Negros PIPH[1]

Oriental Negros Health Investment Plan 2006-2010 1

EXECUTIVE SUMMARY

The Five-Year Investment Plan for Health embodies the four implementation components of the Health Sector Reform Agenda (HSRA): governance, health financing, service delivery and regulation.

The presentation of the Plan is patterned after the format developed and prescribed by the European Commission Team, observing the standard process and cycle which involves situation analysis, gaps and deficiency/problem identification, strategic goals and objective setting, target setting, financing/costing and implementation.

There are six Inter-Local Health Zones (ILHZ) in the province. They are: CVGLJ which includes the five northernmost city and municipalities of Canlaon, Vallehermoso, Guihulngan, La Libertad and Jimalalud. BinaTa ILHZ composes the towns of Bindoy, Ayungon and Tayasan. MaMaBaTaPa ILHZ covers the central town and cities of Manjuyod, Mabinay, Bais, Tanjay and Pamplona. ValeDaLanSaDaCongBulan ILHZ embraces the central towns of Valencia, Dauin, Amlan, San Jose, Dumaguete and Sibulan. SiaZam ILHZ includes the towns of Siaton and Zamboangita. Lastly, StaBayaBas ILHZ is the group of the three southernmost towns of Sta. Catalina and Basay and the city of Bayawan.

A general picture of the province shows that the causes of morbidity are a result of poor environmental sanitation, unsafe drinking water, unhealthy lifestyle, lack of vitamin supplementation or malnutrition. Likewise, CVD tops the ten leading causes of mortality which is attributed to unhealthy lifestyle. Infant and under five mortality remain high due to inadequate supply of medicines, untrained hilots assisting deliveries, failure to give pregnant mothers tetanus toxoid and non performance of newborn screening. Maternal deaths could be attributed to lack of training of some RHMs and untrained birth attendants. Some mothers do not submit to prenatal care and some do not have access to adequately-equipped health facility. There is a need for a Maternal Death Review to ascertain factual causes of maternal deaths. Not one of the RHUs and hospitals are BEMOC or CEMOC capable so that referral to higher levels of care are necessary.

Lack of manpower in all categories especially doctors, inadequate facilities and equipment and insufficient supply of affordable medicines are the major gaps identified in the hospital service delivery in the province. There is also a need for a well implemented referral system to partly solve the overcrowding in the higher level facilities and underutilization in primary and secondary facilities. Another gap is the need for trainings and continuing education for health care professionals.

In terms of health financing, public health and community-based health financing need to be made acceptable and implementable. There is a lack of compulsory insurance plan to address the increasing cost of medical care, limited population coverage, limited service coverage and low level support.

Under governance, major external factors that hinder the efficiency, effectiveness and relevance of the provincial health system include low priority and low allocation of resources for health, the negative impact of the devolution of health services as mandated by the Local Government Code, and the general lack of health consciousness among the people. One major deficiency in the hospital system is the non-operational Provincial Health Information System.


Another gap is the non-functionality of structures. There is a need to strengthen and reorganize different committees such as the Therapeutics Committee, Infection Control Committee, among others. Another deficiency is the lack of training on service areas among health personnel.

Tedious process in drug procurement as well as assuring safety and efficacy of drugs are some issues under the regulation component. Other concerns have to do with the manner of distribution of medicines, and the non compliance with the Generics Act.

The overall goal of the province is to improve the health status of its population. The province aims to reduce prevalence of morbidity by 25 percent (caused by lifestyle-related diseases and others), reduce infant mortality by 17 percent, reduce maternal mortality by 15 percent and reduce malnutrition by 5.1 percent. To attain such improvement, the investment plan aims to ensure the following: access to quality, integrated, comprehensive, continuous, affordable health care services, goods and facilities in partnership with the community; effective and efficient allocation, generation and mobilization of resources; improvement in the unified technical direction and operational coordination of all providers at all levels and sectors province-wide; and strengthened regulatory functions at provincial and municipal level through ordinances and legal mandates.

The specific goals under service delivery include: all RHUs and hospitals are SS certified/Philhealth accredited; all health facilities have adequate and competent HHR; and all private health facilities and providers are regulated.

Under health financing, specific goals are: per capita expenditures would increase by 5 percent every year; Philhealth indigent coverage would increase by 25 percent; Philhealth capitation would increase from P 11 million to P 18 million; benefits from Community Based Health Financing Scheme would complement Philhealth benefit packages; socialized users fees are institutionalized in both public hospitals and RHUs; and DRF/BnB/HPO are established.

For governance, the specific goals comprise: sector-wide approach to health is implemented in all components of the local health system; and there is functional organizational structure and systems in the various levels of governance.

The specific goals under regulation include the following: ILHZ Therapeutic Committees are established; there are policies relative to the detailing of midwives; outsourcing of doctors are carried out; compliance to SS certification and PHIC accreditation is achieved; and policies on revenue generation are adopted through appropriate local legislations.

Activities under service delivery include rationalization of services and human resources in public health facilities, upgrading of health facilities and equipment for SS certification and PHIC accreditation, advocacy on the provincial health implementation plan, capability/capacity building, intensification of campaign on dengue, diarrhea, rabies, STI/HIV, control and management of emerging infectious diseases, intensify early detection of cancer, improvement of potable water supply system, health care waste management, provision of drugs and medicines.


Under health financing, activities are: review of local accounts for health; interface community based HCF with SHI; achievement of universal coverage; establishment of community based, community managed health care financing; ensure fiscal and managerial autonomy of hospitals; standardization of users fees; and establishment of drug revolving fund.

For governance, activities comprise: establishment and operationalization of appropriate management systems; management structure, financial management and management support systems for ILHZ; and community based programs and projects.

