HMN PHL Assess Final 2007 07 En

Health Metrics Network

Philippine Health Information System: Review and Assessment

February - July 2007

by

The Philippine Health Information Network

The Philippine Health Information Network c/o Ms. Charity Tan Information Technology Officer Information Management Service Department of Health

2

Table of contents List of Acronyms 4

List of Tables and Figures 7

1 Background 8

2 The Philippines 8

Geography, Administrative Divisions and Government 8 The Climate 9 Demographic Characteristics 9 Economic Characteristics 10 Organization of the Health Care System 10 Health Care Facilities 11 Health Human Resources 12

3 Frameworks for Generating Health and Nutrition Statistics 13

The Framework Based on the National Objectives for Health 2005-2010 15 The Philippine Statistical Development Plan 2005-2010 18 The Philippine Statistical System 21

4 Government Agencies Generating Health and Nutrition Statistics 22

The Department of Health 23 The Food and Nutrition Research Institute 25 The National Nutrition Council 25 The Philippine Health Insurance Corporation 26 The National Statistics Office 26 The National Statistical Coordination Board 27

5 Previous Studies on the Assessment of Health Information in the Philippines

27

Past Reviews/ Assessment of Health Statistics and Information System in the Philippines

27

Interagency on Health and Nutrition and PSDP 2005-2010 Assessment 29

Issues on Health Information Presented in the National Objectives for Health 2005-2010

30

The Philippine Integrated Disease Surveillance and Response 34 6 Assessment of Health Information System of the Philippines 52

Health Metrics Network Approach 52

Assessment of the Field Health Surveillance Information System and the Civil Registration System in the Subnational Levels

56

7 Results of the Health Metrics Network Assessment 58

8 Recommendations 75

References 78

Annex 1. Matrix of Available Health and Nutrition Statistics in Agencies of the Department of Health

80

Annex 2. Matrix of Available Health and Nutrition Statistics in the Philippine Statistical System

91

Annex 3. CD copy of the Instruments Used in the Assessment of the Field Health Service Information System and the

97

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Civil Registration System Annex 4. CD copy of the results of the HMN Assessment 98

Annex 5. List of Philippine Laws and Administrative Orders on Vital Statistics and Generation of Health Statistics

99

Annex 6. The Philippines’ MDGs Indicators 102

4

List of Acronyms

AIDS Acquired Immune Deficiency Syndrome

LGU Local Government Unit

AO Administrative Order MCH Maternal and Child Health Survey

API Annual Parasitic Incidence MCR Municipal Civil Registrar APSED Asia Pacific Strategy for Emerging Diseases

MDG Millennium Development Goal

ARMM Autonomous Region of Muslim Mindanao

MFHSIS Modified Field Health Service Information System

BAS Bureau of Agricultural Statistics MHO Municipal Health Officer BFAD Bureau of Food and Drugs MIMAROPA Mindoro, Marinduque,

Romblon, Palawan BHS Barangay Health Station MMR Maternal Mortality Rate BIIS Bureau of Food and Drugs Integrated

Information System MPDO Municipal Planning

Development Officer BLES Bureau of Labor and Employment

Statistics MTPDP Medium-Term Philippine

Development Plan BNB Botika ng Bayan MTPPAN Medium-Term Philippine

Plan of Action for Nutrition CALABARZON Cavite,Laguna,Batangas,Rizal,Quezon NCR National Capital Region CAR Cordillera Administrative Region NDHS National Demographic and

Health Survey CBMIS Community Based Management

Information System NEC National Epidemiology

Center CCR City Civil Registrar NEDA National Economic and

Development Authority CED Chronic Energy Deficiency NESSS National Epidemic Sentinel

Surveillance System CHD Center for Health Development NGA National Government

Agency CHO City Health Officer NGO Non-Governmental

Organization CPDO CityPlanning Development Officer NHII National Health Information

Infrastructure CRS Civil Registration System NHIP National Health Insurance

Program DDMS Infectious Disease Data Management

System NNC National Nutrition Council

DFHSIS Decentralized FHSIS NNS National Nutrition Survey DHS District Health System NOH National Objectives for

Health

DOH Department of Health NSCB National Statistical Coordination Board

DOHLIS DOH Licensing Information System NSO National Statistics Office

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DOTS Directly Observed Treatment Short course

OPT Operation Timbang

DTIS Document Tracking Information System

PCHRD Philippine Council for Health Research and Development

DTOMIS Drug Test Operation and Management Information System

PhilHealth Philippine Health Insurance Corporation

e-NGAS electronic-New Government Accounting System

PHIN Philippine Health Information Network

ENHR Essential National Health Research PHN Public Health Nurse EO Executive Order PHNIS F1 Fourmula One for Health

Philippine Health and Nutrition Information System

FBS Food Balance Sheet PHO Provincial Health Officer FGD Focus Group Discussion PHS Philippine Health Statistics FHSIS Field Health Service Information

System PIS Personnel Information System

FIVIMS Food Insecurity and Vulnerability Information and Mapping Systems

PLHIS Philippine Local Health Information System

FNRI Food and Nutrition Research Institute

PMIS Philippine Malaria Information System

FPS Family Planning Survey PNHA Philippine National Health Accounts

FS Field Surveillance PNHRS Philippine National Health Research System

GDP Gross Domestic Product POPCOM Commission on Population GIDA Geographically Isolated and

Disadvantaged Area PPDO Provincial Planning

Development Officer GNP Gross National Product PPMP-DP Philippine Population

Management Program Directional Plan

HAMIS Health and Management Iinformation System

PSDP Philippine Statistical Development Program

HDL-c High Density Lipoproteins – cholesterol

PSO Provincial Statistics Officer

HIS Health Information System PSS Philippine Statistical System HIV Human Immunodeficiency Virus PSY Philippine Statistical Yearbook HMIS Health Management Information

System PWD Persons with Disabilities

HMN Health Metrics Network RA Republic Act HOMIS Hospital Operation and

Management Information System RHM Rural Health Midwife

HPDPB Health Policy Development and Planning Bureau

RHU Rural Health Unit

HSRA Health Sector Reform Agenda RHUMIS Rural Health Unit Information System

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IAC-HNS Inter-Agency Committee on Health and Nutrition Statistics

SEAMIC Southeast Asian Medical Information Center

IBBIS Integrated Blood Bank Information

System SPR Slide Positivity Rate

ICD-10 International Classification of Diseases version 10

SRTC Statistical Research and Training Center

ICT Information and Communications Technology

SS Sentrong Sigla

ILHZ Inter-Local Health Zones SSM Sentrong Sigla Movement IMR Infant Mortality Rate TB Tubercolosis IMS Information Management Service U5MR under 5 mortality rate IMST Internal Management Support Team UHMIS Unified Health Management

Information System KM Knowledge Management UPPI University of the Philippines

Population Institute LCR Local Civil Registrar WFPDS Work and Financial Plan

Database System LDL-c Low Density Lipoproteins - cholesterol LGC Local Government Code

WNDRS Weekly Notifiable Disease Reporting System

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List of Tables and Figures Table page Table 1. Strategies for Health Information Systems under Fourmula One 15 Table 2. Statistical Framework on Health and Nutrition 19 Table 3. Implications of the Devolution and Health Sector Reform Agenda on the Local health System

32

Table 4. Strengths and Weaknesses of the Surveillance Systems of the National Epidemiology Center

35

Table 5. Targets in Knowledge Management in the Philippine Health Sector 38 Table 6. Matrix on Statistical Development Programs for Health and Nutrition Information Systems

42

Table 7. Participants in the Philippine Assessment using the HMN Procedure 56 Table 8. Data Producers of Field Health Service Information System and Civil Registration System that participated in the Assessment in the Subnational Level

58

Table 9. Data Users of Field Health Service Information System and Civil Registration System that participated in the Assessment in the Subnational Level

58

Table 10. Summary of Results of the Assessment of Health Information System Resources

59

Table 11. Problems on HIS Resources Identified by Regional FHSIS Regional Coordinators With the Existing FHSIS at Different Administrative Levels

63

Table 12. Summary of the Result of the Assessment of Indicators 63 Table 13. Summary of Results of the Assessment of Data Sources 64 Table 14. Summary of the Result of the Assessment of Data Management 67 Table 15. Summary of Results of the Assessment of Information Products 68 Table 16. Problems on Information Products Identified by Regional FHSIS Regional Coordinators With the Existing FHSIS at Different Administrative Levels

70

Table 17. Summary of Results of the Assessment of Dissemination and Use 71 Table 18. Problems on Dissemination and Use Identified by Regional FHSIS Regional Coordinators With the Existing FHSIS at Different Administrative Levels

73

Figure page Figure 1. Health and Nutrition Strategies and Expected Outcome 13 Figure 2. Framework for the Development of the Philippine Health Information System

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Figure 3. The Philippine Statistical System 22 Figure 4. HMN Framework 53 Figure 5. Selected Indicators and Results 64 Figure 6. Assessment of Information Products 69

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1 Background The monitoring and assessment of the status of the health and nutrition of the Philippine citizenry is a concern not just of the government but also of international donor agencies and other non-governmental organizations. Such monitoring and assessment require data that shall be used to generate measures/indicators on the health and nutrition status of the population over a period of time. In recognition of the importance of data that feed into the monitoring and assessment of its health system, the Philippines through the Philippine Health Information Network (PHIN) with the support of the World Health Organization and the Health Metrics Network conducted an assessment of the health information systems that generate health and nutrition data. The assessment started in November 2006 with the conduct of a Training of Trainers on the Health Metrics Network (HMN) framework and tools for assessing health information systems. The activities that followed included workshops to evaluate and customize the HMN assessment tool for the Philippines; pretesting and finalizing the customized tool; the actual assessment; workshop to discuss the result of the actual assessment; additional assessment in the subnational level of two specific systems that generate health information – Field Health Service Information System of the Department of Health and civil registration system of the National Statistics Office; and, meetings to finalize the report on the assessment. This report presents the results of the assessment.

2 The Philippines To properly appreciate the discussions of health information systems in the Philippines, an understanding of the country’s characteristics and health system is needed. This chapter presents the Philippines geography, administrative divisions, government, climate, demographic characteristics, economic characteristics, organization of its health care system, health facilities, and health human resources. Geography, Administrative Divisions and Government The Philippines is an archipelago of about 7,100 islands located in the western part of the Pacific Ocean off the coast of Southeast Asia. The country has a total land area of 300,000 square kilometers and is one of the largest islands groups in the world. The three island groupings are Luzon in the north, Visayas in the central area, and Mindanao in the south. Metropolitan Manila, also known as the National Capital Region (NCR), is located in the central part of Luzon. It is the biggest urban center in the country. It is made up of 14 highly urbanized cities and three municipalities. The country is divided into 17 administrative regions: Regions 1 to 5, NCR, Cordillera Administrative Region (CAR) , CALABARZON (Cavite,Laguna,Batangas,Rizal,Quezon), and MIMAROPA (Mindoro, Marinduque, Romblon, Palawan) which are in Luzon; Regions 6 to 8 which are in the Visayas; and, Regions 9 to 12, Autonomous Region of Muslim Mindanao (ARMM), and Caraga which are in Mindanao. Regions are composed of 79 provinces headed by governors while provinces are divided into 117 cities and 1500 municipalities, collectively called local government units. The local government units, headed by mayors, make up the political subdivisions of the Philippines. They are divided into villages or barangays totaling 41,975. These are headed by barangay chairpersons (NSCB, 2004). It must be noted that regions are administrative units only and the political units aside from the national level are the provinces, cities and municipalities, and barangays.

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The Philippines is a republican state with three branches of government- executive. legislative and judicial. The executive power is vested in the President, who is the head of state and the commander-in-chief of the Armed Forces. The President appoints the Cabinet members of who assist the President in executing laws, policies and programs of the government. The lawmaking power is vested in a bicameral Congress composed of the Senate and the House of Representatives. The Senate has 24 senators directly elected nationwide by the people. The House of Representatives has 250 members elected by congressional districts and by party list system. Judicial power is vested in the Supreme Court and a system of several lower courts. The Supreme Court is composed of the Chief Justice and 14 associate justices (NOH, 2005-2010). The Climate The country’s climate is generally hot and humid and favors the existence of disease vectors and parasites. On the average, the temperature is 32o with March to June as the hottest months when temperatures may reach 38oC. On the other hand, November to February provide cooler weather with temperatures around 23oC. The Philippines is prone to natural disasters brought about by volcanic eruptions, earthquakes, floods and typhoons. Rains and typhoons prevail from July to October (NOH, 2005-2010). Demographic Characteristics The population of the Philippines in the 2000 census was 76,504,077, a 58 percent increase from the 1980 census. The population grew at the rate of 2.4 percent annually between 1995 and 2000 while it grew at 2.1 percent between 2000 and 2005. The population is projected to increase to 91,868,309 in 2010. The NCR has an estimated 13.3 percent of the total population of the Philippines. It has the greatest population concentration with 16,091 people per square kilometer, a ratio that is 63 times the national average. The least population areas are the CAR and Region 2 with a population density of 70 and 90 people per square kilometer, respectively. Five out of the 17 administrative regions have growth rates higher than the national average: Region 3, MIMAROPA and CALABARZON, Region 7, Region 11 and ARMM. NCR has the lowest population growth rate of 1.06 percent and ARMM has the highest at 3.86 percent. In comparison with other countries, the Philippine ranked twelfth among the countries of the world in terms of total population. The Philippines is ranked fifth among Southeast Asian countries in annual population growth rate (PSY, 2004 and NOH, 2005-2010). Approximately 52 percent of the Philippine population live in rural areas. However, urbanized areas now attract migrants from rural communities due to more economic, educational, recreational opportunities. Rural-to-urban migration causes much pressure on government to provide basic social services like health care, shelter, water, sanitation and education. The congestion and pollution in urban areas are harmful to health. In frontier areas where more migration is also noted, the people’s health is affected by difficult access to health services and the presence of locally endemic diseases like malaria, filariasis and schistosomiasis (PSY, 2004 and NOH, 2005-2010). The median age of the Philippine population is 21 years old. This makes the Philippines a country of young people with, half of its population below 21 years old. Males outnumber females with a sex ratio of 101.43 males for every 100 females. There are more males than females in the age groups 0-19 and 25-54 years.The age structure of the Philippine

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population is typical broad base at the bottom consisting of large numbers of children and a narrow top made up fairly small numbers of older persons. The dependency ratio is 69, which means that every 100 persons in the working age group (15-64 years old) have to support about 63 young dependents and about six old dependents. Young dependents (65 years old and over) account for 3.8 percent, while 59.2 percent comprise the economically active population (15-64 years old). Women of reproductive age comprise around 51 percent of the total number of females in country (PSY, 2004 and NOH, 2005-2010). Economic Characteristics The Philippines is a developing country. Per capita Gross National Product(GNP) was P56,109 and per capita Gross Domestic Product (GDP) was P52,241 in 2003. The 2002-2003 GNP growth rate was 5.6 percent and GDP was 4.7 percent. In 2000, the annual per capital poverty threshold was estimated at P11,605, an 18 percent increase over the 1997 threshold of P9,843. With this threshold, a family of five members should have a monthly income of P4,835 to meet its food and non-food basic needs. Average annual family income reached P148,757 in 2003, increasing by 2.5 percent over the P145,121 average in 2000. As earnings rose across all income levels, from the 27.5 percent revised estimate from 2000 down to 24.7 percent in 2003 (NSCB, 2005). Unemployment and underemployment rates have increased in the past three years. Unemployment rates stood at 10.2 percent in October 2002, it has gone up to 10.9 percent as of October 2004. Underemployment has also gone up from 15.3 percent in October 2002 to 16.9 percent in October 2004. Average inflation rate has also gone up from 3.5 percent in 2003 to six percent in 2004 (PSY, 2004) Organization of the Health Care System The Philippines recognizes health as a basic human right. It protects and promotes the right to health of the people and instills health consciousness among them. Although this provision is guaranteed by the 1987 Constitution (Article II, Section 15) and the health care system in the Philippines is generally extensive, access to health services, especially by the poor, is still hampered by high cost, physical and social-cultural barriers (NOH, 2005-2010). To address these concerns, reforms in the country’s health care system have been instituted in the past 30 years: the adoption of Primary Health Care in 1979; the integration of public health and hospital services in 1983 (EO 851); the enactment of the Generics Act of 1988 (RA 6675); the devolution of health services to LGUs as mandated by the Local Government Code of 1991 (RA 7160); and the enactment of the National Health Insurance Act of 1995 (RA 7875). In 1999, the DOH launched the Health Sector Reform Agenda (HSRA) as a major policy framework and strategy to improve the way health care is delivered, regulated and financed(NOH, 2005-2010). The Philippines has a dual health system consisting of : the public sector, which is largely financed through a tax-based budgeting system national and local level and where health care is generally given free at the point of services (although socialized user charges have been introduced in recent years for certain types of services), and the private sector (consisting of for-profit and non-profit providers), which largely market-oriented and where health care is paid through user fees at the point of service. The expansion of social health insurance in recent years and its emergence as a potential major source of health financing

