of building new hospitals, concentrated on the less costly preventive and promotive healthcare. While this led to notable successes as we now see a decrease in communicable diseases, the approach left the country behind its ASEAN neighbors. Indonesia and Vietnam have overtaken the existing technology in our government-owned hospitals. In the 1960s, the country had the most modern hospital system in Asia; now Filipino surgeons go to Vietnam for training in laparoscopic surgery. The country is also seeing the rise of non-communicable diseases like heart attacks, strokes, diabetes, hypertension, cancer and trauma. countries. These used to be the problem of rich, industrialized Now, these diseases, which are expensive to treat Dr. Emmanuel Lallana, Executive Director of Ideacorp, facilitates the breakout group on leveraging the use of ICT for Health.

hen a man decides to build a house, he does so with great apprehension. This is because the costs tend to be beyond his means

and he probably will need to take a loan from the bank. Another reason is that the building process itself is complex, involving huge investments and commitment from many people ranging from the architect who designs the house to the plumber who lays down the pipes to the owner who will eventually live there. Adding to the anxiety is the fact that they do not know each other nor trust each other that much. It is therefore customary to prepare a blueprint prior to construction. The blueprint serves as a common reference point for every stakeholder involved in the project. Between the owner and the architect, they share the same vision of how the whole structure will appear and function. For the engineer and the contractors, the blueprint tells them what materials will be used. Once the structure is built, then its the interior designers turn to put in the appropriate furniture and fixtures in each room. At the end of it all, if the blueprint is followed faithfully, the owner is satisfied. It will be a coherent structure built by many hands pursuing a common goal of a comfortable home for a family. The blueprint serves as a contract of sorts.

and manage, are major killers of Filipinos. Under the Universal Health Care of the Aquino administration, the poor will be provided financial risk protection through the National Health Insurance Program or PhilHealth. Making PhilHealth efficient and widening both coverage and benefits are key to financial risk protection. As we improve financial risk protection though, we need to capacitate our hospitals and modernize the services. As the government cannot fully fund such modernization, we call on the private sector to help provide the boost to improve the infrastructure and services in all the different DOH and government hospitals.

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over. At the minimum, they should have documented everything, especially the failures so that the Philippine process can avoid the same pitfalls. Several countries have successfully crafted their Enterprise Architecture. Some of them are in Africa with direr situations than the Philippines. The Enterprise Architecture process is not cheap but it is also not impossible. Governance and leadership of DOH is a key component of the whole process. The resulting blueprint is called the Health Sector Enterprise Architecture. It will detail the major elements in the architecture, how they work within and with other elements in the larger health system. Once this sector-wide Enterprise

mandate) rather than software development (which is not its core competency). More fundamentally, the more DOH creates the software, the less credible it becomes as a regulatory body on information systems. To use another analogy, DOH should not be producing drugs because it may compromise its regulatory function especially when its own drug fails the quality tests. As a significant stakeholder in the larger health system, the private sector should be involved as soon as the organizational structure and processes for the sector-wide enterprise architecture efforts are clarified. This participation is crucial for the following reasons: first, the private sector has extensive experience with Enterprise Architecture methodologies. Second, it recognizes the importance of the private sector in collecting and submitting data from their respective institutions. It is a well-accepted fact that a significant number of Filipinos access private healthcare facilities. Ignoring the data accrued from these facilities will result in epidemiologically flawed analysis and we will not be able to see the complete picture of the countrys health situation. Lastly, they have the flexibility to implement the Enterprise Architecture and the accompanying standards in their local health systems. A true and sincere partnership with the private sector will result in faster deployments which can redound to more effective information systems on the ground. In the end, if DOH does the right thing right now, Juan dela Cruz can enter any health facility and get the service he needs without worrying about whether it will be covered by PhilHealth or not. Repetitive lab tests are detected and avoided, and the health system is financed more viably because it is more efficient. Filipinos can now appreciate their health system, and begin to understand universal healthcare. Any Juan will be happy to live in a home like this. Since the Forum last October, a series of round table discussions have been convened by Dr. Lallana of Ideacorp. These were attended by stakeholders from the public and private sectors and the academe. The cluster has tackled
(Note that since this is an analogy, it is by no means perfect nor comprehensive. Its purpose is to pose a certain view of an abstract thing called the national health information system. Other views should be considered as well, but they should also be subjected to the same level of scrutiny that this will receive. The authors contact details are Alvin Marcelo (info@universalhealthcare.ph).