Regulation activities include strengthening policy on drug procurement and management, and adoption of national policies/laws through local ordinances/resolutions for implementation. Investment Costs by Source as against CO and MOOE (In thousand pesos)

BY SOURCE Capital Outlay

Maintenance and Other Operating Expenses

TOTAL %

PLGU 1,070 43,435 44,505 10% M/CLGU 244,923 244,923 55% DOH 50,350 50,350 11% EC 80,181 19,769 99,950 23% LEAD 1,611 1,611 0% UNICEF 1,268 1,268 0% BIARSP 1,613 1,613 0% TOTAL 81,251 362,971 444,222 100% % 18% 82% 100%

Total investment cost of the province amounts to P 444 million with 65 percent being shouldered by the LGU (provincial and municipal/city combined). The EC grant share is at 23 percent while that of the DOH is 11 percent. A large portion (82 percent) is for MOOE while only 18 percent is set for Capital Outlay. By Year 2006 2007 2008 2009 2010 TOTAL %

Service Delivery

15,667

60,379

67,060

60,876

46,706

250,688 56%

Health Financing

18,111

22,444

25,041

32,253

39,643

137,493 31%

Governance

9,319

10,728

16,543

9,466

9,466

55,522 12%

Regulation

129

300

30

30 30

519 0%

TOTAL

43,226

93,852

108,674

102,625

95,845

444,222 100% % 10% 21% 24% 23% 22% 100%

Service delivery has the highest share among components at 56 percent followed by health financing at 31 percent. Governance comprises 12 percent while regulation does not require much investment compared to the other components.


INTRODUCTION

This 5-Year Investment Plan on Health is a document that presents the condition and status of the health sector, highlighting the district health system otherwise known as the Inter-Local Health Zone. This is a product of a series of orientation seminar-workshops conducted by a Team from the European Commission and the Department of Health Regional Office in the context of the Health Sector Reform Agenda (SHRA) and in the implementation of the health reform package as Fourmula ONE for Health. The format is framed such that it shows the logical sequence and organization of its content. Background and information on the planning area is provided by a brief demographic and socio-economic profile. Highlighted is the health situationer which details the health needs, delivery system, health financing and governance. The situation is translated further in detail within the realm of the health reform framework in four integrated key areas, namely: financing, service delivery, governance and regulation. Current condition of each Inter-Local Health Zone is individually analyzed, thus individual gaps and deficiencies are consequently identified by the ILHZ Teams. The substantial outputs are the 5-year investment plans for each ILHZ. Individual outputs were then consolidated and integrated to form the provincial investment plan. This plan was developed and formulated by the Chiefs of Hospitals, DOH Representatives, City/Municipal Health Officers, Public Health Nurses, City/Municipal Planning and Development Coordinators, key staff of the Provincial Health Office, headed by the Provincial Health Officer and the Assistant Provincial Health Officer and a representative from the Provincial Planning and Development Office and the District Technical Management Committee members. Chapters of the plan include the situationer which discusses the current health status indicators and top causes of morbidity and mortality, among other indicators. Delivery system is likewise clearly presented through the projection of information on health facilities, quality of rural units, quality of hospitals, service utilization, drug management system and other schemes adopted in the delivery of health services. Current enrollment in social insurance and institutionalization of a community-based health financing are illustrated. Structures and systems that govern the local health system within the province, specifically on the ILHZ, information system, financial, and procurement systems are also discussed. The Investment Plan is a vital document and a technical requirement in support of a financial grant from the European Commission in which the province of Oriental Negros is one of the identified convergence areas in the country. Hard counterparts from the different local government units are presented in the costing and financing portion of the plan, broken down in accordance with the program timeline.


CHAPTER I

Demographic and Socio-Economic Profile

Oriental Negros is located on the eastern side of Negros Island in the Central Visayas region, occupying the southern lobe of the island of Negros. It is a narrow strip extending two-thirds of the way from the south to the north of the island. It measures 103 miles from the north to south and from the east to west it is 49 miles at its widest, and 8 miles at its narrowest. It is bounded by a chain of rugged mountains from its sister province of Negros Occidental and separated from Cebu by the Taon Strait.

Other Basic Facts Demography

Population : 1,130,088 (2000 Actual Census) Population Growth : 1.98% Population Density : 189 No. of Families : 4,933 No. of municipalities : 20 No. of cities : 5 No. of barangays : 557

Social Services

No. of Barangay Health Stations : 287 No. of Rural Health Units : 28 No. of Comm. Primary Hospitals : 6 No. of Secondary Hospitals : 7 No. of Tertiary Hospitals : 1 public; 3 private No. of Day Care Centers : 909 No. of Public Elementary Schools : 632 Total Public Secondary Schools : 96 Private Elementary Schools : 30 Private Secondary Schools : 30 Private Universities : 2 Private Colleges : 2 Technical-Vocational Schools : 10 Elementary participation Rate : 81.1% Elementary Cohort Survival Rate : 67.89% Secondary Participation Rate : 84.73% Secondary Cohort Survival Rate : 62.58%

Economy

Income Classification : First Class Economic Base : Agriculture Average Income : P 50,451 Average Expenditures : P 39,867 Average Per Capita Income : P 20,003.00 (2000 FIES) Average Per Capita Expenditure: P 15,728.00 Human Development : 0.448 Median Per Capita Income : 12,695 Median Per Capita Expenditure : 9,909


Poverty Threshold : P 8,940 (FIES 2000) Poverty Incidence : 31.4% Food Threshold : P255.84/day Employment Rate : 19.9 Unemployment Rate : 9.1 Total length of provincial roads : 494.578 km Total length of national roads/highway: 14 909.768 km.

Tourism Facilities/Amenities

No. of hotels : 15 No. of Hotel Rooms : 217 No. of Hotel beds : 234 No. of Beach Resorts : 26 No. of Beach Resort Rooms : 450 Beach Resort Bed Capacity : 704 A good number of Pension Houses

Communication Facilities

Telephone firms : 8 Telegraph Stations : 34 Postal Service Office : 32 Radiophone Stations : 24 Cable TV Stations : 5 Radio stations : AM - 3; FM 4 Telex Station Exchange : 2 Local Weekly Newspapaper : 6 Mobile Communication : 2 Internet Service Providers : 5 Internet Cafes : 33

Financial Institutions

Government Banks : 10 No. of Commercial Banks : 30 No. of Rural Banks : 27


Chapter II HEALTH SITUATIONER

A. HEALTH NEEDS 1. Population by ILHZ The 2004 projected population of Oriental Negros is 1,220,466 with an annual growth rate of 1.98 per cent from the year 2000 actual census. Of the six Inter Local Health Zones of the province, MamaBataPa ILHZ has the highest population of 288,510, which accounts for 23.6 per cent of the total population of the province. This is followed by ValeDalanSaDaCongBulan and CVGLJ districts with 269,770 individuals or 22.1 per cent and 241,184 or 19.8 per cent of the total population of the province respectively. Sta.BayaBas district has a projected combined population of 209,028 population or 17.1per cent, BinATa district with 113,931 or 9.3 per cent and SiaZam district with 98,043 or 8 per cent of the entire population of the province. The northern districts have larger population sizes because they consist of five to seven municipalities/cities as their coverage areas. Smaller districts have either two or three municipalities/cities as catchment areas.