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will have a positive and private sectors and in terms of the people’s health-seeking behavior (NOH, 2005-2010). Under this health system, the public sector consists of the DOH, LGUs and other national government agencies providing health services. The DOH is the lead agency in health. Its major mandate is to provide national policy direction and develop national plans, technical standards and guidelines on health. It has a regional field office in every region and maintains specialty hospitals, regional hospitals and medical centers. It also maintains provincial health teams made up of DOH representatives to the local health boards and personnel involved in communicable disease control (NOH, 2005-2010). With the devolution of health services under the 1991 Local Government Code, provision of direct health services, particularly at the primary and secondary levels of health care, is the mandate of LGUs. Under this set-up, provincial and district hospitals are under the provincial government while the municipal government manages the rural health units (RHUs) and barangay health stations (BHSs). In every province, city or municipality, there is a local advisory body to the local executive and the sanggunian or local legislative council on health-related matters (NOH, 2005-2010). The passage of the 1995 National Health Insurance Act expanded the coverage of the national health insurance program to include not only the formal sector but also the informal and indigentsectors of the population. The program founded under the principle of social solidarity where the healthy subsidizes the sick and those who can afford to pay subsidize those who cannot. PhilHealth, a government-owned and controlled corporation attached to the DOH, is the agency mandated to administer the national health insurance program and ensure that Filipinos will have financial access to health services (NOH, 2005-2010). The private sector includes for-profit and non-profit health providers whose involvement in maintaining the people’s health is enormous. Their involvement include providing health services in clinics and hospitals, health insurance, manufacture and distribution of medicines, vaccines, medical supplies, equipment, other health and nutrition products, research and development, human resource development other and other health-related services (NOH, 2005-2010). Health Care Facilities Various health facilities serve the health needs of the Filipinos. The total number of hospital, both government and private, increase from 1,607 in 1980 to 1,738 in 2002. Though the number of hospitals increased nationwide, the number of beds per 10,000 population decreased from 18.2 in 1980 to 10.7 in 2002 (PSY 2004). The number of government hospitals nationwide increased from 623 in 2000 to 661 in 2002, while private hospitals slightly decreased from 1,089 in 2000 to 1,077 in 2002. Although only 661 or 38 percent of hospitals are government hospitals, these contribute 45,395 beds or 53.3 percent of bed capacity nationwide (PSY, 2004 and NOH, 2005-2010). ARMM has the least number of hospitals, consisting of three private hospitals and 11 government hospitals in 2002. CALABARZON and MIMAROPA have the most number of hospitals with 176 private hospitals and 95 government hospitals (PSY, 2004 and NOH, 2005-2010).

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In terms of government hospital beds, NCR has the most number of 9,965 beds followed by CALABARZON and MIMAROPA at 6,295 beds and Region 3 at 3,385 beds. The regions with the least number of government hospital beds are ARMM at 870 beds, Region 10 at 1,150 beds and Region 12 at 1,195 beds. The government hospital bed to population ratio is worst in Region 11 in Mindanao with one bed for every 3,575 people while it is best in NCR with one bed for every 807 people (PSY, 2004 and NOH, 2005-2010). There is increasing trend in the number of BHSs from 9,184 in 1988 to 15,343 in 2002 while there is a decreasing trend in the number of RHUs in the country from 1,962 in 1986 to 1,879 in 2001. NCR has the most number of RHUs while the Central Mindanao has the least number of RHUs. On the other hand, CALABARZON and MIMAROPA have the most number of BHSs while NCR has the least (PSY 2004). On the average, each RHU serves around 41,000 people while each BHS serves around 5,100 people (PSY, 2004 and NOH, 2005-2010). Health Human Resources Human resources for health are central to managing and delivering health services. They are crucial in improving health systems and health services and in meeting the desired health outcome targets. Human resources for health are enormous but unevenly distributed in the country. Most health practitioners are in Metro Manila and other urban centers. Compared to most Asian countries, the Philippines is producing more and better human resources for health (NOH, 2005-2010). The number of physicians per 100,000 populations slightly increased from 123.8 in 1998 to 124.5 in 2000, which translates into one physician for every 803 people in 2000. The number of dentist per 100,000 population almost remained unchanged at 54.2 in 1998 and 54.4 in 2000 or one dentist per 1,840 people in 2000. The number of pharmacists per 100,000 populations improved slightly from 55.8 in 1998 to 58.1 in 2000. This means one pharmacist for very 1,722 people in 2000. The number of nurses per 100,000 populations almost remained constant from 442.7 in 1998 to 442.8 in 2000, a ratio of one nurse per 226 people for both 1998 and 2000 (SEAMIC, 2003 and NOH, 2005-2010). In 2002, there are 3,021 doctors, 1,871 dentist, 4720 nurses and 16,534 midwives employed by LGUs. Other health personnel employed by LGUs consist of 3,271 engineers/sanitary inspectors, 303 nutritionist, 1,505 medical technologist, 977 dental aides and 2,808 non-technical staff. Assisting these health personnel at the grassroots are 195,928 volunteer barangay health workers and 54,557 birth attendants (FHSIS, 2002 and NOH, 2005-2010). The Philippines has traditionally been a major source of health professionals to many countries because of their fluent English, skills and training, compassions, humaneness and patience in caring. The country is purportedly the leading exporter of nurses to the world (Aiken, 2004) and the second major exporter of physicians (Bach, 2003). Although the country is producing a surplus of health workers for overseas market since the 1960s, the large exodus of nurses in the last four years has been unparalleled in the migration history of the country. While Filipino physicians have been migrating to the United States since the 1960s and to the Middle East countries in the 1970s in steady outflows, the recent outflows are disturbing because they are no longer migrating as medical doctors but as nurses (NOH, 2005-2010).

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STRATEGIES

(1) Eradicate extreme poverty and hunger

(2) Reduce child mortality (3) Improve maternal health (4) Combat HIV and AIDS, Malaria

and other diseases (5) Ensure environmental

sustainability (6) Develop a global partnership for

development

EXPECTED OUTCOMES

(1) Halve, between 1990 and 2015, the proportion of people who suffer from hunger

(2) Reduce by two-thirds, between 1990 and 2015, the under five mortality rate

(3) Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio

(4) Have halted by 2015 and begun to reverse the spread of HIV/AIDS

(5) Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

(6) Halve, by 2015, the proportion of people without sustainable access to safe drinking water

(7) In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries

Based on the baseline survey of nursing-medics in the Philippines, more than 3,500 Filipino doctors have left as nurses since the year 2000 (Galves-Tan, Sanchez, Balanon,2004). A little more than 1,500 doctors have passed the national nurse licensure examination in 2003 and 2004 (PRC, 2002). An estimated 4,000 doctors are enrolled in nursing schools all over the country (Galves-Tan, Sanchez, Balanon, 2004). The Philippine socioeconomic and political situations have not helped munch in retaining licensed and skilled nurses and other health professionals in the country. (NOH, 2005-2010).

3 Frameworks for Generating Health and Nutrition Statistics The Millennium Development Goals (MDGs), the Philippine Statistical Development Program (PSDP) 2005-2010, the Medium-Term Philippine Development Plan (MTPDP) for Health and other health and nutrition sectoral plans such as the National Objectives of Health (NOH) 2005-2010, the Medium-Term Philippine Plan of Action for Nutrition (MTPPAN), and the Philippine Population Management Program Directional Plan (PPMP-DP) provide very clear strategies and expected outcomes of international and national development goals and targets which require statistics and indicators. These frameworks serve as basis for identifying priority indicators/statistics for monitoring and evaluating the progress of the country’s health and nutritional plans, programs and policies. Figure 1 summarizes the major strategies and expected outcomes for health and nutrition as drawn from the different plans and programs.

Figure 1. Health and Nutrition Strategies and Expected Outcome1 MILLENIUM DEVELOPMENT GOALS

1 from the Philippine Statistical Development Plan 2005-2010

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Continuation of Figure 1 HEALTH

NUTRITION

STRATEGIES

(1) Focus on adolescent females,

pregnant and lactating women and children 1-3 years old

(2) Complementation of nutrition

interventions with other development programs

(3) Geographical focus to needier areas (4) Food-based interventions for

sustained improvement in nutritional status

(5) Increased investments in nutrition

.

EXPECTED OUTCOMES

(1) Reduced proportion of Filipino

households with intake below 100% dietary energy requirement

(2) Reduced prevalence of underweight

children 0-5 and 6-10 years old (3) Reduced prevalence of stunting

among children 0-5 years old (4) Reduced prevalence of chronic

energy deficiency among pregnant women

(5) Reduced prevalence of vitamin A

deficiency disorders among children 6 mos.-5 years old, pregnant and lactating women

(6) Reduced prevalence of iodine

deficiency disorders among lactating women

(7) Reduced prevalence of low birth

weight

STRATEGIES

(1) Reduce the cost of essential medicines (2) Expand health insurance particularly for

indigents (3) Strengthen national and local health

systems through the implementation of the Health Sector Reform Agenda for health regulation reforms

(4) Improve Health Care Management

System; (5) Improve health and productivity through

Research and Development; and (6) Establish drug treatment and rehab

centers and expand existing ones.

EXPECTED OUTCOMES

(1) Fifty percent reduction in prices of 22 therapeutic classes essential medicines from 2004 prices by 2010;

(2) Covered 5 million indigent families

enrolled and sustained in National Health Insurance Program (NHIP);

(3) One hundred percent of hospitals

licensed by Department of Health; (4) Standardized training courses,

registration, regulation and accreditation developed and institutionalized;

(5) Seventy percent increase in utilization

of health, nutrition and population related Research and Development results

(6) Treatment and rehabilitation care

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The Framework Based on the National Objectives for Health 2005-2010 The DOH in its quest to strengthen the Philippine health system and make it a vehicle for social change, engineered the Fourmula One for Health (F1) in 2005 as the new implementation framework for vital health sector reforms as stated in its HSRA in 1999. F1 became the DOH’s guiding philosophy and strategic approach to implement health reforms. On the other hand, the NOH 2005-2010 provides the “road map” of key ideas, targets, indicators and strategies to bring the health sector to its desired outcomes. (NOH 2005-2010) . With the F1 in mind, the following was developed by the Information Management Service (IMS) of DOH as its major strategies for developing rationalized and more efficient national and local health information systems through strengthening networking mechanisms and referral systems, sharing of resources, organizational transformation and restructuring, capacity building.

Table 1. Strategies for Health Information Systems under Fourmula One Key Result

Areas Deliverables Unit

Responsible Easy access to health information.

• PHIN established and operational

• Health Information standards developed and implemented

• Various information systems developed

(Hospital Operations and Management Information System(HOMIS), FHSIS, Integrated Blood Bank Information System(IBBIS), Bureau of Food and Drugs Integrated Information System(BIIS), Drug Test Operation and Management Information System (DTOMIS), DOH Licensing Information System(DOHLIS), etc.)

• Data warehouse with the following health

information: o Health service statistics and disease

surveillance o Health regulation o Health statistics such as vital statistics,

health accounts, health surveys, censuses

o Health researches, best practices, lessons learned

IMS, health programs, services, bureaus, other Health Information Generators (NSO, Philippine Council for Health Research and Development(PCHRD), NSCB, medical societies, etc)

Formatted: Indent: Before: -5.4 pt, Bulleted + Level: 1 +Aligned at: 18 pt + Tab after: 36 pt + Indent at: 36 pt,Tabs: Not at 36 pt




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Key Result Areas

Deliverables Unit Responsible

DOH transformed to a knowledge organization

• Health portal which is the repository of the health intellectual capital is established, operational and used

• Resource learning center operational with

virtual health library and knowledge bases established and utilized

• Knowledge management(KM)

infrastructures established

• Knowledge is shared to stakeholders through knowledge networks

• Health workers imbibed KM qualities

such that seeking, sharing and utilization of knowledge has become a habit.

IMS , programs, sectoral support cluster, Internal Management Suppot Team(IMST)

Health data and infrastructure are interoperable

• Information and Communications Technology(ICT) standards developed and used by stakeholders

• Interconnection of central office, Centers for Health Development(CHDs) and DOH retained hospitals

• DOH, Philippine Health Insurance Corporation(PHIC or PhilHealth) and private sector databases are interoperable

IMS with other units

Efficient, rational and appropriate use of funds

• Monitoring and evaluation of Fund

resources • electronic-New Government Accounting

System( e-NGAS) reports/Work and Financial Plan Database System(WFPDB)

• Develop feedback mechanisms for fund utilization at regional level

• Installation of e-NGAS in all regions

Field Surveillance(FS)/ Planning Division

Source: IMS, DOH

Formatted: Bulleted + Level:1 + Aligned at: 18 pt + Tabafter: 36 pt + Indent at: 36pt, Tabs: 18 pt, List tab + Notat 72 pt







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The following framework is then suggested for an integrated Philippine Health Information System: Figure 2

HEALTH AND VITALSTATISTICS

Vital Statistics

National HealthAccount

HEALTH DATAWAREHOUSE

HEALTH SYSTEMSMANAGEMENT

Local Health SystemsDevelopment

Health Care Financing

International HealthCooperationManagement

HEALTH SERVICEDELIVERY

Public Health

Disease Surveillance

Hospital Operationsand Management

HEALTH SYSTEMINFORMATION

Human ResourcesManagement

Information ResourcesManagement

Logistics

Health Facilities

Executive Support System

Decision Support System

Demographic andHealth Surveys

KNOWLEDGE SHARING

BEST PRACTICES / LESSONS LEARNED

PERFORMANCE METRICS

FRAMEWORK FOR THE DEVELOPMENT OF THEPHILIPPINE HEALTH INFORMATION SYSTEM

Health EmergenciesResponse

PORTALS (EXTRANET/INTRANET)

HEALTH RESEARCH

Health Regulation

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It is noted that in a DOH Health Information System (HIS) Integration Workshop on January 16 -17 2007, the following guidelines in constructing a Philippine Integrated Health Information System(PIHIS) was suggested:

Build on existing health information systems to integrate content and information functions,

Develop/Strengthen policy and regulation for data submission and/or information gathering,

Compliance to government policy on ICT, and Compliance to DOH Department Order 2005-0032 – Standard Operating Procedure

and Guidelines on ICT Works in the DOH.

These guidelines are based on the conceptual framework of bringing together data from different information systems, to share and disseminate them, and to ensure that health information is used rationally, effectively and efficiently to improve health action or decision-making process. Additional guidelines are:

Compliance to the General Standards on Statistical Information Dissemination (GSSID) per NSCB Board Resolution No. 8, s. 1999, and,

Compliance to the IMF Data Assessment Quality Framework (DQAF). Furthermore, the following strategies were enumerated:

Standardization – common data indicators, definitions, data formats, data transmission protocols

Data Warehousing – central data repository Process Integration – eliminate redundancies and/or duplications. Integrated Data Management Integrated Human Resource Integrated Financial Resources.

It must be emphasized, though, that the integration workshop focused only on the information systems of DOH which are mainly administrative records and did not include the other health and nutrition data being generated by other government agencies auch as the NSO and the NSCB. The Philippine Statistical Development Plan 2005-2010 The Philippine Statistical Development Program (PSDP) 2005-2010 serves as the blueprint of all statistical activities that will generate the data requirements for all international and national development plans and programs. The PSDP chapter on Health and Nutrition is guided by the above development priorities for the health and nutrition sector. Table 2 depicts the statistical framework for the health and nutrition sector in the PSDP 2005-2010. The framework has 6 components. These are: health status, health resources, health services, nutritional status, nutrition resources, and nutrition services. These components correspond to the major areas of concern and areas where the indicators to be used in monitoring will be identified. Thus, the framework shall serve as a basis for data production and dissemination as well as for coordination among the agencies producing the data.