TECHnICAl ICT GroUP For HEAlTH

In support of the Aquino Health Agenda, Health Secretary Enrique Ona ordered the creation of a technical working group on ICT for health (ICT4H) chaired by Assistant Health Secretary Nemesio Gako with members from the ICT4H Cluster that was formed during the Philippine Health Outlook Forum. Information and Communications Technology (ICT) plays a vital role in ensuring that universal healthcare is achieved through efficient and effective data gathering, policy-making and health service delivery, Secretary Ona emphasized during the Forum held last October 22. We have to determine what ICT for health projects and strategies are best done through public-private partnership (PPP) mechanisms to maximize its benefits, Ideacorp Executive Director Emmanuel Lallana stressed during one roundtable discussion (RTD). The ICT4H Technical Working Group is tasked to undertake inventory and assessment of ICT4H projects and initiatives in the country. The group must also obtain feedback and inputs from stakeholders, then come up with proposals and recommendations to promote and expand ICT for health programs both at the national and local levels. Upon implementation of the programs, the group has to evaluate and monitor the execution.

Architecture is published, it can serve as a guide for organizations when they start building their own local health information systems from the large PhilHealth membership database to the rural health unit electronic medical records system. They can start confidently interacting with outside systems, knowing these systems are also compliant with the sector-wide Enterprise Architecture. This analogy works well for the ideal national health information system. If the country had this blueprint, various stakeholders from the public and private sectors can contribute to building their own specific systems that can fit the larger national health information system. Lets then identify the counterparts of this analogy to the national health system. The owners of the national health information system are the Filipino people. They benefit the most from having an efficient, effective, and responsive system. As they are a diverse set of people, they are represented in this process by the Government of the Philippines, specifically, the Department of Health. It must be pointed out that a national health information system must involve the public and private sectors, the academe, non-government organizations and civil society groups. Internal informational need of the DOH is a mere component of the larger system. The department must practice openness to become a responsible and trustworthy representative of the people in the blueprinting process. Architecture is a specialization that is both science and art. In effect, when it comes to selecting an architect for the national health information system, it is best to identify people and organizations that have done this before, and have failed and succeeded many times

so whats next?
The DOH needs to carry this responsibility seriously and involve other stakeholders to make this happen. Health Secretary Enrique Ona has empowered Assistant Secretary Nemesio Gako to chair a multi-sectoral technical working group on information and communications technology for health (ICT4H). Collegially, they can come up with the sector-wide Enterprise Architecture, which can then serve as a guide for all other stakeholders in the national health information system. DOH then shifts to technical assistance and monitors if the blueprint is being implemented correctly. This may require re-orienting DOH into a regulatory and supervisory role (which is its primary

issues on ICT-enabled PhilHealth processes, ICT-based health information system, telemedicine, ICT standards and protocol. The technical working group is co-chaired by Director Crispinita Valdez of the DOH-Information Management Service. Other members include representatives from the Information Technology and Management Department of PhilHealth, National Telehealth Center, Commission on Information and Communications Technology, Ideacorp, IT Association of the Philippines, Philippine Long Distance Telephone Company, Medilink and Segworks Technologies Corporation.

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The League has also been reaching out to potential partners who would be interested in developing the capacities of provinces around the achievement of the MDGs especially in health. One partnership forged was with the ZFF. A Memorandum of Understanding was signed last February between the parties. This paved the way for the first Provincial Leaders for Health program last June wherein 16 governors across the country learned about public health governance and best practices from resource speakers Albay Governor Joey Salceda, Surigao del Sur Governor Johnny Pimentel and Bukidnon Vice Governor Jose Ma. Zubiri.