2. Crude Birth Rate

The crude birth rate of the province in 2004 was 19.65 per 1,000 population, 5.35 per 1,000 population lower than the national rate of 25 per 1,000 population.

Table 1.0 2004 Crude Birth Rate

Oriental Negros: 19.65 /1,000 Population

Births ILHZ Population

Number Rate 1. Mama Bata Pa 288,510 5,305 18.39 2. ValeDalanSaDacongBulan 269,770 5,327 19.75 3. CVGLJ 241,184 4,995 20.71 4. StaBayaBas 209,028 4,557 21.80 5. Binata 113,931 2,027 17.79 6. SiaZam 98,043 1,770 18.05 Total 1,220,466 23,981 19.65 Source: Field Health Services Information System, Provincial Health Office, Province of Oriental

Negros, 2004 Births in hospitals within the province are not reported in the FHSIS of the LGUs concerned. This is because those giving birth are not residents of the area where births took place. Other reasons for low birth rate are the low level of awareness of some parents on the importance of birth registration, and the lack of money to pay the registration fee. As of now, all LGUs have no market segmentation to provide free birth registration to indigents. The table above presents the crude birth rates by ILHZ where StaBayaBas district has the highest CBR at 21.80 per 1,000 population followed by CVGLJ at 20.71 and ValeDalanSaDaCongBulan at 19.75 per 1,000 population.


3. Morbidity Acute Respiratory Infection or Upper Respiratory Tract Infection topped in the ten leading causes of morbidity in Oriental Negros in the five-year average between 1999 and 2003 and in 2004. This was followed by pneumonia, diarrhea, influenza, bronchitis, cardio-vascular diseases, all types of wounds, pulmonary tuberculosis, skin diseases and dengue fever. ARI/URTI had an average of 30,567 cases between 1999 and 2003 and 28,756 cases in 2004. Below is a table of the ten leading causes of morbidity with their corresponding number of cases and rates.

Table 2.0 Ten Leading Causes of Morbidity

5-Year Average (1999-2003) and 2004 Province of Oriental Negros

5 Year Average

(1999-2003) 2004 Causes Number Rate Number Rate

01. ARI/URTI 30,576 2,693 28,756 2,356 02. Pneumonia 21,308 1,877 21,653 1,774 03. Diarrhea/Acute Gastroenteritis 22,241 1,959 20,788 1,703 04. Influenza 19, 022 1,675 19,841 1,626 05. Bronchitis 12,298 1,083 10,660 873 06. CVD 7,450 656 8,631 707 07. Wounds all types 2,489 219 2,212 181 08. PTB 1,173 103 1,455 119 09. Skin Diseases 1,786 157 1,204 99 10. Dengue Fever 651 57 884 72

Source: Field Health Services Information System, Provincial Health Office, Province of Oriental Negros, 1999-2003; 2004 The causes of morbidity are perceived to be the result of poor environmental sanitation, unsafe drinking water, unhealthy lifestyle or lack of vitamin supplementation or malnutrition. Seven of the 10 leading causes are communicable diseases. Endemic diseases, specifically malaria with 14 cases and filariasis with 13 cases, are still present in several municipalities. Eight of the malaria cases in 2005 are indigenous and 6 are imported. The above situation can be attributed to an environment that is a suitable breeding ground for vectors. Six rabies cases have also been reported in some LGUs despite the campaign on responsible pet ownership and dog immunization.

The influx of tourists both local and foreign poses the emergence of sexually-transmissible infections. While there is no available data on STIs, the increasing number of tourists, from 129,111 in 2002, 138,865 in 2003, and 165,135 in 2004 may prove otherwise. Compounding the problem is the absence of functional social hygiene clinics.

At the health district level, another picture of the morbidity causes can be seen, but ARI/URTI still occupies the topmost cause of morbidity. At Sta. Bayabas District, diarrhea was the top leading cause of morbidity, while at Siazam District it was influenza. However, for the other four health districts, ARI/URTI was the


leading cause of morbidity which is the same province-wide. Details of these are presented in the Annex (Table A). 4. Mortality

Cardiovascular disease leads the 10 causes of mortality in the province followed by pneumonia and cancer. The most number of CVD cases is recorded in the central health district of the province (ValeDaLanSaDaCongBulan ILHZ) claiming 398 lives followed by 254 cases in the northern health district of Bais in MaMaBaTaPa ILHZ (see Annex, Table B). Pneumonia cases vary in the health districts.

Table 3.0 Mortality, Ten Leading Causes, Number and Rate

Per 100,000 Population Five Year Average (1999-2003) and 2004

Province of Negros Oriental

5 YEAR AVERAGE

(1999 - 2003) 2004 CAUSES

No. Rate Male Female Total No. Rate 1. Cerebro Vascular Diseases 1,062 91.87 595 575 1,170 95.87 2. Pneumonia 716 61.94 350 169 519 42.52 3. Cancer all kinds 460 39.79 204 220 424 34.74 4. PTB 210 18.17 126 64 190 15.57 5. Sepsis/Septicemia 182 15.74 99 64 163 13.36 6. Accident all forms 198 17.13 112 36 148 12.13 7. Malnutrition/Severe Anemia 174 15.05 59 78 137 11.23 8. Wounds all kinds 98 8.48 97 29 126 10.32 9. Renal Diseases 102 8.82 64 47 111 9.09 10. Bleeding Peptic Ulcer/GI Bleeding 82 7.09 58 33 91 7.46

5. Infant Mortality and Under Five Mortality Pneumonia, septicemia/sepsis neonatorum and prematurity are among the ten leading causes of infant mortality. While there is regular capability upgrading of health personnel in the management of pneumonia cases, number of cases is still high due to inadequate supply of medicines. There were 43 cases of pneumonia in 2004, only one case higher than the 1999-2003 five-year average of 42 cases. Septicemia had 24 cases in 2004, eight cases higher than the past five-year average. Local health authorities hint that Septicemia/sepsis Neonatorum occurs due to deliveries that are assisted by untrained hilots. In addition, pregnant mothers were not given tetanus toxoid.