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Table 2. Statistical Framework on Health and Nutrition

Sector/Components/ Sub-Components Key Indicators

HEALTH Health Status Mortality Life expectancy Proportion surviving from birth by sex Proportion population 65 and over Crude Death Rate Infant Mortality Rate 2/ Child Mortality Rate Under-Five Mortality Rate 2/ Maternal Mortality Ratio 2/ Causes of Mortality Death rates for selected causes of deaths Morbidity Incidence of Specific Notifiable Diseases No. of bird or avian flu cases Causes of Morbidity Fully Immunized Children Proportion of 1 year-old children immunized against measles 2/ HIV prevalence among 15-24 year old pregnant women 2/ Number of children orphaned by HIV/AIDS 2/ Prevalence and death rates associated with malaria 2/ Proportion of population in malaria risk areas using effective

malaria prevention & treatment measures 2/ Prevalence & death rates associated with tuberculosis 2/ Proportion of tuberculosis cases detected & cured under directly

observed treatment short course (DOTS) 2/ Condom use rate of the contraceptive prevalence rate 2/ Prevalence of Specific Drug and Substance Abuse Proportion of population with access to affordable essential

drugs on sustainable basis 2/ Reported Cases of Drug Dependency DOH-retained and Local Government Unit- hospitals selling

low-priced drugs 1/ Rate of increase / decrease in the number of mental health

facilities upgraded 1/ Proportion of households with Sanitary Toilet Facilities Environmental

Sustainability Proportion of population with sustainable access to improved water source 2/

Proportion of urban population with access to improved sanitation 2/

Disability Prevalence of Disability Causes of Disability Health Resources Facilities No. of government hospitals provided with training to improve

their service capabilities 1/ No. of licensed hospitals 1/ Ratio to Population of Health Facilities Manpower Proportion of births attended by skilled health personnel 2/ No. of government doctors, nurses, dentists & midwives Physicians per 1,000 population

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Ratio to Population of Health Manpower Financing Total Health Expenditure Share of Health Expenditure to GNP and GDP Health Expenditure by Source of Funds Health Expenditure by Use of Funds Gross Value Added on Health Per Capita Health Expenditure Health Services (Provision and Utilization) Health R & D No. of health & population related reaseach and development

utilized 1/ Promotive Percentage of Population Availing of Health Services by Type Preventive Percentage of the Population Covered by Health Insurance 1/ Curative Percentage of population availing of health services by type of

service Rehabilitative Percentage of population using health facilities Overall satisfaction with health facilities and services NUTRITION Nutrition Status Prevalence of Prevalence of underweight children under 5 years of age 2/ Malnutrition Prevalence of underweight adolescents Prevalence of underweight other age group Prevalence of underweight-for-age, underheight-for-age,

underweight-for-height; overweight and obesity Prevalence of low birthweight infants Proportion of population below minimum level of dietary

energy consumption 2/ Prevalence of low birthweight infants Prevalence of CED, overweight and obesity

Prevalence of Vitamin A deficiency Prevalence of Micronutrient Deficiency Prevalence of anemia Prevalence of Iodine deficiency Food and Nutrient Intake Per Capita Energy/Nutrient Intake Percent nutrient adequacy Per capita food intake (total, by food groups, food source) Per capita consumption per day Per Capita Food Supply (per year, per day, per day energy, per

day protein, per day fats) Total Domestic Supply by Major food Group

Prevalence of hypertension Prevalence of high total serum cholesterol

Prevalence of nutrition-related risk factors to chronic degenerative disease

Prevalence of high triglyceride

Prevalence of low HDL-c Prevalence of high LDL –c Prevalence of high fasting blood sugar among adults Prevalence of females with high waist-hip ratio Prevalence of Breastfeeding (BF) and Complementary Feeding

Prevalence of exclusive breastfeeding (BF) among 0-6 monts old children

Proportion of children not breastfed among 0-24 months Proportion of children receiving breast milk + water only among

0-6 and 6-9 months old children

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Proportion of children receiving breast milk + water-based liquids/juice among 0-6 and 6-9 months old children

Proportion of children receiving breast milk + other milk among 0-6 and 6-9 months old children

Proportion of children receiving breast milk + complementary food among 0-6 and 6-9 months old children

Nutrition Resources Financing NGA, NGO and LGU funding for nutrition programs/activities Proportion of Government Expenditures for Nutrition

Programs Facilities No. of hospitals No. of RHUs and BHS No. of weighing stations No. of weighing scales Ratio to Population of Manpower and Facilities Manpower No. of medical personnel No. of dietitians, nutrition officers, nutrition action officers,

barangay nutrition scholars, barangay health workers Ratio to population of manpower and facilities (nutrition

related activities/program by government and private sector) Nutrition Services (Provision & Utilization) Nutrition R & D No. of health & population related research and development

utilized 1/ Promotive Preventive

Proportion of Population Availing Various Nutrition Programs/Services by Type

Curative Rehabilitative

Percent of 0 - 5 year old children given vitamin A supplements

Percent of households using iodized salt Source: Philippine Statistical Development Plan 2005-2010 Notes: 1/ Indicators to monitor MTPDP Goals/Priorities 2/ Indicators to monitor

* - not available (what is available is percent of households with per capita energy less than 100% adequacy based on the 1993 National Nutrition Survey)

The Philippine Statistical System Government and official statistics in the Philippines are generated by a decentralized statistical system called the Philippine Statistical System(PSS). This system is a government-wide decentralized system of government agencies that provide statistical information and services to the public. Statistical services include the gathering, compiling, processing, aggregation, analysis and dissemination of data. The set up is decentralized with the following main government agencies:

• the National Statistical Coordination Board (NSCB) which is the policy-making and coordinating body for the statistical system;

• the National Statistics Office (NSO) which is the single general purpose statistical agency conducting the censuses such as the Census of Population and Housing, the surveys such as the Labor Force Survey, and the civil registration of the country;

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• the Statistical Research and Training Center (SRTC) which is the statistical research and training arm of the system;

• Other major statistical agencies such as the Bureau of Agricultural Statistics (BAS) and the Bureau of Labor and Employment Statistics(BLES) ;and,

• all the departments, bureaus, offices, agencies and instrumentalities of the National Government and Local Government and Government Owned and Control Corporations and their subsidiaries that are engaged in statistical activities either as their primary functions or part of their administrative or regulatory functions.

The following is the structure of the system: Figure 3

The official statistical unit of the DOH, the National Epidemiology Center (NEC), is DOH’s focal point for the PSS under other departments’ statistical units. Being DOH’s focal point, it should represent the statistical concerns of the DOH as a whole. There are at present, however, other units at the DOH that generate health statistics, e.g., Bureau of Health Facilities and Services, that may be considered as part of this system but are not actively involved in the PSS. The creation of an integrated Philippine Health Information System (PHIS) aims to correct this situation. This PHIS framework as presented in Figure 2 is envisioned to be part of the PSS in Figure 3.

4 Government Agencies Generating Health and Nutrition Statistics As presented in the different frameworks in the previous chapters, many government agencies are involved in generating health and nutrition statistics. This chapter presnts the different government agencies and the important data systems they maintain.

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The Department of Health The DOH remains as the major source of data for the health sector. Its statistics are mostly derived from administrative reporting forms regularly furnished by public hospitals, rural health units and other health units in the lower administrative units of government. The Philippine Health Statistics (PHS) is a report of the NEC of DOH. It provides a summary of statistical data on births, deaths and notifiable diseases registered and reported through the Notifiable Diseases Registry of the FHSIS submitted by the RHUs and BHSs. Diseases, injuries and health conditions are coded using the International Classification of Diseases version 10 (ICD-10).The different data systems being generated by different offices in DOH may be classified as:

1. Health Service Delivery Systems

The FHSIS serves as the major source of data for the DOH. The system

provides information on the different public health programs such as: Maternal and Child Health; Nutrition; Family Planning; Expanded Program on Immunization; Dental Health; Communicable Disease Prevention and Control(TB, Malaria, Schistosomiasis, Leprosy); Environmental Health; Vital Statistics (Natality, Mortality, Population); and, Notifiable Disease Reporting System. Data are provided by the local field health personnel through the regional and provincial health offices, and consolidated at the Central Office. These are presented by province, city and region in a publication of the same title.

The Health Management Information System (HMIS) consists of several sub-

systems, two of which are the HOMIS and the Rural Health Unit Information System (RHUMIS).The HOMIS generates information on hospitals to support the delivery of hospital services and the management of the hospital.The RHUMIS is a public health information system designed for the rural health units to efficiently and effectively monitor patient cases. A plan is to create a Unified Health Management Information System (UHMIS) which shall report statistical data of diseases/diagnosis from HOMIS and non-HOMIS users on a daily basis for the Alert System and sending of data to the DOH central storage or database.

Surveillance systems which include the two major disease surveillance

systems that provide information on notifiable diseases are the Weekly Notifiable Disease Reporting System (WNDRS) which comes from the FHSIS and the National Epidemic Sentinel Surveillance System (NESSS).

• The WNDRS provides information on 17 diseases(Anthrax, Cholera,

Diphtheria, Viral Encephalitis, Viral Hepatitis, Leprosy,Leptospirosis,Malaria, Measles, Viral Meningitis, Neonatal Tetanus, Non-neonatal Tetanus, Meningococcal Infections, Paralytic Shellfish Poisoning, Rabies, Typhoid and Paratyphoid fever, Whooping cough or Pertussis) and 7 syndromes(Acute Flaccid Paralysis, Acute Hemorrhagic Fever Syndrome, Acute Lower Respiratory Tract Infection and Pneumonia, Acute Watery

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Diarrhea, Acute Bloody Diarrhea, Food Poisoning, Chemical Poisoning).

• The NESSS is a hospital-based system that yields information on

admitted cases in sentinel to monitor the occurrence of 14 infectious diseases with outbreak potential. These included laboratory-diagnosed diseases (Cholera, Hepatitis A, Hepatitis B, Malaria, Typhoid Fever) and clinically-diagnosed diseases (Dengue Hemorrhagic Fever, Diphtheria, Measles, Meningococcal Disease, Neonatal Tetanus, Non-neonatal Tetanus, Pertussis, Rabies, Leptospirosis).

Registries (HIV and AIDS, Diabetes, Injuries, Cancer, Persons with

Disabilities (PWD), Tubercolosis (TB), Renal Diseases) which are also maintained by various professional societies and non-government organizations.

Philippine Malaria Information System (PMIS) is a relatively new system

which was piloted in 27 project sites, could also be used by other provinces in 2005 and is yet to be deployed in other provinces. It uses a license-free software and runs in any Windows operating system. Its indicators include SPR, API, age-gender-species, % coverage of mosquito net, % coverage of households sprayed. Malaria data for FHSIS can be extracted from PMIS and, thus, it can be integrated into FHSIS. Future enhancements to PMIS are web-based reporting, and use of mapping facilities such as HealthMapper.

2. Health Regulation Systems

BIIS consisting of Health Product Regulation and Health Product

Establishment Regulation DTOMIS which includes DOHLIS and Health Facilities and Service

Regulation Health Devices Regulation

3. Health Governance Systems

WFPDS which collect data on plans and programs of the DOH Central

Office , the Centers for Health Development(CHDs), DOH hospitals, and Attached agencies. Some of the data include: number of health products/establishments/ facilities/devices registered/licensed/ accredited, number of policies/standards/guidelines formulated, number of trainings conducted/attended in persondays (men/women), number of technical assistance provided in person-days, number of LGUs provided with logistics/technical assistance, number of Botika ng Barangay(BNBs) established, number of low cost drugs made available in F1 sites, number of Inter-Local Health Zones (ILHZs) developed as well as hospital data such as number of admissions, number of discharges, number of patient days, number of outpatients served, number of major/minor operations, number of

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laboratory examinations done, number of radiological procedures done, number of prescriptions filled.

National Health Atlas is a facility-mapping software of all rural health units

and government hospitals in the country. Health human resource complement, health care services available and equipment are included in the database.

Philippine Local Health Information System (PLHIS) which provides

information from LGUs Others (eNGAS, LMIS, PIS, eProcurement, Document Tracking Information

System (DTIS), Contract Distribution System of Core Essential Drugs which is being implemented in phases)

4. Other systems

Community Based Management Information System (CBMIS) PhilHealth systems

The DOH also conducts surveys. These include Prevalence Surveys (TB, Leprosy, Schistosomiasis) and the National Health Surveys in 1978, 1981 and 1987 which were eventually stopped when the NSO conducted the National Demographic and Health Surveys (NDHS) starting 1993.

The Food and Nutrition Research Institute

The Food and Nutrition Research Institute (FNRI) remains the major source of data on nutrition. It conducts the National Nutrition Survey every five years. Data generated through this survey include the nutritional food situation of the country, per capita food intake in grams and in nutrient equivalent, anthropometric data, extent of some nutritional deficiencies among various age groups of the population, and food menus fro the poverty statistics being generated by NSCB. The National Nutrition Council

The National Nutrition Council (NNC), the highest policy making and coordinating body on nutrition, is under the DOH and is mandated to formulate national nutrition policies and coordinate the policy formulation, planning, monitoring and evaluation, resource generation and mobilization for nutrition improvement. Its additional mandates are: to address food insecurity by being the focal agency for Food Insecurity and Vulnerability Information and Mapping Systems (FIVIMS), to address hunger as the lead agency to ensure achievement of MDG goals and targets on hunger and malnutritionto, and to ensure that hunger-mitigation measures are in place. Data being generated by NNC include indicators of nutrition resources (financing, manpower, facilities) and nutrition services (promotive, curative, preventive). Specific indicators are: ratio to population of nutrition manpower and facilities, proportion of government expenditure to nutrition program, consolidated data from Operation timbang received from local nutrition committees. The latter is used for the ranking of mutritionally depressed communities.




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The Philippine Health Insurance Corporation

PhilHealth is the agency under the DOH that provides and maintains database systems on health insurance and financing and accreditations of health providers and health facilities. The National Statistics Office The NSO, as mandated by the Civil Registry Law, generates vital health statistics such as marriages, births, deaths, infant deaths, foetal deaths, maternal deaths, and mortality by leading causes.

o The NDHS which is undertaken by the NSO in collaboration with the University of

the Philippines Population Institute (UPPI), DOH, Commission on Population (POPCOM), National Economic and Development Authority (NEDA), and the NSCB, provides national and regional estimates of levels and trends of fertility as well as examines the differentials and determinants of fertility. It also yields information on family planning, childhood and adult mortality, maternal and child health, and knowledge and attitudes related to HIV/AIDS and other sexually transmitted infections. The National Health Survey of DOH was incorporated in the NDHS starting 1993.

o The annual Maternal and Child Health Survey (MCHS) provides information on the coverage and effectiveness of the maternal and child health programs of the DOH at the regional level.

o The Family Planning Survey (FPS) provides data on prenatal and postpartum care, protection at birth against neonatal tetanus, breastfeeding, and immunization.

The National Statistical Coordination Board The NSCB produces the Philippine National Health Accounts (PNHA) with the following indicators: total health expenditure at current and at constant prices, health expenditure per capita at current and at constant prices, share of health expenditure to GNP and GDP, health expenditure by source of funds, health expenditure by use of funds, and selected national health accounts indicators compared with Asian countries. Annex 1 provides a matrix of available health statistics available in the DOH while Annex 2 provides a matrix of Matrix of Available Health and Nutrition Statistics in the Philippine Statistical System. It is noted that health and nutrition statistics come from various sources which operate on systems which are independent of one another. Thus, there is a need to improve, harmonize, and utilize existing data generation systems that may provide the relevant key health and nutrition statistics and indicators that will help monitor and assess the attainment of expected outcomes.

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5 Previous Studies on the Assessment of Health Information in the Philippines

The assessment being presented in this report is not the first one done for the Philippines. Many studies have already been done. This chapter shall presentg the results of these previous assessments. Past Reviews/ Assessment of Health Statistics and Information System in the Philippines Studies assessing health information systems were done in the past. Aguilar (1976) conducted a study to develop a Health Information System in the Philippines in the 70s. The proposed HIS shall have the following features specific subsystems to answer information requirements of activities and programs of the DOH which when viewed in its entirety, shall be so integrated to promote and enhance DOH objectives. It shall provide a mechanism that will effectively connect the data gathering with the information needs of the different management levels through the installation of a database that contains data gathered from the field, data do not necessarily have to be centrally stored; they could be situated in different units in the department; equipped with the capabilities to transform these data into information as required by management and to transmit these to whoever needs them. The database shall employ computers for data processing and storage, and communication facilities as the situation may warrant. The study recognized that problems in HIS development concern the highly dynamic environment within which the HIS must operate, the peculiar problems the Department of Health has as the agency primarily involved in HIS development and the difficulty of applying the MIS concept to situations involving health program and evaluation. Pons and Schwefel (1993) used the Goal Oriented Project Planning (GOPP) methodology determine essential elements in strengthening the Health and Management Information System (HAMIS) in the Philippines. Highlights of this planning strategy are:

• planning by Filipino nationals mainly • participation by various professional groups with different levels of responsibility • use of visualization techniques • smooth consensus finding and democratic decision rules.

The study identified the core problem in health care management as an inefficient and ineffective health and management information system. Six major causes were identified:

• information gaps • underutilization of data • excessive generation of data • poor reliability and validity of data • lack of skills in information management • lack of cost-effectiveness of health management.

Jayasuriya (1994 ) in studying HIS in the Philippines, reported the following:

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1. The Health Services in the Philippines underwent a major change in their organization and structure following the devolution of the delivery of services to LGUs.

2. Information systems development were to a great extent determined by the

management systems in place and the most extensive use of information is in, planning and controlling.

3. Routine information systems were expensive to establish and maintain and if the

validity of some information is questionable it is nonsensical to submit it to levels where action cannot take place.

4. The assessments of the existing systems identified deficiencies that were found in

most HIS. These were the existence of major gaps in information, the inappropriateness of the available information for the needs and most evidently that information is not utilized for management at most levels.