This program seeks to target areas where there is greater need to address the MDGs so investments and improvements are likely to have a greater impact on the overall performance of the country. Also, the work requires strong leadership and the willingness to commit to making the necessary changes to the health delivery system within the province. A pre-selection process shall be undertaken to make sure areas included in the program have a balance of need and leadership potential. The strategic approach includes replication of existing best practices that have allowed some provinces to make significant inroads in achieving their provincial MDG targets. This approach will be the basis of the initial two - day workshop that will be conducted to develop the leadership and management capacities of health leaders within the provinces selected. However, achieving the MDGs in health will require a concerted effort of different stakeholders aside from the province. Therefore, the program is envisioned to be a venue for convergence in the work to achieve the MDGs in health. ZFF and LPP will liaise with the Department of Health (DOH) and other interested organizations to augment the resources of the provincial government. The DOH already said that the Health Facilities Development Program and Universal Health Coverage through PhilHealth are programs that can be fast-tracked for the areas included in the program. The MDGs contribute to transparency and accountability in the work of achieving better quality of life. This same principle will guide this partnership program. Provincial targets will be clearly defined and roadmaps will be developed and can be appraised by the public. Implementation will be monitored and results will be reported back to the program partners and to the public. Work will also be done to ensure that the improvements, once achieved, will be maintained far into the future.

PUrsUInG PArTnErsHIPs AnD sTrEnGTHEnInG loCAlIzATIon sTrATEGy

MOU signing between Zuellig Family Foundation and League of Provinces of the Philippines.
Seated from left: ZFF Chairman Roberto Romulo, Gov. Alfonso Umali Jr. and ZFF President Ernesto Garilao; standing from left: ZFF Director Dr. Anthony Faraon, ZFF Trustee Reiner Gloor, Umalis chief of staff Marifi Hernandez, ZFF consultant Mike Juan, ZFF Director Juan Villamor

The LPP and ZFF propose a two-year program that will have the following objectives: 1. To assist the health leaders in the selected provinces understand the state of the MDGs for health To develop the capacity of the leaders to address the identified needs To assist in the development of plans that are technically sound, needs-based, and vetted by the community To assist in the implementation of the health projects To facilitate continuous learning and capacity building as the programs are being implemented To assist in evaluating the gains of the program and in making sure the gains are sustained beyond the program period.

2.

ProVInCIAl HEAlTH PArTnErsHIP ProGrAM

ConVErGInG PrIorITIEs
By Mike Juan

3.

4. 5.

ocalization strategy has been repeatedly highlighted in the four Philippine Progress Report on MDGs released in 2003, 2005, 2007 and 2010. This strategy recognizes the significant role that Local Government Units play in achieving the Millennium Development Goals. By virtue of the Local Government Code of 1991, LGUs have been given major responsibility in improving governance in the country by bringing the decision-making process closer to the people to develop policies and programs responsive to the needs of their communities. During the second Health Outlook Forum held last 22 October 2010, a breakout session was devoted to localizing MDGs on Health. The group identified initial efforts to achieve the MDGs both at the national and local level. However, the group pointed out the need for stronger governance and capability building mechanisms at the local government level to ensure that the country will be able to reach the targets by 2015. As post-forum initiative, a series of round table discussions were convened to bring together the League of Provinces of the Philippines (LPP), the Zuellig Family Foundation (ZFF) and the Department of Health and develop the initial framework

of a program envisioned to improve health conditions in the Philippines. 6. The current research of the ZFF from areas where there have been significant progress in the achievement of the MDGs suggests that the provincial government is an important actor to achieve the MDGs, especially in health. Provincial governments of Albay, Bukidnon, and Negros Occidental show the different possibilities available for provinces to have a great impact over a wide area in a relatively short period of time. This is the quality of change required for the Philippines to have a chance of achieving its MDG targets by 2015. The LPP is likewise interested in achieving the MDGs. The current national board, led by its National President, Governor Alfonso Umali Jr. of Oriental Mindoro, and its Secretary General, Governor Josephine Sato of Occidental Mindoro, made the achievement of the MDGs its priority program. The LPP believes that governors are in a unique position to enable the achievement of the MDGs in their provinces. The LPP has, in fact, completed a road trip during which Umali visited provinces with best practices in health service delivery. This is an effort to increase awareness of health delivery best practices among its members.