Table 4.0 Ten Leading Causes of Infant Mortality 5 Year Average (1999 2003) & 2004

Province of Oriental Negros 5 Year Average

(1999-2003) 2004 Causes Number Rate Number Rate

01. Pneumonia 42 1.76 43 1.81 02. Septicemia/Sepsis Neonatorum 16 0.67 24 1.01 03. Prematurity 28 1.18 22 0.92 04. Congenital Anomaly 20 0.84 16 0.67 05. Asphyxia 10 0.42 8 0.34 06. Infant Respiratory Disease Syndrome 7 0.29 8 0.34 07. Accident 2 0.08 4 0.17 08. Birth Injury 1 0.04 3 0.13 09. Meningitis 3 0.13 3 0.13 10. Anencephaly 1 0.04 3 0.13

Source: Field Health Services Information System, Provincial Health Office, Province of Oriental Negros, 1999-2003; 2004

Other leading causes of infant deaths are prematurity, congenital anomaly, asphyxia, infant respiratory disease syndrome, accident, birth injury, meningitis and anencephaly. The ten leading causes of infant mortality by ILHZ are found in the Annex (Table C). In terms of under five mortality, there has been a decreasing trend in the past years. Percentage of under five deaths to total deaths in year 2000 was 10 percent. In 2001, it decreased to 7.6, and further to 5.4 percent in 2004.

6. Maternal Mortality Postpartum Hemorrhage is the number one cause of maternal mortality in the province. Other causes of maternal deaths are complications related to pregnancy occurring in the course of labor, delivery, and postpartum. Maternal deaths could have been prevented had well-equipped lying in clinics been existing and functional. Other factors that may have caused maternal death could be that pregnant women did not have pre-natal check ups. Causes of maternal death have not yet been categorically identified, thus there is a need to conduct the Maternal Death Review to ascertain the factual causes so prevention can be instituted.

Meanwhile, results of the Basic Emergency Obstetrical Care (BMOC) and Comprehensive Emergency Obstetrical Care (CEMOC) capability assessment conducted by DOH on eight health facilities indicate that not one of the eight RHUs and hospitals is BEMOC or CEMOC-capable which could mean that referral to a higher level facility is necessary and that ambulances with complete accessories are most needed by the RHUs and district hospitals to quickly respond to emergency cases.


Leading causes of maternal mortality by ILHZ is provided for in the Annex (Table D).

Table 5.0

Maternal Mortality, Leading Causes, Number and Rate Per 100,000 livebirths and percent distribution

Five Year Average (199-2003) and 2004 Province of Negros Oriental

5 YEAR AVERAGE

(1999 - 2003) 2004 CAUSES

No. Rate No. Rate % 1. Postpartum Hemorrhage 10 42 8 33 67 2. Eclampsia 3 13 2 8 17 3. Ruptured Uterus 2 8 1 4 8 4. Postpartum complications 2 8 1 4 8

TOTAL 12 100 7. Malnutrition

Malnutrition rate of the province in 2004 was 16.72 per cent, 209 percent increase from the 2003 rate of 5.4 per cent. Bayawan City has the highest malnutrition rate at 25.6 per cent (see Annex, Table E). The increase in the malnutrition rate can be due to the adoption of the International Reference Standard (IRS) instead of the use of the Philippine Reference Standard in the measurement of malnutrition level. B. SERVICE DELIVERY 1. Public Health Programs

There used to be trainings on CVD for health personnel which included Hypertension, Rheumatic Heart Disease/Fever, and Diabetes. Regular reporting was done after the trainings which would cover the areas on BP screening and CVD and Rheumatic Disease cases. Logistics like Penadur and antihypertensive drugs were provided from the CHD for about five years. However, the supplies were dwindling which resulted in the unintensified activities and directions on CVD because the health personnel lost interest on the program due to the withdrawal of support from the CHD. Some health personnel were then trained on Healthy Lifestyle which gave more emphasis on Hataw Exercise. At present, some RHUs are implementing the Hataw after the flag ceremony. Aside from this, Amlan RHU has existing community rehabilitation facilities where physical therapist students are affiliated. There was no training conducted with regards to Asthma Management and Smoking Cessation to all health personnel. The public health programs currently prioritized are Maternal and Child Health, Nutrition, Family Planning, Expanded Program on Immunization, Dental Health, Control of Communicable Diseases like TB, Leprosy, STIs, Mosquito-Borne


Diseases and Environmental Sanitation. Since the provinces budget for health is very limited, poor communities were given utmost priority in these programs.

Another public health program is the blindness prevention program. All

RHU personnel were trained on Primary Eye Care. Activities include screening of patients with eye defects due to Vitamin A deficiency, with Bitots spots, treating or referring patients for treatment and teaching the prevention of eye disorders in the community. Severe eye care problems that cannot be resolved at the primary level are referred to tertiary health facilities.

Yearly activities include cataract operations done at the 6 district hospitals

and NOPH done by 2 groups; DOH CHD7 group and Rotary Blindness Foundation led by Dr. Edgardo Caparas. The Average number of patients operated per district is forty cataract patients and 250 eye refractions. In terms of immunization of children under one year old, program coverage accomplishment was only 79 percent in 2004 and 76 percent in 2005 compared to the national benchmark of 90 percent and provincial benchmark of 85 percent. Universal supplementation of Vitamin A to target beneficiaries such as 6-11 months old children and 12-71 months old children, which were conducted in the months of April and October 2005, were only 82.4 percent and 89.2 percent respectively, compared to the 95% national target.

The CPR in the province is only 64.1 percent compared to the national target of 70 percent. Since 2004 up to the present, the provinces donor, USAID, has little by little withdrawn its support until such time that the support is totally withdrawn except for IUD supplies. The LGUs are now totally responsible for the contraceptive needs of their clientele.

2. Health facilities The existing health facilities in Oriental Negros are found to be adequate to provide primary, secondary and tertiary health care services. They include six government secondary or district hospitals, eight community primary hospitals, two private tertiary hospitals, four city health offices, 28 rural health units and 309 barangay health stations and eight privately- owned laboratories. However, some RHUs still need improvement and upgrading to meet and comply with Sentrong Sigla standards. There are still six RHUs that are not SS-certified. This may be due to the low level of priority given to SS accreditation by some LGUs. In addition, some RHU staff are resisting SS accreditation since it implies that the facility will have more patients to cater to and thus RHU staff workload will increase. Twenty six out of the 28 RHUs are not yet certified on Sentrong Sigla Phase 2. However, 22 RHUs are already SS Phase1 certified. Amlan and Bindoy RHU have just recently been certified on SS Level1 Phase 2. List of RHUs/CHOs certified under Sentrong Sigla, Maternity Care Package, PhilHealth and TB DOTS are found in the Annex (Table F).