Marcelo et. al.( 2004) did an evaluation study in three of six pilot sites, i.e. Samar province, Baguio City and Cotabato City of the Decentralized FHSIS (DFHSIS). This study discovered that the DFHSIS reduced the number of required national indicators collected by local health personnel and simplified the data flow as intended. For these reasons, the DFHSIS was preferred over the Modified FHSIS (MFHSIS). Despite this however, the new system did not generate enough information needed by the national program managers. Furthermore, it did not result into better data accuracy, timeliness, and completeness, nor did it encourage the implementors, i.e., local health personnel, to customize the system for their local health needs. The software component of the DFHSIS was considered incomplete by end-users and therefore not useful. Reasons noted for these problems include lack of policy or implementing rules and regulation, poor support systems and structures, lack of financing, and lack of capacities at the community level for health data utilization for program improvement.The same problems of inaccuracy, incompleteness, and delay that hounded the original FHSIS and MFHSIS also plagued the pilot implementation of the DFHSIS. Thus, it was recommended that the DFHSIS, as planned and implemented in the three pilot sites, not be adopted in other areas of the country unless fundamental management systems and structures at all health system are put in place.

Decentralization, participatory governance and the principles of the declaration of Primary Health Care are key concepts that should anchor a sound national health information system. The authors further recommend [1] an enhancement of capability building packages for local health personnel on health information systems management; [2] a review of the data model of the DFHSIS/FHSIS; [3] innovations in collection such as acceptance of barangay level data as soon as these are available; [4] automation of transaction systems to facilitate transmission to higher levels of the DOH; and [5] use of computerized tools to assist health units in understanding their own data through data clubs and integrating their analysis of health information into their barangay health plans. Such an approach will help make the DFHSIS a valuable asset not just for the DOH but also for the community, which it intends to serve. The role of the National Epidemiology Center must be sharpened as it takes the lead in managing the DFHSIS and ultimately, in setting directions in knowledge-based decision-making at all levels of health care.

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While administrative reports and surveillance systems are in place, these are limited only to government-owned health facilities. Thus, only the surveys are able to capture the contribution of privately-owned health facilities. However, the estimates that result from these surveys are at best available up to the provincial level. Sub-provincial disaggregations are not available. Current initiatives to address the unavailability of local-level data include measuring LGUs health systems performance through the Organizational Performance Indicator Framework (OPIF) or through small area estimation. The latter has been applied but on vety limited health/information statistics. Initiatives to address data quality assurance have led to the upgrading of health facilities to conform to effective management standards. Facilities with such standards are referred to as Sentrong Sigla. The upgrades include, among others, facilities for information systems. Another concept being promoted is the ILHZs which aims for better data collection and transfer from health facilities at municipal and provincial level. Interagency on Health and Nutrition and PSDP 2005-2010 Assessment

The Inter-Agency Committee on Health and Nutrition Statistics (IAC-HNS) was created by the NSCB to tackle issues on health and nutrition statistics. The IAC, co-chaired by the DOH provided inputs to the PSDP through an assessment of the the different data sources, and recognized the need to improve and synchronize/harmonize the various health information systems. The PSDP specifically cites the problems of the FHSIS, PHS, and the NESSS of the DOH. Issues on completeness, timeliness, quality/accuracy, and relevance of health and nutrition statistics, especially those monitored in the MTPDP and in global concerns like the MDGs, need to be resolved. The NSO also recognizes problems in its vital statistics in some areas in the country, which need to be improved..

The PSDP, following one of its key result area, shall maximize use of information technology in data collection, processing, analysis, dissemination and archiving to enable faster and wider utilization of data and promote transparency, information sharing and user confidence on official statistics. This particular key result area aims to capitalize on existing developments in information technology, specifically in enjoining government agencies to establish websites and develop statistical information systems that would enable them to upload/share statistical information available in the agency. The development of interactive national statistical databases shall be promoted for different sectors and to develop innovative statistical software that could be used within the PSS. An improvement on the information systems of different agencies is likely to be expected.

The PSDP programs designed to address issues and challenges towards improving the generation, dissemination and utilization of quality statistical information for health and nutrition, are as follows:

Generation and improvement of the timeliness, accuracy and reliability of statistics,

especially those that address the requirements of the MTPDP, MDG especially on the estimation of Maternal Mortality Rate (MMR) and improvement of Infant Mortality Rate (IMR), Under Five Mortality Rate (U5MR), life expectancy, dissemination of a single figure for IMR;

Comment [FVNDL1]: Mention of NSO (only) should not be under IAC..

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Providing implementers and policymakers with reliable and timely information, through the conduct and improvement to the following health and related surveys the same period: a) 2008 NDHS; b) 2005-2007, 2009-2010 Maternal and Child Health Care (MCHS); c) 2008 NNS; d) 2005, 2007, 2009 Regional Updating of the Nutritional Status of Filipino Children;

Development and improvement of administrative reporting forms to generate

official statistics more frequently and for lower levels of disaggregation;

Generation of the following new indicators to address the problem in data gaps: • Proportion of population with access to affordable essential drugs on

sustainable basis. • DOH-retained and LGU hospitals selling low-priced drugs • HIV prevalence among 15-24 year old pregnant women • Number of children orphaned by HIV/ AIDS • Proportion of population in malaria risk areas using effective malaria

prevention and treatment measures • Proportion of tuberculosis cases detected and cured under directly observed

treatment short course (DOTS) • Number of doctor/physician deployed to doctor-less 5th and 6th class

municipalities • Number of health and nutrition and population related R and utilized • Rate of increase/decrease in the number of mental health facilities upgraded • Number of bird/avian flu cases;

The development and implementation of a coordinated and comprehensive Philippine Health and Nutrition Information System (PHNIS) covering the different information systems within the DOH and other health-related agencies, foremost of which is the FHSIS, the surveys on health and nutrition, and the civil registration system; and,

The improvement of statistical methodologies and framework of the Philippine

National Health Accounts (PNHA). Issues on Health Information Presented in the National Objectives for Health 2005-2010 The NOH 2005-2010 also documented the impacts of the a devolved health system mandated by the Local Government Code (LGC) of 1991 and emphasizes importance of the leadership and political authority of LGUs in terms of their greater role in the delivery of health services. It further highlights the role of a good health information system as written in the following statements: Good governance also necessitates a clear knowledge of what is happening in the health system in order to develop policies, programs and strategies that support the overall health goals and objectives. The health sector, in general, gathers large amount of information from those collected and compiled by thousands of health personnel most of which are never used. A good health intelligence and knowledge management system needs to be selective in the information it generates to avoid inefficiencies and wa stage of limited resources. It is critical that knowledge is disseminated to provide support for policy and decision-making, to build constituency of public

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support for health policy, to form part of capacity-building program, and to inform and influence behavior and events within the health system (NOH, 2005-2010 and WHO 2000). In documenting the impacts of devolution of health services to the local government units, NOH 2005-2010 identified the following three phases:

• Pre-devolution phase

The pre-devolution period covers the period prior to the enactment of the LGC. During this period, the Philippine health care system was administered by a central agency and a unified health service delivery network was in place through the establishment of District Health Systems (DHS). The DHS is a well defined administrative and geographic area, either rural or urban, and all institutions and sectors whose activities contribute to improve health.

• Devolution phase The devolution phase is the period of the implementation of the LGC to establish local autonomy. During this phase, the devolution of most of the national government social services including health to the various levels of local government (i.e., province, city, and municipality) was implemented. The devolution of health services weakened the DHS, resulting in a fragmented health service delivery system. This situation and the inadequate regulatory mechanisms and poor health care financing compromised access to health services and hampered the improvement of the country's health status.

• Health sector reform implementation phase

The government developed and implemented the HSRA in 1999 to address the problems encountered due to devolution. It is noted that one of the reform areas under the HSRA is the development and strengthening of local health systems capacities. Implementation of reforms, however, was a challenge. Thus, an implementation strategy, called “Fourmula One for Health” of F1, consisting of four components, namely: health financing, health service delivery, health regulation and governance, with all the major flagship programs and projects to carry out reforms under each component was developed in July 2005.

The following table documents the impacts of the devolution and the HSRA:

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Table 3. Implications of the Devolution and Health Sector Reform Agenda on the Local health System2

2 Source: National Objectives for Health 2005-2010

Comment [JB2]: Restate!!!!

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Table 3(continuation)

Under the HSRA, the Local Health System is expected to serve as the venue for the integration of all the reform efforts. Inter-Local Health Zones (ILHZ), similar to the the DHS before devolution, were identified to serve as a focal points of convergence of the reforms. The ILHZ is a well-defined geographic area where individuals, communities and all other health care providers participate in providing quality, equitable and accessible health care with inter-LGU partnership as the basic framework. It is envisioned that with the ILHZ, reforms are achieved through the integrated governance, management, financing, resource sharing and provision of health services among the local government units and partner agencies. To date, 39 LGUs have already signed the Pledge of Commitment to implement health reforms in their areas. Activities have already been initiated in 30 out of the 65 targeted convergence sites and 73 ILHZs have been established in both convergence and non convergence sites. Solon, Panelo and Gumafelix (2003) emphasized the key role of local government officials in all levels of administration in achieving the reforms in the

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ILHZs. They specified the following key elements needed for the reforms to take place: a dynamic and reform oriented local chief executives; creative and innovative provincial, city and municipal health officers; collaborative effort between DOH, PhilHealth and LGU staff; and, the presence of technical assistance and capability building efforts (NOH 2005-2010). Another reform effort of the DOH is the implementation of the Philippine Local Health Information System (PLHIS) in 6 provinces (i.e., Bulacan, Iloilo,Agusan del Sur, Ilocos Norte, Camiguin and Negros Oriental) has also contributed timely and accurate data for local health system planning to both DOH and LGUs. The PLHIS is a web-based, data collection system which is directly accessible from local government units or convergence sites. To ensure equitable access to health care, the concept of a health system model for geographically isolated and disadvantaged areas (GIDAs) is being developed as an approach to support the implementation of local health systems development. The GIDA is being linked or integrated to a nearby functioning ILHZ in order to address the health care needs of the isolated and disadvantaged communities and vulnerable groups separated from the mainstream of socio-economic activities. So far, local health system development was initiated in four GIDAs. One of the GIDA sites, San Juan/San Pedro in Southern Leyte, won the WHO Sasakawa Award on Primary Health Care (NOH, 2005-2010). It must also be noted that to ensure quality health care, services and facilities, the Quality Assurance Program (QAP) developed in 1998 and renamed as the Sentrong Sigla Movement (SSM). The objectives of this movement are to institutionalize quality assurance through capability building, developing a cadre of quality experts, advocates and practitioners; to establish mechanisms to coordinate, support and monitor efforts, develop and implement an effective information and advocacy campaign, and make clients active partners in health. The program's two main strategies were the certification or recognition of health facilities - rural health units, health centers and barangay health stations- that have met established criteria under QAP; and capability building to internalize continuous quality improvement of health services in these facilities. As of 2005, 58 percent of Rural Health Units and Health centers have been certified with Sentrong Sigla (SS) seals (NOH, 2005-2010). The Philippine Integrated Disease Surveillance and Response A National Strategy for Emerging Diseases 2008-2010 named the Philippine Integrated Disease Surveillance and Response (PIDSR) was developed by the NEC in response to the gaps and weaknesses of the epidemiologic surveillance and response systems that resulted in an assessment in 2006. The assessment reported that:

• There is a lack of capacity especially in the local level to perform the required epidemiologic surveillance and response functions. Thus, the quality of information being generated is put into question.

• Surveillance staff at the local level do not have training in performing their functions and are not supervised in performing critical functions

• Support for equipment, travel, logistics and other supplies essential for the optimal operations is inadequate.

The assessment reported inefficiencies, redundancises, and duplication of efforts that result in extra costs and training requirements as well as an overloaded and unmotivated workforce.

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The following table provides the strengths and weaknesses of the two major disease surveillance systems of the NEC:

Table 4. Strengths and Weaknesses of the Surveillance Systems of the National Epidemiology Center

Disease Surveillance System

Strength Weakness

Weekly Notifiable Disease Reporting System(WNDRS)

1. It can provide better estimates of morbidity rates and trends of certain diseases at the community level.

2. Community epidemics could easily be detected since the lowest data collection units are the barangay health stations.

3. It complements community-based disease surveillance systems.

4. The data are readily accessible to the rural health unit for purposes of prioritizing planning and evaluating public health programs.

5. It provides estimates for the national morbidity rates and trends.

1. Standard case definitions are often not used for purposes of case detection and reporting.

2. Analysis of data by time,place and person is not possible due to limited information obtained from reported cases.

3. Cases admitted to hospitals are often not captured or included in the rural health unit notifiable disease report. This affects the accuracy of calculated morbidity rates and trends.

4. Notifiable disease reports are often not transmitted regularly or are submitted very late to the next higher levels (e.g., Provincial Health Office , CHD, NEC). This limits the usefulness of this information at the higher levels in terms of providing prompt and appropriate assistance, establishing trends at the provincial or regional levels, guide prioritization,allocation of resources, planning , evaluating programs and policy-making.

5. Laboratory confirmation for the diagnosis of some notifiable diseases (e.g., cholera, hepatitis, typhoid fever) is often not performed. Therefore, reported morbidity rates for these diseases may not be that accurate.

National Epidenic Sentinel Surveillance System(NESSS)

1.It can provide weekly trend of notifiable diseases.

2.It can detect disease outbreaks if cases are admitted to sentinel hospitals.

3.Its case-based data provide better epidimeologic profile of diseases under surveillance.

4.It provides accurate diagnosis of some reported cases since these laboratory-confirmed.

1. The system cannot provide morbidity or incidence rates of notifiable diseases since the source of reported cases come from selected hospitals or sentinel sites only.

2. Most community disease outbreaks could not be detected by the system because oftentimes, the cases are not admitted to any of the sentinel sites or hospitals.

3. The morbidity trends of diseases

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Disease Surveillance System

Strength Weakness

5.Data analysis (by time, place, person) and dissemination of reports are done regularly by trained surveillance staff at the epidemiology and surveillance unit(ESU) and national levels.

6.Reporting to the nest higher level is efficient.

provided by the system in a particular areas could be misleading because it does not include cases coming from the community or sentinel hospitals.

Both systems(WNDRS and NESSS)

1.Both systems are supported by mandates for their operations.

2.Both systems are currently existing

1.Both systems operate independently and are not adequate to fully comply with the International Health Regulations(IHR) and APSED requirements.

Source: Philippine Integrated Disease Surveillance and Response(PIDSR): A National Strategy for Emerging Diseases 2008-2010 The following is the NOH 2005-2010 summary of the problems which need to be addressed in order to create an environment where planning and policy decisions are knowledge based:

(a) Weak health research and information systems. The Philippines has an active health research environment where government agencies, non-government organizations, public and private hospitals, academic institutions and private agencies have some form of research activities. A closer look, however, would reveal that these researches are uncoordinated, fragmented and duplicated which precludes the optimal use of time, effort and resources (Acuin, 2001). The Philippine National Health Research System (PNHRS) is a collaborative effort from Department of Science and Technology Philippine Council for Health Research and Development (PCHRD) and DOH to improve the current status of Philippine health research system. The main focus is on integration and creating synergy to address the perennial concerns such as lack of resources for research, unsynchronized research agenda, maldistributed and undercapacitated researcher pool, and underutilized research information. (b) Gaps in the management of health information. There are several sources of health information in the country. These information are collected by various agencies both government and private through routine information systems, population surveys and special studies. There are, however, weaknesses in the management of such information. For instance, timeliness and completeness are two major limitations in generating

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health information. Disseminated and published reported are critical ingredients I knowledge sharing and utilization. Most of the bigger surveys are published every 3 to 5 years. Official published reports are often times delayed by more than 2 years in the case of the Field Health Service Information System (FHSIS) and the Philippine Health Statistics (PHS). This is brought about by non-compliance and incomplete submissions of report by some LGUs and private health facilities, and the delay in the submission of civil registry records to NSO or DOH by the LGUs. In some case, important indicators are not reported. The 2003 National Demographic and Health Survey (NDHS) failed to include the maternal mortality ratio (MMR) due to sampling limitations. There are also information systems that lack complete information for knowledge-based decisions. In the case of the National Epidemiology Sentinel Surveillance System (NESSS), private facility data sources are not included. Furthermore, while several systems have been developed to generate vital information, these information system have yet to be integrated. For instance, hospital system such as Hospital Epidemiology Program (HOMIS) have been initiated by DOH to better manage a wide range of activities ranging from planning to procurement and staffing. However, the systems are run independently by DOH hospitals and have yet to be linked to the central office. Given the gaps in the management of health information, there is a need to standardize health indicators and health information requirements in order to eliminate inefficiencies and reduce cost in data collection. A compendium of health indicators should be made in order to have a unified definition of health indicators and terminologies. Likewise, there is a need to standardize health information requirements and ensure the appropriate systems (whether automated or manual) are properly linked from the local to national levels .(NOH,2005-2010)

The following matrix provides targets that aim to address problems identified above:

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Table 5. Targets in Knowledge Management in the Philippine Health Sector

Objective Indicator Target Baseline Data and Source

Standardized and harmonized health data requirements and indicators

Standardized definitions of health indicators nationwide Standardized health data requirements for every level of health facilities Harmonized system of health data generation among different government agencies

Begun later part if 2004 and finalization 2005 NEC, 2004

Compliance to a standard health information reporting system of all public and private health facilities

80% of LGU and private sector facilities with accurate and complete FHSIS reports 80% of LGU and private sector facilities with timely reports

All health facilities ran by LGU and/or government agencies are at 100% submitting complete reports except ARMM For timeliness, only 50% were submitting forms on scheduled date NEC, 2004

Number of health personnel trained on health information systems

At least 1 health personnel per LGU trained on data generation, basic health information system or database administration

At present, all health facilities have trained personnel in charge of FHSIS NEC, 2004

Quality, timely and relevant health information at all levels is ensured

Number of staff in health facilities (up to the level of the RHU) who are computer literate

At least 1 staff per health facility who is computer literate

To be determined

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Objective Indicator Target Baseline Data and Source

Interoperability standards developed and adapted by health sectors stakeholders (e.g. private hospitals, PhilHealth, pharmaceutical and other health-related industries etc.)