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GoVErnors AnD PArTnErs ToWArDs MDGs

A partnership to equip governors and provincial health officers with skills and knowledge in public health leadership and governance was forged between the Zuellig Family Foundation and the League of Provinces of the Philippines. Signing the Memorandum of Understanding on behalf of the LPP was its national president Oriental Mindoro Governor Alfonso Umali Jr., who expressed optimism that the partnership will bring the needed improvements in governance that will lead to the attainment of the health Millennium Development Goals on time. We see this as a great opportunity for the local government to contribute to the national agenda of President Noynoy Aquino to prioritize and meet the MDGs, hopefully in the appointed time, Umali said.
Mayors from Cohort 1 partner-municipalities together with municipal health officers and socio-civic leaders rally to show solidarity in efforts to improve health outcomes particularly among the poor

Last June, the first batch of governors and their provincial health officers undertook the pilot training program. The training introduced participants to best practices in public health that governors can use as models for replication in their provinces. Needs-based health action plans were developed by the health leaders to address the existing gaps in the provincial health system and inter-local health zones. As Umali stated, the partnership is actually a step towards improvements in government that mirrors the direction that President Aquino outlined: forging private-public partnerships; investments in competent and accountable leadership; and generation of policies reflective of the real needs of the people.

Creating Impact: Improving MMR in ZFF

Partner-Municipalities M
aternal healthcare in the country is still wanting despite To their credit, health leaders, particularly the mayors, gave their full support to the various innovative programs and poured substantial resources to make sure the programs are successfully implemented. There were programs to educate pregnant women through the Buntis Congress, closely monitor pregnancies through pregnancy mapping and data boards, and In 2008, healthcare for mothers was worse in the nine municipalities that form the Zuellig Family Foundations first batch of partner-municipalities. Average MMR of the municipalities was 167 per 100,000 live births, with one municipality actually registering an MMR of 460. Two years after the ZFF started its engagement though, the average MMR of the nine partner-municipalities went down to 136.
Zamboanga Del Sur Governor Antonio Cerilles poses a question to Bukidnon Vice Governor Jose Ma. Zubiri Jr. following the latters presentation on Bukidnons exemplary practice on Healthcare Financing and facilities development.

efforts to hit the Millennium Development Goals by 2015. In 2008, maternal mortality ratio (MMR) in the country was still high at 162 deaths for every 100,000 live births and will not likely go down to the 52.2 target by 2015.

upgrade the skills of frontline health workers. With funding from the ZFF, birthing clinics were also built to encourage deliveries attended by skilled health personnel. Figure 1 below shows the decreasing trend in the average MMR of Cohort 1. Should the linear trend continue, MMR could fall to 57.33. If they achieve an annual decrease of 21.3%, their average MMR could go down to 52 by 2014, hitting the MDG target a year earlier.

In fact, six municipalities recorded zero

maternal death. These are Bacolod (Lanao del Norte), Dao (Capiz), Padre Burgos (Quezon) and the Maguindanao municipalities of Datu Paglas, Paglat and Sultan sa Barongis.

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Aside from the aggregate increases in MHI, the nine municipalities out-performed other rural, similarly-classed municipalities from the same provinces in terms of improvements in MMR and facility-based deliveries (FBD) for the years 2008 and 2009. The ratio of facility-based deliveries in the partner-municipalities rose by 58% but fell by 8% in non-partner municipalities. Two other health indicators that constitute the Maternal Health Index (MHI) showed similar improvements since 2008. Average facility-based deliveries posted a 104% increase from its baseline of 20.14% in 2008 (Figure 2). The average percentage of births attended by skilled health personnel also increased from 54.52% to 56.88% (Figure 3). Relational and leadership changes were also observed in the nine municipalities. After attending the leadership training, the mayors views on the value of health and the important role that health workers play changed.