The year 2006 target is to make all RHUs and CHOs facilities SS1 Level 1 Phase 2 certified.


For the past year, admission rate of the community hospitals were very low with only 10-15 %. This is because patients prefer to be admitted at the district and provincial hospitals. The community hospitals are not fully equipped and there is inadequate manpower. There is also duplication because the RHU is providing the services being provided by the community hospitals. 3. Manpower Requirement Manpower supply in the different health service facilities still fall short of the standard requirement. Hiring of more health service providers can not be done due to personal services limitations and fund constraints. Other than hospitals and RHUs being understaffed or undermanned, there is also low percentage of trained health service providers in the province. Only 30 per cent of the health workers are trained on Safe Motherhood and Family Planning Program, specifically on Partograph and Natural FP and Fertility Awareness. The number of health service providers trained on Integrated Maternal and Child Health Counseling Course represents only 25 per cent of the total health manpower. The effects of lack of training on the above program may render the health personnel inability to give quality health service to mothers and children. Moreover, some doctors and nurses have not yet undergone trainings on IMCI, FP Clinic Supervision for Quality Assurance, refresher courses on STI management and on FP and on facilitative supervision. As a result, doctors and nurses are not highly-capable to teach and guide field health workers on these areas of health service. C. HEALTH CARE FINANCING 1. Community Based Health Financing Schemes

A good number of health financing innovations originating from the different component municipalities and cities of the province have developed over the years. Foremost of these is the initiative of some LGUs to institutionalize a community-based insurance system, through the PESO for Health Program even before the introduction of the Medicare Para sa Masa, a PhilHealth Insurance Program seen as a more sustainable insurance system, especially among the lower income municipalities. However, assessment and evaluation of the community based health insurance is necessary in order to measure its sustainability. Other innovations are the granting of fiscal autonomy to hospitals and the pooling of funds of the ILHZ, among others.


Table 6.0 Community-Based Financing Innovation

Province of Oriental Negros

Financing Initiative Area

No of Enrolees Unit of Enrolees Benefit Package

Peso for Health Singko for Health

CVGLJ 32278 5,907

Individual P200 benefit pckge P1000 benefit pckge

Singko for Health

Amlan 2962 Individual P1000 benefit package

Peso for Health Sta. BayaBas

Basay 2,239 Sta. Catalina 4,128 Bayawan 20,775

Individual P200 P1000 P2000 P2500

SHIP Sustainable Health Insurance Program

Ayungon 3188 Individual P1000 for P5 2000 for P10

Hospital Subsidy Valencia All residents Individual 3000/member Sibulan All residents Individual 2000/member Dauin All residents Individual 3000/member Dumaguete All residents Individual 5000/member Source : Field Heath Services Information System, PHO-Province of Oriental Negnros : 2004

PESO for Health is an innovative program that is affordable and enables poor members who have no money to contribute in kind to pay their monthly contributions. It encourages people to take care of their health, since they are made to cover part of the costs through their contributions. PESO means People Empowerment Save One. 2. National Health Insurance Program (PhilHealth) The table below shows the number of enrolees in the PhilHealth Insurance Program by ILHZ. Data per municipality and per city are provided in the Annex (Table G). The NHIP aims to cover the bottom 25 percent of the total population which are classified as indigents. The same table further shows that the PhilHealth Insurance coverage based on the PHIC target is already 61 per cent, but based on the total number of families, the coverage is only 15 per cent with the highest coverage in BinATa District (43%) and the lowest in Sta. BayaBas District (2%) (see Annex). Translated into capitation fund, this would total to about P11 Million which the LGUs could use to finance their respective health services.


Table 7.0 PhilHealth Coverage per Municipality by ILHZ, 2005

Province of Oriental Negros

Area

Population

Estimate Indigent Family (25% of

pop)

Total Family

Enrolled (2004)

% coverage

Estimated Household

Total

% of total household

CVGLJ DISTRICT 241,184 12,059 7,108 59% 48,237 15% BinATa District 113,931 5,697 9,813 172% 22,786 43% MaMaBaTaPa

District 288,510 14,426 5,733 40% 57,702 10%

ValeDALan Sa DaCong Bulan district

269,770 13,489 10,784 80% 53,954 20%

SiaZam District 98,043 4,902 3,108 63% 19,609 16% Sta. BayaBas

District 209,028 10,451 709 7% 41,806 2%

PROVINCIAL TOTAL 1,220,466 61,023 37,255 61% 244,093 15% Source: Philhealth Dumaguete Field Office

While the principle of financing and insurance was stimulated and appreciated through the community-based insurance innovated by various LGUs, the problem of portability, individual unit of enrolment, and limited benefits in terms of preventing catastrophic health expenditure hamper its acceptance and adoption.

D. GOVERNANCE 1. The Structures and Systems The emergence of a wide range of health issues and concerns brought about by devolution has set forth the realization of the need for collaboration of the health sector at the various levels for sustainability and survival. In this regard, Oriental Negros made an innovation of establishing Inter-Local Health Zones (ILHZ) adopting the existing six health districts which have been institutionalized prior to devolution. It is a cluster of three to five municipalities in a given coverage area, the district hospital of which is the center of wellness. ILHZ is a comprehensive management approach of the district health system which evolved in anticipation of a need to survive the impact of devolution. ILHZ was set off with a signing of a Memorandum of Agreement among the participating local government units. The MOA serves as the legal framework for the establishment of ILHZ in each health district; and, resolutions were passed by the Sangguniang Panlalawigan and the different Sangguniang Bayan expressing support to the ILHZ. Successes were noted which can be attributed to the creation of effective structures in the local health system and legislative initiatives. The six Inter Local Health Zones in the province are contractions of the municipalities or cities within the catchment area. They are:


1) Sta. BayaBas ILHZ Bayawan District Hospital

a. Sta. Catalina b. Bayawan City c. Basay

2) SiaZam ILHZ Cong. Lamberto L. Macias Memorial Hospital in Siaton a. Siaton b. Zamboanguita