Framework for National Health Information Infrastructure (NHII) developed; Repositories for essential and codified health information established;

To be determined

Health sector portal established

Health portal established that will integrate and harmonize health information from different sources (e.g. routine reports, vital registries, survey researches)

To be determined

Establish networks/communities to facilitate knowledge sharing and exchange

At least one functional network and communities established per domain

Structural organization of PHNRS already in place

Access to and sharing/exchange of health knowledge and information is increased

Physical infrastructure for health information system established

At least one functional computer for health information management is available in every municipality Health facility routine health related reports encoded in electronic format in all municipalities

To be determined

Essential health researches, data and information, best practices are published/disseminated

2-3 health data and information published/dissemination

Essential health researches, data and information are used for policy and program development

5-10 health researches and information used for policy and program development per year

Health policy development and decision-making, including clinical management decisions, are evidenced-based

Health systems performance measures among LGUs are institutionalized

Data generated from standard health indicators utilized for measuring LGU performance

Health information publications (Phil. Health Statistics; FHSIS) Completed Essential National health research (ENHR) studies Research/policy advocacy fora NEC/Health Policy Development Planning Bureau (HPDPB-DOH)

Source: National Objectives for Health 2005-2010

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The Philippine Statistical System through the Inter-Agency Committee on Health and Nutrition Statistics (IAC-HNS) as well as the DOH itself have made assessments of the status of these different data sources and have recognized the need to improve and synchronize / harmonize the various health information systems. The PSDP 2005-2010 specifically cites the FHSIS, PHS, and the NESSS of the DOH. Specifically, issues on completeness, timeliness, quality/accuracy, and relevance of health and nutrition statistics, especially those monitored in the MTPDP and in global concerns like the MDGs, need to be resolved. The NSO also monitors and assesses the completeness, coverage and timeliness of its vital statistics and recognize that some areas in the country need improvements on these.

One of the key result area of the PSDP 2005-2010 is to maximize use of information technology in data collection, processing, analysis, dissemination and archiving to enable faster and wider utilization of data and promote transparency, information sharing and user confidence on official statistics. This particular key result area aims to capitalize on existing developments in information technology, specifically in enjoining government agencies to establish websites and develop statistical information systems that would enable them to upload/share statistical information available in the agency. The development of interactive national statistical databases shall be promoted for different sectors and to develop innovative statistical software that could be used within the Philippine Statistical System. An improvement on the information systems of different agencies is likely to be expected.

The statistical development programs pertaining to health and nutrition are designed to address issues and challenges towards improving the generation, dissemination and utilization of quality statistical information. One of the programs is the generation and improvement of the timeliness, accuracy and reliability of statistics, especially those that address the requirement for MTPDP, MDG monitoring especially on the estimation of MMR and improvement of IMR, U5MR, life expectancy, dissemination of a single figure for IMR. Statistics on maternal mortality will be produced from the census of the population while improved methodologies to estimate mortality statistics will be developed. To provide implementers and policymakers with reliable and timely information, the following health and related surveys will be improved and conducted within the same period: a) 2008 NDHS; b) 2005-2007, 2009-2010 MCHS; c) 2008 NNS; d) 2005, 2007, 2009 Regional Updating of the Nutritional Status of Filipino Children. To have a cost-effective approach that will reduce reliance on statistical surveys for more frequent and finer levels of disaggregation, the development and improvement of administrative reporting forms to generate official statistics will be likewise undertaken. Another program is to generate data to complete and fill in data gaps to monitor the MTPDP, MDGs and other sectoral plans. A total of 10 new indicators will be generated to address the problem in data gaps and are given below:

• Proportion of population with access to affordable essential drugs on sustainable basis.

• DOH-retained and LGU hospitals selling low-priced drugs • HIV prevalence among 15-24 year old pregnant women • Number of children orphaned by HIV and AIDS • Proportion of population in malaria risk areas using effective malaria prevention

and treatment measures

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• Proportion of tuberculosis cases detected and cured under directly observed treatment short course (DOTS)

• Number of doctor/physician deployed to doctor-less 5th and 6th class municipalities • Number of health and nutrition and population related R and utilized • Rate of increase/decrease in the number of mental health facilities upgraded • Number of bird/avian flu cases

Another important program in the PSDP is the development and implementation of a coordinated and comprehensive PHNIS. In response to the need to coordinate the generation of and to improve the quality of statistics from the various health information systems, the DOH will lead the design and development of the PHNIS in collaboration with the NSCB, the NSO, the PCHRD and other health-related agencies. This will cover the different information systems within the DOH and other health-related agencies, foremost of which is the FHSIS, the surveys on health and nutrition, and the civil registration system. And the last program is the improvement of statistical methodologies and framework enhancement of the PNHA.

In the following table, Table 6, the PSDP 2005-2010 enumerates the statistical development programs to address the problems with health information.

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Table 6. Matrix on Statistical Development Programs for Health and Nutrition Information Systems3

Statistical Program/ Project/Activity

Brief Description/Objective of the Statistical Program/Activity/Project Policy Use/Relevance

Target Date of Implementation (Specific Year/s)

Lead/Implementing Agencies

1. Regular Statistical Activities 1.1 Conduct of Censuses and Surveys Inclusion of question of maternal mortality in the census of population

(Refer to PSDP Chapter on Population and Housing)

2005-2010 NSO

Improvement of health and nutrition related surveys and studies:

Conduct of the 2005-2007, 2009-2010 Maternal and Child Health Care Survey (MCHS)

The MCHS presents up-to-date data on prenatal and postpartum care, protection at birth against neonatal tetanus, breastfeeding and immunization. The MCHS aims to provide the DOH info on the coverage and effectiveness of its maternal and child health programs at the regional level.

Offers facts that are useful in influencing policy makers and program manages on the support needed to effectively implement the health programs of the government.

2005-2007, 2009-2010

NSO

Conduct of the 2008 National Demographic and Health Survey

The NDHS is a nationwide sample survey designed to collect information on fertility, family planning and health in the Philippines.

This provides an up-to-date set of relevant data useful to evaluate population, health and family planning programs.

2008 NSO, DOH, UPPI

3 Source: Philippine Statistical Development Plan 2005-2010

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Conduct of the 2008 National Nutrition Surveys

To assess and update the food consumption and nutritional status of Filipino households and selected population groups.

Provide basis in planning, monitoring, & evaluation of nutrition and health programs for the prevention and control of nutrition-related and lifestyle diseases.

2008 FNRI-DOST

Conduct of 2005, 2007, 2009 Regional Updating Nutritional Status of Filipino Children

To update the state of nutrition of Filipino children in various regions of the country. Anthropometric measurements such as weight, height and recumbent length, which were collected using standard techniques, served as database.

Provides an update on the nutritional status of children 0-10 years old in between national surveys that This also serves as a basis in planning, monitoring and evaluation of nutrition programs.

2005, 2007, 2009 FNRI-DOST

Improved statistics on PWDs from the Census of Population (Improved questions in the census)

Updating of the population count and other information on the demographic, social economic, and cultural characteristics of the population, including PWDs

Provide government planners, policy makers and administrators with data on which to base their social and economic development plans and programs on PWDs

2006, 2010 NSO

1.2 Administrative-Based Data Systems Provision of more timely, accurate, reliable, valid and consistent statistics from the existing administrative-based reporting systems - Field Health Service Information System (FHSIS) - Vital statistics from the Civil Registration System

The FHSIS is a nationwide compilation of health indicators from health facilities collected through the provincial and regional health offices.

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Full implementation of the automated civil registration system such as the CRIS in the Local Civil Registry Offices (LCROs)

This includes information dissemination to non-CRIS users and eventual training of LCROs on CRIS usage.

To help encourage the use of information technology in building-up databases and enhance the capability of LCROs in establishing vital statistics in their areas of concern.

2005-2010 NSO

Institutionalization of the Registry of Persons with Disabilty

Includes the maintenance and updating of the Philippine Registry for PWDs (PRPWD) which has the main objective of monitoring health services rendered to PWDs.

Results from the registration are stored in the DOH Field Health Information System

2005-2010 DOH

1.3 Statistical Frameworks and Indicators System Development of new health and nutrition statistics and indicators systems

The development of new health and nutrition statistics and indicator systems will generate data to complete and fill-in data gaps needed to monitor development goals

2006-2010 IAC on Health and Nutrition Statistics with implementing

agencies

�Proportion of population with access to affordable essential drugs on sustainable basis

�DOH-retained and LGU hospitals selling low-priced drugs

�HIV prevalence among 15-24 year old pregnant women

�Number of children orphaned by HIV/AIDS

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� Proportion of population in malaria risk areas using effective malaria prevention and treatment measures

� Proportion of tuberculosis cases detected and cured under directly observed treatment short course (DOTS)

� No. of licensed hospitals � Number of doctor/physician

deployed to doctor-less 5th and 6th class municipalities

� No. of health and nutrition and population related R & D utilized

� Rate of increase / decrease in the number of mental health facilities upgraded

�No. of bird or avian flu cases

Development and adoption of a set of indicators on the rights to food, water and health.

The rights-based approach will be used to substrantiate indicators on the rights to food, water and health

2005-2010 CHR

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Generation of annual Operation Timbang (OPT) statistics

The OPT results from municipalities will be used to rank municipalities based on prevalence of underweight 0-5 years old children and identify nutritionally depressed municipalities for reference in identifying geographic focus for programs.

2005-2010 NNC

Improvement of the Philippine Food Balance Sheet(FBS), and publication of the 2007-2009 estimates

The FBS of the Philippines presents a country's pattern of food supply and utilization during a specified reference period. It gives an indication of the adequacy of food supply relative to the nutritional requirements of the population.

A useful tool in the formulation of national food production aimed at satisfying the dietary and nutritional needs of the Filipinos.

2005-2010 NSCB

Improvement of Food Insecurity and Vulnerability Information Mapping Systems (FIVIMS)

The Philippine FIVIMS is a system that assembles, analyses, identifies, and disseminates information to policy makers on food insecure and vulnerable or at risk provinces. Its main goal is to contribute to the reduction of food insecurity and vulnerability in the country.

Provide basis in planning and monitoring of food security issues such that areas identified as food insecure and vulnerable will receive higher priority in policy and strategy formulation, program development and assessment, amd resource allocation.

2005-2010 NNC

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Upgrading of statistical methodologies and framework enhancement of the Philippine National Health Accounts (PNHA):

The PNHA is a framework for the compilation of information on the country’s health expenditures. It consists of a set of statistics that systematically presents national health spending for a given year.

It provides insights on the efficiency and effectiveness of health care financing and helps determine appropriate interventions to improve the delivery of health care.

2005-2010 NSCB

Improvement of the PNHA based on the WHO / OECD Producer’s Guide (PG)

This aims to expand the usefulness of PNHA through the development of new matrices; also designed to enhance capacity for estimation and use among stakeholders.

Analysis of the allocation of expenditures by certain categorization - geographic, population groups, priority programsComparison of PNHA with other countries.

2005-2006 NSCB, DOH, PIDS

Development of a projection model for the PNHA

This aims to expand the usefulness of PNHA through the development of a projection model; also designed to enhance capacity for estimation and use among stakeholders.

Examining future financial requirements and prospects for increasing funds for health.

2005-2006 DOH, PIDS

Improvement of data generation to support the PNHA

To put in place a more systematic generation of data inputs to the NHA. This can build on the current data collection/ generating system of involved agencies (eg DOH, COA, DSWD etc.). Household and establishment surveys will be conducted to provide benchmark estimates for specific sources and uses of health expenditures

Updated parameters and easier/faster collection of more accurate data inputs

2006-2010 NSCB

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Improvement of the existing methodology in generating mortality statistics


2005-2010 Tech Committee on Population and

Housing Statistics (TCPHS)

1.4 Statistical Policy and Coordination Improve the timeliness, accuracy, and reliability of statistics, especially those that address the requirements for MTPDP, MDG monitoring especially on the improvement of IMR, U5MR, MMR and life expectancy estimates

2005-2010 DOH/ NSO, NSCB, PCHRD/other

producers of health information

Formulation of policy on the dissemination of a single figure for IMR


2006 TCPHS

Enhanced information disssemination and awareness campaign on civil registration

Educating and motivating the public to register vital events such as births, deaths and marriages accurately within the prescribed period

This activity will increase the circulation base of vital statistics information to include new users and non-users as well.

2005-2010 NSO

Adoption of standard classification systems for international comparability

Improvement of morbidity, mortality statistics based on ICD-10

To promote the use of ICD-10 in the tabulation of morbidity, mortality data in all health facilities. And to train statisticians on ICD-10 at all levels.

Comparability of morbidity/mortality statistics

2005-2007 DOH

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Adoption of International Classification of Functioning, Disability and Health (ICF)

To provide the health sector a common system of defining and classifying disability

2005-2006 DOH, NSO

1.5 ICT and Related Activities Development and implementation of a coordinated and comprehensive Philippine health and nutrition information system (PHNIS)

The project is a collaborative effort among government agencies, donor organizations, academe, private sector as well as other stakeholders in health information to develop and implement a coordinated and comprehensive PNHIS.

Streamline the delivery of timely, relevant and reliable health information to users

2005-2010 DOH/ NSO, NSCB, PCHRD/other

producers of health information

Improvement of the Field Health Service and Information System (FHSIS)

The FHSIS is a nationwide compilation of health indicators from health facilities collected through the provincial and regional health offices.

Can be utilized by national and local government officials and managers for policy-making, monitoring and evaluating health activities. Also for planning appropriate public health interventions, stimulating medical researches and highlighting topics of relevance in health education of the public.

2005-2010 DOH

Development of a National Hospital Statistical Reporting System.

To revise the Hospital Statistical reporting system; conduct orientation on the revised system; and generate a National Hospital Statistical Report.

More wholistic picture of health statistics with the inclusion/ maintstreaming of hospital data; better and more sound-evidence for policies and programs.

2005-2007 DOH

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Development and Implementation of SPReAD

The SPREAD is a content management system of Corporate Planning in support of its mandate of data and information management on the National Health Insurance Program. It shall be an archive of in-house and external data. The range and scope of information shall be both quantitative (statistical) and qualitative (textual and descriptive).

Provide accurate data and information that are organized, readily available and easily accessible. The system will be used for planning and decision-making of management and other stakeholders.

2005-2006 PhilHealth

Establishment of linkages among data producers and data users of health and nutrition statistics to enhance data dissemination and utilization

Improvement of the Philippine Health Statistics (PHS) publication

PHS is a summary of statistical data on births and deaths registered and reported in a given years. It also contains reports on notifiable diseases which were taken from the FHSIS.

Supply vital information for planning appropriate public health interventions, stimulating medical researches and highlighting topics of relevance in health education of the public.

2005-2010 DOH

Establishment of the Philippines' Knowledge Center on Food and Nutrition (e-Nutrition)

E-Nutrition is an information system that will allow the electronic dissemination and maximum utilization of nutrition survey results to pave the way for collaborative projects of national significance with NGOs and other local and international government agencies.

This activity is essential for policy making and community empowerment, will be made available and easily accessible through the internet and a website.

2005-2010 FNRI-DOST

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1.6 Statistical Capacity Building Capability building of personnel involved in the production of health and nutrition statistics

Training of processors of civil registry documents such as personnel of the Civil Registry Offices, of the National Statistics Office on all aspects of vital registration and statistics. This will also include follow-up training of personnel as a support mechanism to maintain and sustain their operations.

This activity is essential in building the capability of Local Civil Registry Offices and the NSO Provincial and Central Office in the civil registry and vital statistics operations.