Foundation to care so much about our health outcomes, said Nurse Milma Gedo-Cruz of Bacolod, Lanao del Norte. For Lucy Yturalde, a midwife from Gen. S.K. Pendatun, her mayors concern for health gave her and other midwives reason to serve the people. Mas nadagdagan ang dedication namin ngayon sa pagbigay nang serbisyo sa mga tao; dati kahit walang suporta kinakaya namin na lakarin ang ilang kilometro para magbigay lang ng bakuna sa mga bata, mas lalo na ngayon na may suporta na si Mayor at nakikita namin na may pagbabago sa aming datos (We used to walk kilometers just to be able to give vaccines to kids, now that we have the support of our Mayor and we see improvements in our data, our dedication to serve was heightened.), Yturalde said. The developments have been significant but other issues still need to be addressed. Child mortality is still a major concern, particularly those due to pneumonia and malnutrition. Cases of tuberculosis and diarrhea must also be reduced. To ensure that programs reach the grassroots, barangay health systems must be further strengthened.

People do value and appreciate health programs if delivered regularly and expanded. Innovative and responsive health programs would greatly benefit a great number, if not all, of our constituents, said Dao, Capiz Mayor Joselito Escutin. The number of frontline health workers increased. Municipalities also started providing honorariums to their barangay health workers as added incentives, encouraging commitment and passion of health workers. I came in with very little expectations but after the seminar, I felt guilty because it took total strangers like the Zuellig Family

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UNDEVOLVED HEALTH IN ARMM:

An IssUE In ATTAInInG MDGs?
by Jaime galvez-tan
The Millennium Development Goals were crafted such that some of the goals also serve as means to other ends as expressed in MDG 8: Developing a Global Partnership for Development. When this is achieved, all sectors sustain the gains from the achievement of other goals. This will be truly beneficial to the Autonomous Region in Muslim Mindanao (ARMM). In the ARMM, regional health authorities and LGUs should strengthen their partnership with the DOH while at the same time, increase their interaction with international development agencies and broaden multi-stakeholder involvement and participation. To increase the involvement of the community, participatory The LGUs have adopted the conditional cash transfer program There is a vast potential in the decentralization policy enshrined in the LGC and the devolution process that ensued. LGUs were given powers to more effectively provide basic services, particularly health. However, the level of implementation of services remained under other national oversight agencies such as the Department of Health, Department of Agriculture, The national government (NG) devolved health to the regional level and not to the local government level as is the case for other LGUs in other regions. The reason for this was that the ARMM Regional Legislative Assembly had not passed its own LGC. Though an LGC was eventually passed, health services remained a transitory provision under the regional government. This is still in effect today. After increases in IRA, the LGUs of ARMM have forgotten what the increases were for, thereby creating another
health intel 2011 www.zuelligfoundation.org

roles of lGUs to achieve MDGs

In its research, the Foundation found out that eighty-five percent of barangays in the region have no barangay health stations. The report further stated that, the ARMM show the worst health statistics that are way-off desired standards.

Uniqueness of the health system in the ArMM

Governance in ARMM is uniquely funded as the regional government and the local governments are independent of each other. The regional government gets its funding from the national budget through the General Appropriations Act while local governments are funded through the Internal Revenue Allotments under the Local Government Code (LGC).

bureaucracy - a local government system which sadly does not include much needed health services.

mechanisms should be made available not only to more formally-organized and registered NGOs but also to the informal but more operational and relevant indigenous and Muslim groups, volunteer organizations, and community-based peoples organizations. This way, the opportunities for citizens to work together with their LGUs in the delivery of basic social services, including health, are enhanced. Efforts should be commensurate with the development of relevant and necessary capacities and competencies of civil society organizations (CSO).

or the Pantawid Pamilyang Pilipino Program (4Ps) of the Department of Social Work and Development (DSWD). This aligns with the MDGs of providing health and education through direct financial support to the poorest families who keep their children in school and ensures that children and pregnant women get regular health checkups; thus, addressing as well the slow progress in maternal mortality reduction. The DSWD ties up the 4Ps program with the Credit for Better Health Care Project in partnership with the Development Bank of the Philippines (DBP), targeting LGUs and identifying loan opportunities. This holds tremendous potentials for ARMM as well as responds to and supports the Public-Private Partnerships (PPP) in Health of the Aquino Administration.

Department of Environment and Natural Resources, and Department of Education. These agencies increased the amount of resources for the implementation of national programs and projects which otherwise would have been more efficiently and effectively carried out by the LGUs. At best, the LGUs serve only as the conduit of the NG projects that were designed and formulated with either very little or no input from the local stakeholders in the ARMM.