3) ValeDalanSaDacongBulan ILHZ Negros Oriental Provincial Hospital,

Dumaguete a. Valencia b. Dauin c. Amlan

d. San Jose e. Dumaguete City f. Bacong g. Sibulan

4) MaMaBaTaPa ILHZ Bais District Hospital

d. Mabinay e. Manjuyod f. Bais City g. Tanjay City h. Pamplona

4) BinATa ILHZ Bindoy District Hospital

a. Bindoy b. Ayungon c. Tayasan

5) CVGLJ ILHZ Gov. William Billy Villegas Hospital

a. Canlaon b. Vallehermoso c. Guihulngan d. La Libertad e. Jimalalud

The structures that govern the ILHZs or the district health system within the province are the Provincial Health Board, Health District Board, District Hospital Board and the Local Health Board. The Provincial Health Board is composed of the Provincial Governor, NGO representative, Sangguniang Panlalawigan Representative, the Provincial Health Officer, and DOH Representative and PHIC Representative. Its function is to take up and address issues confronting the entire provincial health system. Members of the Health District Board are the Provincial Governor, Member of the Sannguniang Panlalawigan representing the Congressional District where the ILHZ is located, Chief of the District Hospital, Municipal/City Mayors of the covered municipalities/cities of the zone, representative from the Religious Sector, Sangguniang Bayan Chairman of the Committee on Health, PHO representative, DOH representative, Civic Organization representative, and Peoples


Organization. However, Health District Board membership is left open to include other members deemed necessary for inclusion in the Board, as the case so requires. Its functions are to formulate policies towards an integrated health care, to oversee the financial management of the district and to approve an integrated health fund for the sustainability of the health service.

The District Hospital Board is composed of the Sangguniang Panlalawigan representing the Provincial Governor, Chief of Hospital, Municipal/City Mayors of the zone coverage area, NGO Representative, Religious Group representative, and a Private Sector representative. The functions of the District Hospital Board are: to assist the Provincial Governor in the financial management of the district hospital; to review the budgetary requirements of the hospital and indorse same for approval and funding; to device mechanism for internal control, ensure participation of the LGUs and the community in hospital service; and, to perform other duties as may be assigned by the Provincial Governor from time to time. The over-all Chairman of all the Health District Boards is the Provincial Governor. The NGO member of the Hospital Board comes from the St. Maria Goretti Foundation and is also tasked to do regular monitoring and evaluation function and conduct selected relevant trainings. Chairperson(s) of the District Hospital Board(s) is/are the Member(s) of the Sanggunaing Panlalawigan of the district where the ILHZ belongs. 2. Information System Manuals on policies and guidelines, integrating health operations, referral system and treatment protocol are in place, but have not yet been reproduced and disseminated. In effect, there is still a low level of awareness on the referral system. There is an urgent need to know the criteria for referral and the rudiments of referral management. There is no designated section/point person to receive and monitor the referrals from the satellite health facility so that not all referral slips are returned to the referring authority. Also, reproduction of forms, specifically on the maternal death review, under-five mortality review, CBMIS, CBDSS, HOMIS, FP, HBMR, ECCD, FHSIS and on new born screening could not be made available for the reason of insufficient funds. This has resulted to the under and late reporting of some vital statistics required for monitoring and planning. Magnifying this concern is the lack of training of PESU, CESU, DESU and MESU on disease surveillance and outbreak response protocol. FHSIS and HOMIS are integrated in the Health Information System to expand the management tools available to policy and decision-makers. Thus far, Bayawan and Canlaon District Hospitals are the only hospitals that have been installed with the Health Management Information System. This is so because the HOMIS trained computer operator of DOH-CHD 7 was requested by DOH Central Office to install Module I software in DOH-Retained hospitals such as the Vicente Sotto Memorial Medical Center, St. Anthony Mother and Child Hospital and Eversley Child Sanitarium. Module II Software was installed at the Gov. Celestino Gallares Memorial Hospital. However, the initiative of Bayawan District Hospital was timely in terms of IT-HOMIS development program. Other common complaints on the existing information system are the duplication of reports being requested by both regional and national agencies and the lack of appreciation on health reports by the local chief executives as policy and decision making bodies, by the service providers as part of their


planning, monitoring and evaluation activities, and by the community in terms of the need to elicit their cooperation in the implementation of health programs. This lack of appreciation on health information by various users is attributed to the health workers lack of skills to validate, analyze and interpret health data and package them such that these information would create positive reception from among its users.

Data gaps, specifically on health expenditures and financing sources at

the provincial level are evident. Thus, there is a need for the establishment of Local Health Accounts.

3. Financial System Hospitals are given some form of financial autonomy as they are allowed to retain their income. The Hospital Boards approve work and financial plans to determine hospitals expenditures. The collected users fees from the hospitals are kept by the Provincial Treasurer and supplemental budgets are approved by the SP, giving hospitals access to these funds. While RHUs and CHOs are devolved to the municipal and city LGUs, operation of the provincial, district and primary hospitals are retained by the provincial government. Based on the 2004 provincial budget, health sector had a share of 27 percent of the total budget. Source of funds are the IRA, Congressional Development Fund (CDF), ADB loan, grants, and trust funds from various NGOs and national government agencies.

The provincial government has also evolved a system of pooling a

common fund to operationalize the different ILHZs which is seen as a good start for an inter-local collaboration and cooperation.

Annual provincial counterpart for ILHZ development is P2,300,000.00,

allocation of which is prorated based on the area and population coverage and size of the district hospital. Each component city and municipality has its individual share of the pooled funds. (See Table below)

Table 8.0

Pooled Funds of the different ILHZ As of CY 2004

Component Municipalities

Component City ILHZ

Share No Subtotal Share No Subtotal

Provincial Counter part

Total Fund Pooled/yr

CVGLJ P100,000 4 P400,000 P100,000 1 P100,000 P200,000 P700,000 BinATa P150,000 3 P450,000 - 0 0 P400,000 P850,000 MaMa BaTa Pa - 3 0 - 2 0 P500,000 P500,000 ValeDaLanSaDa ongBulan

- 6 0 - 1 0 P500,000 P500,000

SiaZam P 50,000 2 P100,000 0 0 P200,000 P300,000 Sta. BayaBas P130,000-

P150,000 2

P280,000 P400,000 1

P400,000 P500,000 P1,180,000

Source : Memoradnum of Agreement between the Provincial Government of Oriental Negros and Cities and Municipalities