2005-2010 NSO

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6 Assessment of Health Information System of the Philippines After the assessments of Aguilar (1976), Pons and Schwefel (1993), Jayasuriya (1994), Marcelo et. al. (2004), as well as recommendations from the IAC-HNS and self-assessments of the DOH , there is still recognition of uncontrolled growth of data and information that are not integrated and harmonized.

Health Metrics Network Approach A global initiative of the HMN is for different countries to integrate their respective health information systems. The goal of the HMN is to increase availability and use of timely, reliable health information in countries and globally through shared agreement on goals and coordinated investments in health information systems. Its objectives are:

• HMN framework and standards for health statistics • Country HIS strengthening and transformation • Better dissemination and wider use of health statistics

It identifies its partners as the producers (nurses, doctors, statisticians) and users (managers, policy makers, patients) of health statistics: health and statistical constituencies and non-health sectors: economic institutions, political parties, social organizations and citizens The Philippine participation in the HMN was spearheaded by the PHIN with the DOH as lead agency. The PHIN goal of integrating and harmonizing the Philippine HIS is along the same goal as HMN’s. The PHIN was formally launched on 9 September 2005 with DOH, NSO, NSCB, and PCHRD as the founding members. It aims to strengthen coordination among stakeholders (government agencies, donor organizations, academe, private sector, and other constituencies involved in health information); to expand the network to include those in the private sector and the academe; and, to work at integrating and harmonizing the Philippine HIS. The assessment of the Philippine HIS using the HMN framework, tools and procedures was done in February 2007 with 51 key informants. Prior activities included a training of trainers by the HMN in November 2006 and a pretest and customization of the HMN questionnaire on February 9 to 14, 2007. All these activities were conducted with the financial and technical support of the HMN through Dr. Bruno Piotti.

The HMN Framework The HMN Framework centers on six components for the assessment of HIS. It emphasizes on the principles, processes, and tools for the achievement of an integrated and harmonized HIS. Below is the framework:

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The following provides the items under each component of the assessment: a. HIS Resources

• Information policies – Supportive legislative framework and regulatory environment – Institutional policy (e.g. coordinating mechanisms; engagement of private

sector, non-health sectors) – UN Fundamental Principles of Official Statistics

• Financial resources – Relation with health status or GDP – $0.50 to $3.00 per capita per year or between 5-10% of projects and

programme – Requires international and domestic funding

• Human resources – National level: epidemiologists, demographers, statisticians, public health

experts; – Front lines: Training, sub-national cadres; multi-tasking burdens – Level of remuneration in DOH, Non Profit Organizations, University

• Infrastructure and communications – Well-defined paper based systems – Computers, communications, internet connection, database policies,

compatible systems • Coordination and leadership

– National stakeholders committee of key health and statistical constituencies – Build upon existing mechanisms

HMN GoalIncrease availability, accessibility, quality and

use of health information that is critical for decision making at country & global levels.

HMN Framework

Roadmap for implementation

Health information system components & standards

Data Sources

HIS Resources

Indicators

Data Management

Dissemination and use

Information Products

Principles

Process

Tools

Figure 4.

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– Links to national statistical plans beyond the sector, Poverty Reduction Support Programme, MDGs, etc.

b. Indicators • Key principles

– Development of minimum set of core health indicators, with targets – Indicators should be national priorities, but also harmonize with global

initiatives such as MDGs – Comprehensive across the indicator domains of health determinants, health

systems, and health status outcomes • Selection process

– Involves key stakeholders (national and international) – Incorporates health statistics into national statistical plans, link with poverty

monitoring master plans, health sector support programme or similar Government plans

– Links indicators with data collection strategies over 10 year time (Ten year frame, Plan x 2015) that encompasses routine system (HMIS), episodic surveys (MCH, Malaria) and periodic surveys (DHS or similar)

c. Data Sources

• Population-based census, population-based surveys, civil/vital registration • Health services based- health administrative records , health service records, health

and disease records d.Data Management

• Overall structure: All data collection and reporting tools need to be coordinated and aligned. Data elements, data sets and data sources need to be coordinated, combined and clearly defined (in a "data dictionary")

• User dimension: there are multiple users and purposes, from local management to monitoring MDGs for policy and national resource allocation

• Standards dimension: core indicator set with measurement strategies, independence of statistics, data flow and analysis protocols

• Tools dimension: enhancing access at all levels: e-doc for reports, district and national data warehouse or repository, micro-data repository (Data Dissemination Toolkit), standardized dissemination tools

e.Information Products

• Availability and quality of the products of health information systems are the health statistics which can be evaluated using international standards for statistics (notably Data Quality Assessment Framework)

– Timeliness: most recent data collection – Periodicity (frequency): more data points provide better basis for health

statistics – Consistency: if there are more points, consistency is a good sign; use for

calibration and validation – Representativeness: for whole population, sub-populations – Disaggregation: socio-economic, geographic regions, urban rural, sex – Estimation methods and statistical techniques: transparent, international

standards

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d.Dissemination and Use

– Who utilizes the information products and for what purpose. The Procedure The HMN Procedure for the assessment uses a Group Consensus through workshops. It is not a survey but is more a variant of focus group discussions (FGDs) where participants’ individual responses are reviewed by the whole group to reach a group consensus. It uses the HMN assessment tool which is an Excel-based questionnaire. The participants are actually key informants composed of all major stakeholders (producers, users, financiers). The assessment process is done by groups followed by a plenary to present the groups’ assessment results. These are further followed by consensus building in both group and plenary sessions and, finally, feedback. The Assessment Tools An electronic questionnaire in Excel which carries a switchboard and automatic computation of scores once filled up. Questions are perception-type questions but are expected to be answered by key informants so the respondent’s “perception” is based on proper information at his level. The questionnaire has a total of 244 items. Each item is scored:

– Highly adequate 3 – Adequate 2 – Present but not adequate 1 – Not adequate at all 0

The total score for each category is compared to a maximum score to yield a percentage rate. The scores are then given adjectival ratings based on quintiles of scores:

– Lowest quintile (<20th percentile) >>Not functional – Second quintile >>> Not adequate at all – Third quintile >>> Present but not adequate – Forth quintile >>> Adequate – Fifth quintiles >>> Highly adequate

HMN conducted a training of trainers on November 14 – 16, 2006 with participants coming from the member agencies of the PHIN including the academe. The HMN questionnaire was pretested on February 9, 2007 in Ba-y, Laguna and was customized to the Philippine context. The changes that were made to Philippinize the questionnaire were mainly the use of existing administrative levels in the Philippines (from national, regional, provincial, municipal/city, down to barangay level) and to reflect devolution of health services in the Philippines(i.e., the health facilities in the provincial, municipal/city and barangay levels are under the respective local government units and not under the national office of the DOH).

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The group builder which identifies which groups are to answer what questions was utilized. The following participated in the assessment:

Table 7. Participants in the Philippine Assessment using the HMN Procedure Group Area of Interest G1 Census, Demography, University/ Research entities G2 Senior DOH Planners G3 Project and Programme Managers G4 Subnational (Regional, Provincial, City, Municipal)

G5 Aid donors G6 Financial, Monitoring and Evaluation

G7 Administrative Statistics G8 PHIN Steering Committee*

*done on February 15, 2007 at DOH

The group organisation followed the following guidelines: • Persons competent to give answers to specific questions are grouped together, so

each group responds only to a part of the questionnaire. • Tasks of the group facilitator:

– To respond to doubts and clarify meanings, – To promote the discussion among the participants, – To enter the scores of each participant, – To write down the comments raised by participants

• Each participant should receive his/her own identification number in the filled up assessment tool for an ordered scoring.

• Participants are encouraged to discuss every question, but they should score only the matter that they really know and/or have direct experience. Facilitators should supervise this aspect.

• At the end of each Question Sections the facilitator presents the results to the group and allows supplementary comments and alterations of the score, if necessary.

• Keep an objective attitude all along the exercise: feel relaxed toward their own situation and express freely what you feel about the HIS. No generosity neither negativism during the appraisal.

Assessment of the Field Health Service Information System and the Civil Registration System in the Subnational Levels

To augment the results from the HMN assessment, the PHIN did focus group discussions with FHSIS regional coordinators and conducted a survey of selected regions, provinces and municipalities nationwide to focus on the two important sources of administrative or reporting statistics – the FHSIS of the DOH and Civil Registration System (CRS) of the NSO. It must be reiterated that the generation of these statistics are devolved to the local government units and are not under DOH and NSO. The national and regional agencies, however, provide technical, capacity building, and other logistical support for the local government units.

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The FGDs with the regional FHSIS coordinators under the CHDs in the different regions was conducted on May 18, 2007 at Ba-y, Laguna. Two FGDs were done simultaneously:

• FGD with FHSIS coordinators of NCR, Caraga, ARMM, and Regions 3, 8, 10, 11, 12; and,

• FGD with FHSIS coordinators of CAR, MIMAROPA, CALABARZON and Regions 1, 5, 6, 7, and 9.

Only one region, Region 2, was not represented in the FGDs. For additional assessment in the provincial and municipal/city levels, a survey of key informants was conducted where areas covered by the assessment were selected to represent regions and provinces exhibiting best, average, and poor performance in the generation of FHSIS and Vital Statistics. The following were selected using this procedure:

• Region 1 – Ilocos Norte – Ilocos Sur

• Region 8 – Western Samar

• Region 9 – Zamboanga del Norte (Zambo City) – Zamboanga del Sur (Isabela)

• Region 11 – Davao Sur – Compostela Valley

• Region 12 – South Cotabato(Cotabato City) – S. Kudarat(Gen Santos City)

• MIMAROPA – Marinduque – Palawan

• NCR – Manila , Marikina

• ARMM – Maguindanao – Lanao del Sur

• CAR – Baguio City – Ifugao

The assessment was supported by the HMN. The survey for Region 8 was done in collaboration with GTZ. The respondents of the survey were the following:

• Provincial Statistics Officers(PSOs) • Provincial Health Officers(PHOs) • Regional and provincial FHSIS coordinators • City and Municipal Health Officers(CHOs, MHOs) • City and Municipal Civil Registrars(CCRs, MCRs)

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• City and Municipal Planning Development Officers(CPDOs,MPDOs) • Provincial Planning Development Officers (PPDOs) • Public Health Nurses(PHNs)/Rural Health Midwives(RHMs).

Two survey instruments were constructed – one for the data producers and one for the data users. Annex 3 provides the instruments used in the field operations. These instruments are the revised versions after pretesting. It is noted that the questionnaires include items that follow the components of the HMN framework. A total of 559 respondents were interviewed for Questionnaire 1, the questionnaire for data producers while a total of 86 respondents were interviewed for Questionnaire 2, the questionnaire for data users. The questionnaire items were those under the different areas of assessment of the HMN. Thus, the framework of the assessment followed that of the HMN’s. The following tables show the number of respondents for the two kinds of respondents:

Table 8. Data Producers of Field Health Service Information System and Civil Registration System that participated in the

Assessment in the Subnational Level Type of Respondent Total Percent Provincial Health Officer 15 2.7Provincial Statistics Officer 18 3.2Municipal Health Officer /City Health Officer 125 22.4

Local Civil Registrar 71 12.7Public Health Nurse 131 23.4Rural Health Midwife 142 25.4Provincial FHSIS Coordinator 20 3.6Provincial NSO Staff designated for Civil Registration 17 3.0

Others 20 3.6Total 559 100.0

Table 9. Data Users of Field Health Service Information System

and Civil Registration System that participated in the Assessment in the Subnational Level

Type of Respondent Total PercentCity/Municipal Planning Development Officer 66 76.7 Provincial Planning Development Officer 20 23.3 Total 86 100.0

7 Results of the Health Metrics Network Assessment The assessment was done with three members of the PHIN steering committee (Group 8 of the working groups) on February 15, 2007 and on February 21- 23, 2007 with 48 participants from the national and subnational levels comprising the different working groups: Census, Demography, University/ Research entities (G1), Senior DOH Planners

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(G2), Project and Programme Managers (G3), Subnational -Regional, Provincial, City, Municipal (G4), Aid donors (G5), Financial, Monitoring and Evaluation (G6), Administrative Statistics (G7). Annex 4 is the HMN assessment tool with the results. The following is a discussion of these results. a. HIS Resources HIS Resources was rated overall as present but not adequate with a score of 48%, which rates as “present but not adequate”. For this component, Policy and Planning is considered not adequate; HIS institutions, human resources and financing is present but not adequate; and HIS Infrastructure is adequate.

Table 10. Summary of Results of the Assessment of Health Information System Resources

Summary Result

Policy and Planning 35%

Not adequate

HIS institutions, human resources and financing

46%

Present but not adequate

HIS Infrastructure 71%

Adequate

Overall 48%

Present but not adequate The following issues came out of the discussions under HIS resources: On information policies:

There are comprehensive laws and executive orders governing the generation of vital statistics. Though not as comprehensive as those for vital statistics, laws and executive orders on generation of health statistics have also been administered. Annex 5 provides a listing of these laws. There is no law, however, focusing specifically on a health information system. Instead, Executive Order No. 121 created a decentralized PSS already presented in Chapter 3 of this report. The different agencies producing health and nutrition statistics are part of the PSS. The NSCB is the highest policy and coordination body on statistical matters in the country. It designates important statistics as official and identifies the agency that produces the statistics. However, there are statistics produced by other agencies that are beyond the designated statistics. These statistics include those that are generated by the DOH usually from projects with foreign funding. The problem is that these statistics are inconsistent with the ones being officially released. On the subnational assessment of the FHSIS and the CRS, majority of the data producers said that they are aware of national laws, executive and administrative orders, legislation on FHSIS/CRS with respondents for CRS posting higher percentages(90%+)

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than those for FHSIS (percentages less than 80%). The percentages are much lower when data producers are asked about awareness of local laws and ordinances. The high percentages are from those doing CRS. This indicates that most provincial and municipal level ordinances are made more for CRS concerns and not for FHSIS or health information. On the other hand, only fifty percent (33) of the 66 municipal and city development officers are aware of national laws, executive and administrative orders, legislation on FHSIS/CRS. The positive result is that the percentages are much higher when these respondents are asked of local laws and ordinances: sixty three percent (41 out of 66). Provincial development officers seem to be the least aware of legal bases for HIS. Out of the twenty provincial development officers, only 40 percent (8) are aware of national laws, executive/administrative orders, legislation on FHSIS/CRS. Legislations cited are on blood letting vital registration, family code, and HIV/Malaria. For awareness on local ordinances, the percentages are much lower: only 21 percent (4) of the 20 provincial development officers interviewed gave a positive answer.

On Coordination and Leadership

On 9 September 2005, the PHIN was formally launched to strengthen collaboration among stakeholders, expand the network to include those in the private sector and the academe, to work at integrating and harmonizing the Philippine HIS. Its founding members are: DOH, NSO, NSCB, and PCHRD. This collaborative effort has been continuously expanded to include other government agencies as well as donor organizations, academe, private sector, and other constituencies involved in health information. The steering committee of this network has not been meeting regularly, though, but its secretariat has been working since 2006 on the assessment and construction of a strategic plan for an integrated and harmonized PHIS. It must also be noted that a committee to review the Philippine Statistical System was created in July 2007 to evaluate and make a strategic plan to address the concerns of the different stakeholders of the system, both data producers and data users. The committee’s evaluation and recommendations are due in January 2008. It has already conducted consultations with DOH and its concerns regarding data generation and data use within the statistical system as a whole and DOH in particular.

On the subnational level, local health boards in the provincial and municipal//city levels are supposed to serve as recommending bodies for their respective local chief executives on health concerns including health inforation systems. They also serve as the recommending body for the creation of ILHZ. However, less than half of the provinces have functional local health boards and more than half for the cities and municipalities. Given their critical contribution to the decision making process, there is a need for the local health boards to be more responsive towards the development of the local health systems through the ILHZs.While a Local Health Assistance Division (LHAD) has been created at the CHD, the unit is currently ad hoc in nature. They are yet to be integrated as part of the organic structure of the regional health office. This would synchronize functions and staff complement between the DOH and its regional offices, and ensure appropriate resource allocation with the end in view of enhancing the CHD's capacity to provide technical assistance to LGUs. It must be noted that use of information technology in decision making has yet to be optimized at the local level. While the PLHIS has contributed to the performance of some LGUs within the

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convergence sites, the utilization of the system remains to be weak in most local health zones as well as local government units. Also, (NOH, 2005-2010). Results of the assessment of FHSIS and CRS, on the other hand, reveal that majority of all data producers said that there a committee/group/venue that addresses FHSIS/ CRS at the subnational ( provincial/city/municipal/barangay) level. These are local health boards as well as meetings where FHSIS/CRS generation and submissions are discussed. On the other hand, there seems to be no such activities for PHIS concerns, in general. This is more evident from those doing CRS than from those generating data for FHSIS. Majority of the planning officers also said that there is a committee/group/venue that meets regularly and addresses FHSIS/CRS in the subnational (provincial/municipal/barangay) level.The commonly cited committees are local/provincial health boards, committee on health, nutrition council, and local/provincial development council. In addition, most of the His concerns are discussed by the committees.