An effective strategy in increasing community participation is conducting technical assistance on advocacy to Muslim Religious Leaders (MRLs). In Basilan, an innovative approach encouraged the active participation of women by engaging women MRLs or the Alimas. This addresses the international cooperation (Goal

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GSKP Mayor Bonnie Kali spearheads the vitamin supplementation program in his municipality

8) as well as the other health components of the MDGs - Goals 4 (reducing child mortality rates), 5 (improving maternal health), and 6 (combating HIV/AIDS, malaria, and other diseases). The Local Government Support Programme in ARMM - Canadian International Development Agency (LGSPA-CIDA) addressed the issues of poverty by localizing the MDGs as a strategy to improve citizens participation. Similarly, the DILGs Seal of Good Housekeeping award allows winning LGUs to have access to the Performance Challenge Fund. One of the factors considered for the award is the degree of citizens participation. Effective advocacy materials must also be developed, such as the ARMM Strategy for Health Improvement (ASHI). In the Islamic City of Marawi, a city mayor initially opposed family planning as he believed that Muslims needed to increase their population. After getting oriented on the advocacy, he realized the benefits of the program and supported its implementation. He eventually had proceeds from the Philippine Health Insurance capitation funds used to procure family planning materials for the city.

Another challenge is getting more indigent families enrolled in the Philippine Health Insurance Corporation (PhilHealth). The Aquino administration is working towards enrolling the bottom 20% of the population through the National Household Targeting System. Both local governments and the regional health authorities must then assist the remaining poor and informal sectors in the next economic bracket to become PhilHealth members as well. Soliciting LGU support pose a challenge, but experiences in Basilan, Lanao del Sur, Maguindanao, and Marawi City, and the Integrated Provincial Health Office-LGU Good Governance Caravan in Tawi Tawi provide evidence that LGU support can be had. Inside a duyan (makeshift hammock), little Adjulamin sleeps More importantly, with national agencies and the regional ARMM authorities having failed to resolve the devolution issue for over a decade now, it behooves the present governments leadership to mandate the LGUs and the ARMM to urgently work cooperatively with the DOH and international partners to facilitate the achievement and progress of health services in the ARMM towards achieving the MDGs. peacefully, being rocked to sleep by his mother, 20-year-old Marina Usop. He came as a blessing to us, said Usop who narrated her difficult childbirth which left the doctor no other choice but to perform a caesarean operation. amount for the poor, jobless mother. Little did she Usop is only one among 5,000 indigents in Datu Paglas town in Maguindanao enjoying the benefits of PhilHealth. This came know that the cost of the surgery was P19,700, a staggering I was shocked. I do not have work and I could not afford it. Thanks to the PhilHealth card the local government of Datu Paglas provided her, she ended up paying only P120 to the provincial hospital where she gave birth.
Datu Paglas Municipal Health Officer Dr. Agustina Almirante (in white shirt) listens intently as local health leaders discuss health issues and possible solutions during the municipal health summit.

InVolVED lGU DEsPITE non-DEVolUTIon

by Wesley Villanueva

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as another blessing, she said while expressing thanks to their local government who is paying the annual premium of P120 per indigent family. Datu Paglas is a 4th class municipality in the province of Maguindanao in the Autonomous Region of Muslim Mindanao, where provision of health services are not devolved to the local government units. The Department of Health-ARMM (DOH-ARMM) administers, manages and implements the public sector health program. As an unintended outcome of non-devolution, some municipalities have suffered from the separation of health workers with the LGUs. This has been the case for years. The health professionals have been working independently from the LGUs, which in turn, is hesitant to assert their initiatives as they believe that they do not have the mandate. In most cases, the minimal role given to the LGUs resulted to the growing apathy and lack of ownership among the LGUs particularly on the issues of health. Despite the challenge of non-devolution, Datu Paglas is making innovations to strengthen its health systems and processes with the support of Zuellig Family Foundations Community Health Partnership Program. The LGU owned the issue and developed innovative ways to respond to the health challenges. Citizens access to affordable and reliable medicines is improved through the establishment of six Botika ng Barangay (Community Pharmacies). The community pharmacies were set-up in partnership with the Philippine Charity Sweepstakes Office (PCSO) and the DOH-ARMM. The PCSO also provided Datu Paglas with a municipal ambulance as part of the grant to support their health program. Using local funds, Datu Paglas partnered with PhilHealth to provide 5,000 indigent heads of households with socialized health insurance. During times of hospitalization, the heads of households and their families can now rely on PhilHealth. Promotive and preventive healthcare was also given focus by increasing the frequency of visits of 25 BHWs and midwives to all 23 barangays. The LGU and barangays equally shared the cost of the modest monthly honorarium and allowances of the rural health workers to enable community members to benefit from health education.