CVGLJ ILHZ is putting in P100,000 per municipality/city with a provincial counterpart of P200,000.00; BinATa ILHZ is giving a share of P150,000 per municipality with a provincial counterpart fund of P400,000.00; MaMaBaTaPa ILHZ


municipalities have not put in their share yet, as of this plan formulation, but the province has earmarked P500,000.00 for this ILHZ. SiaZam ILHZ municipalities share is P50,000 each while the provinces share is P200,000.00; NOPH or the ValeDalanSaDacongBulan ILHZ has a provincial counterpart of P500,000.00, share has not yet been recorded from any of the component town and city; and Sta. BayaBas ILHZ has a share ranging between P130,000,00. P150,000.00 with P 500,000 provincial counterpart. Lastly Bayawan City had put in P400,000.00 with provincial share of P500,000.00. 4. Procurement System Bulk procurement of drugs and medicines is done with the Philippine International Trading Corporation (PITC) and direct purchase are done with exclusive distributors or direct manufacturers through public bidding. Drug Procurement Plan is based on the reported morbidity and mortality cases of the health facilities of the province, annual procurement plan of each hospital and the Philippine National Drug Formulary and DOH-BFAD. The fact that the hospitals are limited in their utilization of the revolving fund (trust fund) as prescribed by the SP, contributes to the problem of inadequate supply of drugs. It is recommended that a review on the utilization of the revolving fund (trust fund) be done by the governing body. E. REGULATION Regulation is one function that should be considered of paramount importance by the Local Government Units. It should be carried out with the primary aim of ensuring that quality essential drugs are available and affordable at the facilities at all levels. Also, all available services should be in conformity with the standards set by the Department of Health. Each hospital in the province of Oriental Negros has its individual therapeutics committee. The therapeutics committee is organized in hospitals and ILHZs to ensure the procurement of safe, quality and affordable drugs and medicines, specifically reviewing compliance with the Generics Law and the Philippine National Drug Formulary of requested drugs and medicines for procurement. However, these committees are not fully functional and there seems to be lack of awareness of Local Government Units on their importance. Likewise, training of members of the therapeutic committees in both hospitals and the ILHZ regarding management is needed. One of the problems identified on the drug utilization is the non-compliance with the rules on prescription of generic drugs by some doctors. They seem not to favor the use of generic drugs because of the substandard drugs provided by fly-by-night suppliers. This is coupled with the difficulty of doctors in memorizing the generic drugs list. Efficacy of drugs can not be ascertained or validated immediately due to the delay of test results from BFAD. While random sampling of drug delivered to the hospital is very important to determine the efficacy and quality of drugs, BFAD fails to deliver the results promptly. Results come long after the drugs have already been consumed which defeats the purpose.


There is a number of unregulated private laboratories and sari-sari stores operating in the province that are not conforming to licensing and accreditation requirements, hence the need for DOH-BFAD licensing section to conduct regular monitoring and inspection. On the matter of voluntary blood donation, there is a need for the Provincial/Local Chief Executives to formulate guidelines on the proper screening and selection of blood donors. There is also a need to develop local policies on health-related national laws and issuances such as the Food Fortification Law.


Chapter III GAPS AND DEFICIENCIES

A. HEALTH NEEDS

- Births and Deaths

The 2004 Crude Birth Rate (CBR) and the Crude Death Rate (CDR) from the FHSIS of the different LGUs do not tally with the CBR and CDR figures of the NSO. The discrepancy could be due to the fact that there are births and deaths that are not recorded in the LGUs because they took place in the hospitals located in other areas. Likewise, lack of policy guidelines on the retrieval of data on births and deaths confront the problem on the recording of actual rates of these indicators. - Mortality

Cardio vascular disease tops the 10 leading causes of mortality. This

condition is attributed to unhealthy lifestyle of the people like smoking, excessive drinking of alcohol, physical and mental stress and eating fatty foods as well as salty foods. In addition, there is poor compliance of medical treatment of cardio vascular disease cases due to high cost of medicines and high cost of diagnostic examinations.

Another cause of mortality is TB. Passive case detection and delayed

consultation due to social stigma attached to the disease contribute to the increasing number of TB cases. Although cure rate of more than 85 per cent was noted, there were individuals who died of TB without being seen by doctors. Making the situation worse is the fact that as of now, there is non-adherence of some public and private hospital physicians to the National Tuberculosis Program (NTP) guidelines. Cervical cancer is likewise identified as one of the main causes of mortality. This is attributed to the lack of a government cervical screening facility. Moreover, there is no adequate treatment for cervical cancer in the provincial hospital. Pathologists are also not trained on cervical screening. - Maternal Mortality

Maternal deaths could be attributed to the lack of training of some rural health midwives to manage emergency obstetrical cases. Although some midwives have the capabilities, they do not reside in the area of assignment. The fact that midwives are given wide service area coverage contributes to the difficulty in accessing their services. The Reside or Resign policy for midwives should be instituted if only to render needed quality service. On the other hand, some mothers submit to prenatal care consultations on their second or third trimester only, instead of beginning consultation in the first trimester. There are also mothers who do not have access to adequately-equipped health facility and this condition is aggravated by the problem of inavailability of vehicle to transport the mothers to the nearest higher level health facility. Moreover, more deliveries are handled by untrained birth attendants or non-professionals.


There may be other several illnesses and conditions that may have caused maternal death, but official or confirmed ones are not available because of the non-functionality of some Maternal Death Review Committees.

- Infant deaths and under-five deaths

Inadequate supply of IMCI drugs and lack of capabilities of RHMs to

manage childhood diseases are the contributing factors that led to infant and UFC deaths. Other factors that may have caused IMR and UFMR are non-performance of newborn screening, poor or unhygienic practices of some mothers especially in the food preparation in the feeding of children, low access to potable water supply and sanitary toilets, low FIC coverage, and poor housing conditions in urban slums and marginalized communities.

Metabolic diseases could have been identified and managed earlier had

newborn screening been done in every newborn. As of now, only Bayawan District Hospital and two RHUs of Tanjay, and Amlan, Silliman Medical Center Foundation and Holy Child Hospital are performing newborn screening. - Malnutrition

The five component cities of Bayawan, Dumaguete, Bais, Tanjay and Canlaon have reflected high malnutrition rates in CY 2004. One of the reasons given is the low percentage of mothers exclusively breastfeeding. Reports from the local health office indicate that the 2004 percentage of exclusive breastfeeding was only 66 per cent. Lack of knowledge of some mothers on the importance of proper nutrition also contributes to the prevalence of malnutrition. B. SERVICE DELIVERY 1. Public Health

In terms of immunization of children under one year old, supply of vaccines is enough to cater to target clientele but then several factors were identified that hinder the attainment of 90 percent coverage accomplishment. The following are some of the determining factors: There is no active master-listing and follow-up of mothers and children not immunized; non- adoption on the team approach in the conduct of immunization rounds; Presence of cultural and religious factors; Mobility of health personnel is very limited especially in hard-to-reach areas because they are not provided with transportation allowances by concerned LGUs.