On Financial Resources

There is no written HIS strategic plan specifically on an integrated HIS. Thus, there is no allocation of resources specifically for such a system. Furthermore, although each data-generating agency under the DOH and the PSS does its own monitoring and evaluation of its processes in generating, processing and disseminating data, there is no regular system in place for monitoring the performance of the PHIS as a whole. It must be noted, though, that the NSO has demonstrated best practices in its generation of vital statistics. This may be because laws mandating it have been properly established. Furthermore, it must also be pointed out that the PSS in the PSDP and the DOH as stated in the NOH have recognized the need to have an integrated HIS. This was already pointed out in the previous sections of this report. Local planning officers indicated that there is some budget allocated for FHSIS although, this is usually integrated in the line functions of the LGUs. It is noted that there is more budget allocation for FHSIS in the provincial level than the municipality level. On the other hand, there is a bigger percentage of the budget allocated for CRS compared to FHSIS in the municipality than the provincial level.

On Human Resources

There is national capacity in core health information sciences to meet health information needs (epidemiology, demography, statistics, health planning). For vital registration, personnel , capacity building for them, equipments and supplies for their use are suffiecient. However, this is not so for the generation of health and nutrition statistics, especially at the subnational levels. The participants of the HMN workshops noted that less than 50% of health offices in regions and provinces have a designated full-time health information officer position. HIS capacity building activities have occurred over the past year for HIS staff but these are largely dependent on external (e.g. donor) support and input. HIS capacity building activities have occurred over the past years for health facility staff but these are also very limited. Fast turnover of staff involved in generation, processing and turnover of data is also a concern and any capacity building cannot keep up with such turnovers. Availability of IT and database support to health and HIS staff at the national level seem to be adequate but this is not

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so for the subnationals levels. They are limited and do not meet the needs of staff. In fact in the municipalities and the barangays telephone access is still a problem and internet connection is non-existent. As regards guidelines for the processes of HIS data collection, management and analysis, these exist and are used but no proper orientation seem to be done for new staff. Majority of data producers interviewed in the subnational assessment of the FHSIS and the CRS said that they have an operations manual with those doing CRS posting very high percentages (93% and up) compared with those in FHSIS (80% and up). When asked about formal trainings, orientation, and updates for them, higher percentages of respondents for CRS answered positively at all levels (provincial and municipal). For respondents for FHSIS, high percentages of nurses (82%), midwives(90%), and provincial FHSIS coordinators (79%) answered positively while lower percentages of provincial health officers (47%) and municipal or city health officers (48%) did so.

It is noted that majority of those in FHSIS who did not undergo formal training or orientation said that they learned their skills either through self-study or while doing their job.

On Infrastructure and Communications

One of the problems often cited by data producers for FHSIS is the lack of supply of forms. Such a problem is cited by 57% of nurses and 58% of midwives. Different problems occur at different levels. First level data generators- nurses and midwives-have problems with supply of forms and duplications of entries for different forms. On the other hand, the next levels ( provincial and regional) see the problems of timeliness, completeness and quality of data. Computers, printers, calculators, mimeographing machines are available at all levels. More telephones and fax machines seem to be needed at the municipal level. Internet access is generally available at provincial level only. Majority of provincial health officers only have LCD projectors.

Software for data entry is available at all levels for both FHSIS and CRS. However, only CRS has software for data processing, tabulation and reporting. Manual filling up of forms is still generally done for FHSIS. Any use of electronic processing is dependent on advocacies of the CHDs and local chief executives. It is noted that data entry software for FHSIS is usually Excel. Data generators for FHSIS seldom do more in-depth analysis of the data and are not usually aware of simple tools for summarizing data in Excel such as graphs and desciptive statistics. All said yes to provision of a software. Majority of the development planning officers said that there were capacity-building activities provided to personnel for HIS in 2006. The activities cited are scholarships for formal education, study tours, and trainings and seminars. In cases when capacity-building activities were not provided, the reasons usually cited are;

a. No funding/budget b. Not a priority c. This is the concern of the RHU and not the LGU.

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Table 11. Problems on HIS Resources Identified by Regional FHSIS Regional Coordinators With the Existing FHSIS at Different Administrative Levels

Barangay Municipal/City Province Regional

Type of Problems Encountered

Number of FHSIS Coordinators Who Identified the Problem Percentage




Inadequate training of health workers on how to fill out forms 12 100.0 11 91.7 5 41.7 0 0.0 Lack of technical expertise of staff to properly analyze the data collected 8 66.7 9 75.0 9 75.0 4 33.3

b. Indicators

Of the six components of HIS for assessment, Indicators got highest score – 82% . The participants agreed with this since the assessment items were on the existence of core indicators which were identified by consulting different stakeholders and using clear explicit criteria including usefulness, scientific soundness, reliability, representativeness, feasibility, accessibility. The list of indicators is presented in Annexes 1 and 2. Furthermore, the Philippines has a clear and explicit official strategy for measuring each of the country relevant health-related MDG-indicators. Annex 6 lists the Philippines’ MDGs with metadata information.

Table 12. Summary of the Result of the Assessment of Indicators

Summary Result

Indicators 82%

Highly adequate

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Figure 5

c. Data Sources

Data Sources was rated as present but not adequate with a score of 58%.For this component, data from the NSO(census, population-based surveys, vital statistics which are from the NDHS) received high scores, a result the participants validated since there is the Philippine Statistical System coordinated by the NSCB follows international standards for methodologies used. Facilities-based information, however, have a number of non-functional and inadequate ratings. These are shown by the table and graph below:

Table 13. Summary of Results of the Assessment of Data Sources

Data Source Contents Capacity & Practices Dissemination Integration

and use Total

Census Present but not adequate

Adequate Present but not adequate

Highly adequate Adequate

Vital statistics Adequate Adequate Adequate Adequate Adequate

Population-based surveys

Highly adequate

Highly adequate Highly adequate Adequate Highly

adequate

Health and disease records (incl. disease surveillance sys.)


Not functional Present but not adequate

Not adequate

Health service records





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Data Source Contents Capacity & Practices Dissemination Integration

and use Total

Administrative records

Not adequate


Not adequate Not adequate Not adequate

On the census, the Philippines has adequate capacity to (1) implement data collection, (2) process the data and (3) analyze the data. A census was carried out in 2000 and in 2006 and results have been published or are likely to be published in the next five years. Questions on recent household death or questions for indirect estimating either child mortality or adult mortality are present but not adequate. Census sample re-interview undertaken for the 2000 census but no report was made available for public use. On dissemination, all provinces have immediate access to 2000 census results including descriptive statistics (age, sex, residence by smallest administrative level). These are available and widely distributed online and with paper copy. Lag between the time that descriptive statistics (age, sex, residence by enumeration area) were last published and the time that the data were collected is from 2 to 3 years. Accurate population projections by age and sex are available for provinces/regions but not for lower levels (municipal and barangay). Microdata are available on request and with restrictions. Census projections are used for determining of coverage and for planning of health services but only for provinces/regions and not for lower levels. On vital statistics, the civil registration system has completeness of 50% to 89%. The coverage of vital registration of deaths is from 70% to 89%. Cause of death information is always recorded on the death registration form as required by law. The country has adequate capacity to (1) implement data collection, (2) process the data and (3) analyze the data from vital registration since the NSO has a nationwide network of civil registrars that it constantly meets for trainings, updates, and consultations. Frequency of the assessment of completeness of vital registration is evetry five years. International Statistical Classification of Diseases and Related Health Problems (ICD) that is currently in use is the ICD10. Proportion of all deaths coded to ill defined causes (garbage codes) is 5-10%. Published statistics from vital statistics (VR) are disaggregated by (1) sex, (2) age, and (3) geographic region (or urban / rural). To aid in effective decision policies, an overall burden of disease study was undertaken. Population-based surveys rated vey high in terms of capacity and practices, dissemination, an integration and use. This is a reflection of a well-developed statistical system in the Philippines in the national and regional levels. It must be noted, though, that subnational levels still need to be developed under the different local units. On health disease records including surveillance systems which were rated as not adequate, for all key epidemic prone diseases and diseases targeted for eradication / elimination (see text) appropriate case definitions have been established and cases can be reported on the current reporting format. Also, for major infectious and some non-communicable conditions of public health importance a measurement/assessment strategy exists and is reflected in appropriate plans, tools, supporting structures, and assignments of responsibility. Mapping, however, is available only for a few public health risks or resources. Adequate capacity is present only for diagnosis and recording cases of notifiable diseases but reporting and transmiting timely and complete data on these diseases are not yet achieved fully. Low percentages are recorded for the following indicators of capacity

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and practices- percentage of health workers making primary diagnoses who can correctly cite the case definitions of the majority of notifiable diseases, percentage of health facilities submitting weekly or monthly surveillance reports on time in the subnational levels, and 4 percentage of municipalities, cities, provinces submitting weekly or monthly surveillance reports on time to the next higher level. It is noted tjoigh that 90 % of investigated outbreaks are with laboratory results. Essential patient information is often not recorded and/or records cannot be retrieved for most patients. Although there are a number of reporting forms, there is good coordination and efforts to integrate the reporting requirements of public health programs. Surveillance data are produced regularly and available at the national level .At least 75% of epidemics noted at regional or national levels are first detected at the provincial level. On health service records, there is a health services based information system that brings together data only from public health facilities . There is information on quality of services but only from a convenience sample of health facilities. The health information system has a cadre of trained health information specialists who have at least two years of training only in about 1% to 9% of provinces. Most health workers received training in the last 5 years in health information, which is either integrated into continuing education or through special workshops. Mechanisms are in place at national and regional levels for supervision and feedback on information practices as well as verification of completeness and consistency of data from facilities. However, these are not yet adequate. Population projections based upon census statistics are used to calculate coverage rates (e.g. for immunization) at the provincial level in at least 90% of provinces. Dissemination is rated as present but not adequate because of the following: the last time that an annual summary of health service statistics was published with statistics disaggregated by major administrative region\ was from 4 to 5 years ago; compilation of monthly and annual summary reports by health facility is available but not adequate since these are only for public health facilities ; managers and analysts at national and regional levels use findings from surveys, vital registration to assess the validity of clinic-based data but these are not adequate; data derived from health service records are only occasionally used to estimate coverage with key health services. It must be noted, though, that vertical reporting systems such as those for tuberculosis and vaccination communicate well with the general health service reporting system. Administrative records on health facilities, human resources for health, financing of health sertvices, database on equipments, supplies and commodities are not considered adequate at all:

• These include the roster of health facilities which does not include adequate list of private health facilities and which does not have a unique identifier code for each health facility that permits data on facilities to be merged. The maps of provinces showing the location of health infrastructure, health staff and key health services are not adequate. Managers and analysts at national and provincial levels are not always able to evaluate physical access to services by linking information about the location of health facilities and health services to the distribution of the population.

• The national HR database tracks numbers by professional category but only those working in the public sector. Numbers graduating from certain health training institutions (e.g. nursing; private institutions) are not tracked. There are human resources for maintaining and updating the national HR database but they are not adequate. The national HR database statistics on the number of public sector health professionals was last updated six years ago or more.

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• Financial records are available on general government expenditures on health, private expenditures on health (and their components) and external expenditure on health. Estimates of routine NHA are computed every year with at most 2 year lag. NHA routinely provides information on the following 4 classifications - sources, agents, providers, functions. However, government budget/expenditure plus at least one more source such as donors are available but only at national level. Adequate numbers of qualified, long-term staff are regularly devoted to work on NHA but are in need of external technical support. Estimates are available of expenditure on some areas of policy concern but they exclude some important sources of finance (e.g. out-of-pocket) NHA findings are available within the agency but have not been widely disseminated. Policy makers and other stakeholders are aware of the NHA findings but there is no evidence that these findings have shaped policy and planning.

• Each facility is required to report at least annually on any one of the following: inventory/ status of equipment/physical infrastructure. Each facility is required to report at least once a year on its stock of health commodities (drugs, vaccines, contraceptives, other supplies). There are sufficient numbers of adequately skilled human resources for managing the logistics of equipment, supplies and commodities. However, reports are incomplete and reporting systems for different commodities are not integrated. Managers at national and regional levels rarely attempt to reconcile data on consumption of commodities with data on cases of disease reported.

d.Data Management

Of the six components of HIS for assessment, Data Management got lowest score – 17% - considered not functional. The participants agree with this since there is still no integrated data warehouse with written procedures for data management and metadata data dictionary. Furthermore, there are no identifier codes for health facilities. Available data are for public health facilities. There is no comprehensive database for private health facilities. It must be noted that the Philippine Health System is one wherein the DOH is the agency tasked for health on the national level and local governments on their respective levels.It must be noted that policy planning is from national to local level while data generation is from local level to national.

Table 14. Summary of the Result of the Assessment of Data Management

Summary Result

Data management 17%

Not functional There is no written set of procedures for data management including data collection, storage, cleaning, quality control, analysis, and presentation for target audiences, and these are implemented throughout the country. Actually, there is no integrated “data warehouse” containing data from all data sources (both population-based and facility-based sources including all key health programmes) yet. This is true for both national and subnational levels . "Metadata dictionaries'' for health and nutrition statistics exist in the government agencies that generate them but usually incomplete sets of definitions and specifications. It must be noted, though, that for the MDGs indicators, complete metadata whish are

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disseminated well are maintained by the NSCB. Identifier codes are not available for health facilities and administrative geographic units (e.g. province, district, municipality, etc.) to facilitate merging of multiple databases from different sources e. Information Products

The component Information Products was rated as adequate with a score of 69%.Participants validated this result since the NDHS is the official source of mortality and morbidity. The DOH also estimates such indicators from its FSHIS, but the participants from DOH said that these estimates are designed for internal use only recognizing the limitations and weaknesses of FHSIS. Risk factors indicators asked in the assessment are generated by the DOH. In addition to NDHS, the assessment items asked about other surveys, e.g., on malaria. These are done by DOH; thus, the adequate assessment. It must be noted, though, that administrative records are the sources of inadequacy. This result seems to be inconsistent with the assessments already done wherein timeliness, completeness, and consistency were recognized as still not achieved. The source of this result was traced by the participants to the questions in the HMN questionnaire. They are noted not to be sensitive to situations in the Philippines.

Table 15. Summary of Results of the Assessment of Information Products

Marking Indicators Health status

Elements for assessing selected

indicators Mortality Morbidity Overall

Health system

indicators

Risk factors

indicators

Overall health

indicators quality

Data collection method

present but not

adequate adequate adequate adequate adequate adequate

Timeliness present but not

adequate adequate adequate

present but not


Periodicity adequate adequate adequate adequate present but

not adequate

adequate

Consistency / completeness adequate adequate adequate

present but not


Representativeness / appropriateness adequate highly

adequate adequate adequate adequate adequate

Disaggregation highly adequate

highly adequate

highly adequate adequate adequate adequate

Estimation method / transparency

highly adequate highly

adequate adequate adequate Overall assessment

of results adequate adequate adequate adequate adequate adequate

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Figure 6 Assessment of Information Products

Majority of the data producers said that they had experienced delays in submissions to the next level. The following are the percentages who said so:

a. 80% of provincial health officers b. 65% of provincial statistical officers

c. 58% of municipal and city health officers

d. 62% of nurses

e. 94% of provincial FHSIS coordinators

f. 77% of provincial NSO staff designated of CRS

Only 37% of city/municipal civil registrars and 40% of rural health midwives said they had delays.

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Table 16. Problems on Information Products Identified by Regional FHSIS Regional Coordinators With the Existing FHSIS at Different Administrative Levels







Duplication of forms 4 33.3 4 33.3 3 25.0 3 25.0 Too many record books/forms being filled out at this level 10 83.3 5 41.7 2 16.7 1 8.3 Reports not submitted on time 10 83.3 11 91.7 12 100.0 7 58.3 High degree of inaccuracies in data collected 8 66.7 7 58.3 4 33.3 0 0.0

Majority of the problems cited by data generators for FHSIS in the provincial and municipal levels are concerned with data management:

a. There are difficulties in collecting data for this form from all geographic or service areas covered (64% of provincial health officers)

b. Completed form not submitted on time(64% of provincial health officers 75% of FHSIS provincial coordinators)

c. Lack of constant supply of this form Entries in this form duplicate those of other forms (50% of provincial health officers

d. High degree of inaccuracies in data collected (50% of FHSIS provincial coordinators)

e. Not all items in the form are filled out or completed( 70% of FHSIS provincial coordinators)

Majority of the development planning officers encountered difficulties/problems in the different FHSIS programs. Usual problems are on:

a. Timeliness b. Coverage c. Data quality.