Datu Paglas invested in upgrading its Rural Health Unit (RHU) in order to meet the standards set by Philhealth for accreditation. With accredited facilities and enrolment to the Indigent Program, the expectant mothers now have access to a ten-bed ward when they recover after giving birth at the Zuellig Family Foundation-provided birthing unit at the Barangay Poblacion. The refurbishment of the ward was sourced from the PhilHealth capitation fund. Datu Paglas also allocated part of the capitation to stabilize the supply of primary care medicines at the RHU and its refurbishment. With the significant reduction in the number of citizens asking for medical dole-out from the LGU and the upgrading of health facilities and improvement in health services, Datu Paglas intends to continue the partnership with PhilHealth and ZFF in order to achieve better health for all its citizens.

ARMM Health Secretary Kadil Sinolinding congratulates the four SLAM mayors for the gains achieved in improving health indicators. (L-R) Dr. Anthony Faraon, ZFF Director; Abdulkarim Langkuno (Mayor of Paglat); Allandatu Angas (Mayor of SSB); Datu Mohammad Paglas (Mayor of Datu Paglas); Datu Boniao Kali (Mayor of GSKP).

slAM WIns GAlInG Pook AWArD

THE ZUELLIG Family Foundations four partner-municipalities in Maguindanao were recently named winners of the prestigious Galing Pook Award for their health programs. Community Health Summits allowed government leaders to Mayors of these four towns--Datu Paglas, Gen. S.K. Pendatun, Paglat and Sultan sa Barongis--formed the Southwestern Ligawasan Alliance of Municipalities (SLAM) in 2008 so they can pool their resources together in solving their common problems. Late that same year, they also became the partners of the Foundation. With the Foundations support, SLAM created health programs which encouraged the participation of various stakeholders in their respective towns. The participation of government officials, civic leaders, business representatives, the religious sector and After the ZFFs two-year partnership with these towns, maternal health and infant mortality statistics have shown improvements. Based on the Foundations data analysis, the improvements in maternal health in the SLAM were also significantly higher than those of the other Maguindanao towns. (see related article, page 26) present their health plans to their constituents and get quick feedback, while the Buntis Congress enabled pregnant women and their partners to learn about proper natal care. ordinary citizens in the health activities raised awareness and improved the chances of success of planned programs.

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about the Zuellig faMily foundation

The Zuellig Family Foundation (ZFF) refocused its efforts in 2008 to address health system inequities to bring better health outcomes for the poor Filipinos. The ZFF uses the Health Change Model that works on the premise that outcomes can only improve if local political and health leaders are responsive, and health interventions are targeted and institutionalized. Since 2008, the ZFF has partnered with 30 rural municipalities coming from the most impoverished regions having serious health challenges. Leadership training programs have been given to 157 health leaders, and medical skills upgrade programs have trained 535 frontline health workers. Well-equipped village health centers funded by the ZFF can be used by close to a million people living in our partner - municipalities. But working with a staff of less than 30, the ZFF seeks more partnerships with public and private sector groups to reach more people. Linkages with groups that provide better education, increase incomes and adopt technology can lead not just to better health but the overall development of quality human life.

zuellig Family Foundation

5/F Zuellig Pharma Head Office Km. 14 West Service Road Brgy. Sun Valley Paraaque City, Metro Manila , Philippines Tel. No. (632) 821-4332, 821-4428, 8213329 Fax No. (632) 776-4727 communications@zuelligfoundation.org http://www.zuelligfoundation.org