The most common difficulty/problem encountered among the different types of FHSIS programs are insufficient funds, late/lacking reports, narrative reports are difficult to understand, data has no analysis and interpretation, target population used by municipal health is different from the municipality, health targets are overestimated, lack medicines, lack support, and lack midwives.The most common problems/difficulties encountered with vital statistics are lack of personnel, low registration on birth/death especially for far flung areas, no data maintenance, some deaths are not registered, and delay in reporting.

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The following ratings were given by the FHSIS regional coordinators when asked to rate the performance of FHSIS data.

Frequency Performance Indicator 1 2 3 4 5

Mean rating

Timeliness 0 1 10 1 0 3.0 Completeness 0 0 5 4 3 3.8 Accuracy 0 1 7 4 0 3.3 Adequacy 0 2 5 4 1 3.3

Note:1 is the lowest rating and 5 is the highest rating The FHSIS regional coordinators highlighted the following problems when asked to evaluate the system:

• Accuracy of the data is a problem. Those who fill up the FHSIS forms, especially the midwives, do not seem to have the proper understanding of how to fill up the forms;

• Late submission of reports is a problem in all levels;

• Incomplete data being submitted are also noted ; and,

• Some reports are also not standard for all geographic areas; e.g., age brackets vary from province to province.

It is observed that ratings that resulted in the survey for the assessment of FHSIS are higher than one expected after hearing the comments on problems with FHSIS. This is consistent with the results of the HMN assessment of the performance of indicators. The ratings seem to be inconsistent with the comments that the key informants give in focus group discussions and in the other responses when probed on their experience with the data systems they generate and use. It is hypothesized that there is a tendency for key informants to be more neutral and provide a more optimistic attitude when asked to make ratings.

f. Dissemination and Use

Dissemination and Use was rated as present but not adequate. The following table provides the specific items:

Table 17. Summary of Results of the Assessment of Dissemination and Use Summary Result

Analysis and Use of Information 50% Present but not adequate

Policy and Advocacy 56% Present but not adequate

Planning and Priority Setting 72% Adequate

Resource allocation 54% Present but not adequate

Implementation/action 75% Adequate

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Summary Result

Overall 59% Present but not adequate

The data on health are used by policy makers and planners. However, there is a need to do more analyses on existing data. Thus, “analysis and use of information” received a rating of “present but not adequate”.

For planning and prority setting the data available are more general; and, thus, what are available are usually adequate. On the other hand, for policy formulation, more specific information and more in-depth analyses are needed.

As to uses, provincial health officers, provincial NSO staff designated for CRS, and provincial statistical officers use the data more for planning and prioritizing. Health officers, nurses, midwives, and local civil registrars state that aside from planning and prioritizing, they use the data for reports and bases for compliance. Provincial FHSIS coordinators also use the data for planning and prioritizing, for reports and bases for compliance, as well as detection of epidemics and resource allocation. A large percentage of them (89.2% of municipal and city officers and 94.7% of provincial officers) used/requested the data and/or reports from FHSIS in the municipality/province. Majority said that the data/reports from FHSIS are readily available. Also, a large percentage of the municipal and city planning offficers (81.8%) requested data/reports from CRS in their municipality. On the other hand, only 55.6% of the provincial planning officers used/requested data/reports from CRS. The most common uses of both FHSIS and CRS for local development officers are for planning and prioritization of activities; for reports; as bases for accomplishments; for resource allocation and budget estimation; for monitoring and evaluation; for program/project development; and, for research. Other uses of CRS data/reports in 2006 were:

a. Profiling of the province b. Monitoring growth and death rate c. Population projection

Majority of them said that the data are sufficient for their purposes. However, those who indicated otherwise gave the following reasons why they considered the FHSIS data/reports are not sufficient :

a. No data analysis b. Not all indicators relevant to the municipality are in the FHSIS (morbidity,

mortality, nutrition, poverty threshold, population) c. Lacks data disaggregation by barangay, purok, sex d. Inconsistent forms (e.g. age grouping do not coincide)

Those who did not request for FHSIS data/reports said that they were either unaware of the FHSIS, that there is no funding for FHSIS data/reports, and that the local chief executive’s priority is infrastructure and not health and nutrition.

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Those who requested data/reports from CRS stated that they are always available (municipal and city planning offficers - 98.2%, provincial planning officers – 100.0%). Majority, 90.7%, of the municipal and city development officers and 70.0% of the provincial development officers, said that the CRS data/reports were sufficient for their purposes. Those who did not request for CRS data said that this was because they did not need the data or that they are not familiar with data from the CRS.

Table 18. Problems on Dissemination and Use Identified by Regional FHSIS Regional Coordinators

With the Existing FHSIS at Different Administrative Levels







Lack of utilization of data being collected 8 66.7 7 58.3 7 58.3 4 33.3 Low level/no dissemination of and feedback about data collected 4 33.3 9 75.0 8 66.7 4 33.3

FHSIS regional coordinators are optimistic about future use and dissemination of FHSIS because of the “horizontal flow” of information dissemination. This means that reports shall not only be submitted to the next administrative level (from barangay to municipality , from municipality to province, from province to region, from region to DOH central office) but also to the stakeholders within the geographic area (e.g., barangay level data to be disseminated in the barangay level, municipal level data to be disseminated to municipal health boards and the local chief executive).

g. Summary

In summary, the assessment using HMN tools, indicated warning signals on data management, inadequacy of HIS resources, data from health administrative records, dissemination and use. Information products and indicators are rated adequate. The latter needs closer inspection though since this result seems inconsistent with other previous assessments. Component with Highest Score

• Of the six components of HIS for assessment, Indicators got the highest score – 82% .

• The participants agree with this since the assessment items are on the existence of core indicators which were identified by consulting different stakeholders and using clear explicit criteria including usefulness, scientific soundness, reliability, representativeness, feasibility, accessibility.

• Furthermore, the Philippines adopts a clear and explicit official strategy for measuring each of the country relevant health-related MDG-indicators.

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Component with Lowest Score

• Of the six components of HIS for assessment, Data Management got the lowest

score – 17% - considered not functional. • The participants are in agreement with this since there is still no integrated data

warehouse with written procedures for data management and metadata data dictionary. Furthermore, there are no identifier codes for health facilities. Available data are for public health facilities. There is no comprehensive database for private health facilities.

• The Philippine Health System has the DOH as the agency tasked for health at the national level while the LGUs are the ones responsible for health at the local level.

• Policy planning follows the top-down approach while data generation is undertaken from the local level to the national level.

Component Rated as Adequate

• Information Products – 69% – Participants validated this result since the NDHS is the official source of

mortality and morbidity. The DOH also estimates such indicators from its FSHIS, but based on feedback from the participants from DOH, these estimates were designed for internal use only recognizing the limitations and weaknesses of FSHIS

– Risk factors indicators asked in the assessment are generated by the DOH – In addition to NDHS, the assessment items asked about other surveys, e.g.,

on malaria. These are done by DOH and got adequate scores. It must be noted, though, that administrative records are the sources of inadequacy.

Components Rated as Present but Not Adequate

• Dissemination and Use – 59% – For this component, planning and priority setting as well as

implementation/action got high scores but Analysis and Use of Information, Policy and Advocacy, Resource allocation had low points and, thus, need to be addressed.

• Data Source – 58% – For this component, data from the NSO(census, population-based surveys)

received high scores, a result that the participants validated since they follow international standards for concepts and methodologies.

– Facilities-based information, however, have a number of non-functional and inadequate ratings.

• Resources – 48%

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– Policy and Planning under this component is considered not adequate; HIS institutions, human resources and financing are present but not adequate; while HIS Infrastructure is adequate.

8 Recommendations The results of the assessment based on the HMN framework serve to bring to a new light the situation of health information in the Philippines. They also confirm what have been perceived as the problems besetting the state of health information in the Philippines. Solutions to the problems of health information have long been identified and planned for, but lack of resources hampers its implementation. This chapter reiterates some of the solutions but emphasizes on the construction of a framework that shall provide based for the rationale of these solutions. The following are recommended: to develop a comprehensive plan and coordinated health information system, to advocate the importance and utilization of health information to health workers and local officials, to capacitate the health workers on health information, to revisit and re-engineer the FHSIS, to involve the local governments as partners in the FHSIS detailed assessment and planning activities, and to network the health information agencies for more concerted and consolidated actions to strengthen health information. In all these recommendations, the Department of Health, the National Statistics Office, and the National Statistical Coordination Board have direct influence albeit a bit less on compelling local governments to submit health data. Addressing these identified concerns should be the priority of the Philippine Health (and Nutrition) Information Network. The following provide more detailed discussion of the recommendations.

1. Develop a comprehensive and coordinated health and nutrition information

system. There are a number of key players in the country’s health information scene. Currently, each bureau, agency, and program within DOH develops and implements its own plan with minimal coordination and no integration with other statistics-producing units and organizations. They are working vertically which results in overlapping and duplication that increases the burden on the field health workers. Although there are existing statistical coordination mechanisms in place to resolve issues on duplication of statistical activities such as the Inter-agency Committee on Health and Nutrition Statistics, and the formulation of the PSDP being coordinated by the NSCB and participated in by the DOH and other health stakeholders , there are still vast areas for improvement. A common framework would align and harmonize the efforts of all concerned agencies within and outside the DOH and ensure that quality health information is efficiently produced. The suggested conceptual framework is characterized by a decentralized network of non-duplicating, synchronized, and harmonized health information subsystems maintained and managed by different agencies following the same set of quality standards.The framework identifies the data sources of health information categorized as presented in Figure 2. The framework identifies the data sources of health information categorized as: health and vital statistics, health service information delivery, health system information.The system is expected to provide all the indicators for the evaluation of the performance of the

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health system. It is also noted that the framework should emphasize knowledge sharing; health research; documentation and use of best practices and lessons learned; and, provides for intranet and extranet portals. The framework is a combination of Figures 2 and 3 where Figure 3 reperesnts the decentralized system and Figure 2 provides the details of the different subsystems. Ultimately, the DOH, the major stakeholder and in collaboration with other stakeholders, shall maintain a central data warehouse that will sustain an executive support system and a decision support system. The next activity of the PHIN is to construct a comprehensive plan for the envisioned health information system and to advocate for the provision of a budget for actualizing such a plan. The plan shall be constructed so that it is aligned with the NOH’s health sector strategic plan and the PSDP’s health and nutrition component. The following specific items should be reflected in the said plan:

HIS Resources

o Proposed NSCB Resolution designating clearly what health and nutrition data/indicators to produce, what agency will produce the data to ensure non-duplication, frequency and level of disaggregation, how harmonization should be achieved within a devolved health system

o Budget allocation at different levels of disaggregation

o Human resources(continuing capacity building, deal with turnovers)

o Other resources(communication facilities including internet connection, hardware and software to automate)

Indicators

o Core indicators are clearly identified and prioritized should have clear single data source

o Compliance to standard concepts and definitions, classifications, and coding systems as well as to sound statistical methodology

Data Sources and Data Management

o linked data from the different data sources ( health to be linked with socioeco databases) are easily linked (unique identifiers exist at different levels of disaggregation, variable names and definitions are standardised )

o existence of a central data warehouse of all data or a website linking different databases maintained by a group or agency

Information Products and Dissemination and Use

o regular information products easily accessible to users at different levels of disaggregation

Formatted: Indent: Before: 72 pt, Bulleted + Level: 2 +Aligned at: 54 pt + Tab after: 72 pt + Indent at: 72 pt,Tabs: 90 pt, List tab + Not at 72 pt




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After the plan is constructed and a budget for its actualization is determined, the next concrete step is to develop and submit proposals for its actualization for external funding.

2. Strengthen the Philippine Health Information Network. The PHIN is an inter-agency body composed of agencies that have critical stakes in health information. The existing technical working groups and inter-agency committees should be rationalized and re-structured as part of the PHIN. To ensure that LGU concerns are addressed, participation of the Department of Interior and Local Government shall be actively sought. A critical role of the PHIN would be to define policies on health information, develop comprehensive health information strategic plan, and identify data producer of particular indicators.

3. Advocate for the importance and utilization of Health Information specifically FHSIS in health program management. The field health workers should realize the value of health information. It must be emphasized that health information is more than a service statistics reporting tool. It is the foundation of policy development and health program management and is, thus, is a very critical program management tool. The advocacy should be done specifically for the FHSIS.

Advocacy programs should be done separately for the following different stakeholders: national and regional health workers; provincial and municipal health workers; local health boards and local officials; data producers for health, in general; and, users of health data in the national and subnational levels.

4. Capacitate health care facilities, health workers and local officials on health information. Capacity building involves human resource, infrastructure and systems and processes for health workers that generate health information. A more responsive roll-out program should be developed to ensure that health workers acquire the statistical and IT skills. A user-friendly users’ manual for the generation of health data should also be developed so that health workers would have reference materials.

ICT infrastructure in the Philippines is not very mature. Very limited areas have broadband connections. Municipalities with landlines may access the internet through dial-up connection but most rural health units do not have computers. Such an environment should be corrected by the provision of proper infrastructure.

5. Revisit and re-engineer the FHSIS and other legacy systems. The public health information system of the country is 17 years old. Since the time it was implemented, there have been two major organizational developments occurred: the devolution of health services in 1993 (it was ratified 1991 but implemented 1993) and the reengineering of DOH in 2000. The devolution transferred the service delivery function from the DOH to the local governments. The DOH reengineering on the other hand, integrated, consolidated and flattened the different public health services. The latter limited the functions and roles of DOH staff to policy development and technical assistance. Despite the major changes that have transpired, no corresponding overhaul was done on FHSIS. As a result, there are sections of FHSIS that are no longer relevant while new programs have to be added.

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Automation shall also address the issues identified under Information Products: late and incomplete submission. Currently, the flow of reports is hierarchical. From the lowest primary care level, reports would be submitted to the next higher level then to the next until it reaches the central office in Manila. Because of the progressive nature of the delay, by the time results reach Manila, delays would be in months. We should make use of available technology to improve the health information system. A suggested flow of reporting would be using the internet to submit directly to central office, thereby submission of reports would be in real time. In the absence of internet connection, an alternative would be submissions in diskette or CD. The system would have the capability to be automatically appended.

6. Invest in health information. There is a need to invest in health information. Significant capital investment should be made by the DOH as well as the LGUs. Such investment shall be to develop systems, infrastructure such as ICT equipments and internet connection, human resource development such as statistical and IT trainings and research.

The human resource component would be a major investment since there is need to train health workers (doctors, nurses and midwives) on the new system as well as increase their appreciation and awareness of the value of health information in health system management. Because most health workers are not computer literate, they will need to be trained on basic computer operation.

References Aiken, Linda, Buchan, James, Sochalski, Julie, Nichols, Barbara and Powell, Mary (2004), “Trends in International Nurse Migration”, May/June 2004; 23 (3): 69-77, Bethesda, MD: Project HOPE. Aguilar,Francisco (1976 ).Development of a Health Information System in the Philippines. Bach, Stephen (2003), : Labour and Social Issues,Working Paper No. 209, Geneva: International Labour Office.Health Affairs International Migration of Health Workers. Estimation of Local Poverty in the Philippines(2005),National Statistical Coordination Board. Field Health Service Information System Annual Reports 1996-2002. Department of Health. Galvez-Tan, Jaime, Sanchez, Fernando and Balanon, Virginia (2004),, Manila: UP-NIH.The Philippine Phenomenon ofNursing Medics: Why Filipino Doctors are Becoming Nurses Jayasuriya, Rohan (1994 ).Health Information System in the in the Philippines.

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Marcelo, Alvin et. al.( 2004).Evaluation of the Decentralized Field Health Service Information System in Selected Infectious Disease Surveillance and Control Project Sites. National Health Survey 1987, Department of Health. National Objectives for Health in the Philippines 2005 – 2010, Department of Health. Philippine Statistical Development Plan 2005 – 2010, National Statistical Coordination Board. Philippine Statistical Yearbook (2004), National Statistical Coordination Board. Pons, Melahi and Deylef Schwefel (1993) .HAMIS: Strengthening Information Support for Health Care. Smith, Jack (1998 ).Health Management Information Systems Situational Analysis. Solon, Orville, Panelo, Carlo and Gumafelix, Edwin (2003), A Review of the HSRA Implementation Progress, Quezon City: UP-School of Economics. Southeast Asian Medical Information Center (SEAMIC) (2003),Tokyo: International Medical Foundation of Japan.Recent Trends in Health Statistics inSouth East Asia 1974 to 2000. Sta. Maria, Manuel O. (1993).Field Health Services Information System:Its Role in Decentralizing Health Services in the Philippines. The Philippine Integrated Disease Surveillance and Response (PIDSR), A National Strategy for Emerging Diseases 2008-2010, publication of the Public Health Surveillance and Informatics Division of the National Epidemiology Center, Department of Health. World Health Organization (2000),World Health Report 2000, Geneva:WHO. Health Systems: Improving Performance.

Documents

HMN PHL Assess Final 2007 07 En