Health personnel from the field identified several reasons for low coverage in Vitamin A supplementation such as high target, some areas are hard to reach, some mothers seek consultation from private clinics and there are still few who do not want their children given Vitamin A. However, Vitamin A (10,000 I.U.) supplementation to pregnant mothers was not implemented for the reason that Vitamin A capsules (10,000 I.U.) were not available.

In terms of family planning program, factors that contribute to prohibiting high performance are the following: Lack of trained personnel for permanent sterilization; Lack of trained personnel to provide quality services for temporary methods; Inadequate masterlisting of target clients; Poor follow-up of FP defaulters and dropouts; and Poor IEC on FP.


A major problem identified under the primary eye care is the lack of a permanent ophthalmologist in the provincial hospital. In addition, patients are deprived to seek consultation from private sector because of high consultation fees.

2. Manpower The Negros Oriental Provincial Hospital (NOPH), which is the biggest of the

eight hospitals in the province and the tertiary level core referral hospital, has only 76 per cent manpower complement. This is a primary concern which requires immediate resolution considering that the hospital has a wide area coverage being served. Patients from Negros Occidental, Southern Cebu, Siquijor and Northern Mindanao find it convenient to seek tertiary medical care here. For this reason, hospital admissions oftentimes exceed the 250 authorized bed capacity and sometimes reach figures up to 350 or even over 400. Thus, overcrowding of patients is common, where beds or cots are lined up in the corridors, the hospital chapel or the passageway to the dining room.

One of the causes of the overcrowding is the under-utilization of primary

and secondary health care facilities where simple cases of suturing of wounds, pneumonia, gastro-enteritis and simple deliveries are still referred to the Provincial Hospital. Unscreened referrals from the different municipalities also contribute to the overcrowding.

Thus, there should be a good, functional, and well implemented referral

system to partly solve the over-crowding. Under-utilization of the secondary and primary level health care facilities should be corrected. Although the Integrated Provincial Health Office has come up with a unified Provincial Referral System, there has been no orientation and training conducted for all personnel involved in referrals at all levels of health care due to lack of logistics. Only a few copies of the Manual of Referrals were printed which are not enough for the needs of the entire health system of the province.

In more related concerns, manpower development in the form of trainings and continuing education of health care professionals in all levels of hospital care is likewise a must to ensure quality delivery of health service by a highly competent set of professionals at desired standards of care. Again, because of budgetary constraints, the desired number and type of trainings are not always met. Furthermore, learning materials such as medical books, medical and nursing journals, teaching models and charts, presentation tools (LCD projector), and computers with internet access are not available. Most health care professionals are behind in medicine and patient care because of non-attendance in conventions in specialty fields. Support for requests to attend conventions and seminars are mostly in the form of on official time and not on official business. While the province is the venue of several Lakbay Aral with participants from 31 provinces, there have been no similar activities conducted in other provinces where Negros Oriental personnel can participate in.

Academic activities among the medical staff have somehow increased in

both quality and quantity but still wanting for more improvement. Medical audits, drug usage reviews, clinical presentations and lectures, grand rounds, mortality/morbidity reviews and similar activities have to be practiced more often.

There is a need for training on smoking cessation, asthma, diabetes and osteoporosis for all health personnel in the province. If possible, the DOH should


provide not only trainings but also logistics and supplies in order for these programs to be sustained.

3. Facilities

Lack of manpower in all categories especially doctors, inadequate facilities and equipment and insufficient supply of affordable medicines are the major gaps identified in the hospital service delivery of the Oriental Negros Hospital System involving its tertiary, secondary and primary level hospitals. Since our 2006 goal is to make all RHUs/CHOs be SS Level 1 Phase2 certified, the lack of program on Healthy Lifestyle can soon be addressed.

Expansion of the hospital facility at the Provincial Hospital is needed, more specifically in the female surgical ward which needs 10 more beds, male surgical ward also needs additional 20 beds, an obstetrics ward for 20 beds and a gynecology ward for 10 beds. Other facilities urgently needed are a surgical intensive care unit, a pathological nursery, and a modern kitchen/dining hall.

In terms of equipment, the latest DOH evaluation of the hospital points out

that the Emergency Room lacks emergency equipment such as a defibrillator, emergency lights, fire extinguishers signages and facilities for the disabled. Emergency care services also need to be strengthened for more efficient and effective response to trauma cases. The hospital also needs equipment for Maternal and Child care such as infant incubators, bili lights, infant/child resuscitators, steam sterilizers and delivery tables. NOPH, GWBVMH, Bayawan District Hospital and Bais District Hospital need a Vacuum Extractor Breech for these facilities to be CEMOC certified. Other hospital departments and sections are also wanting of equipment upgrade to improve the overall service capability of the hospital.

A waste management system needs to be set in place in the provincial hospital in compliance with the Solid Waste Management Act. The provincial hospital lacks vault for infectious wastes and storage for wastes. Likewise, a treatment facility for waste water is needed.

There is a need to construct a septic vault, on- site storage facility for solid

waste, and a wastewater treatment facility. Likewise, a shredding machine for infectious sharps is needed in compliance with the standard Health Care Waste Management policies. Personnel directly involved in handling hospital waste are not yet immunized.

Equipment maintenance, especially the CT scan, ultrasound machine, X-

ray unit, mammography machine, the aging dialysis machines and the automated analyzers of the hospital laboratory as well as the different equipment in the OR and anesthesia department, is another major problem confronting the management and operations of the hospital. When these equipment bog down, repair takes a long time and this results to more unserved patients and loss of hospital income. Governor William Billy Villegas Memorial Hospital (GWBVMH) of the CVGLJ district, Bais District Hospital of MaMaBaTaPa district and Bayawan District Hospital of SantaBayaBas district share similar problems in terms of manpower gaps as well as facilities and equipment upgrade.


The Canlaon City Hospital needs upgrading from a 10-bed primary community hospital facility to a 25-bed facility due to its occupancy rate of 137 per cent. Bais District Hospitals wards in the entire annex floor of the Medical Annex building had been closed for lack of personnel. The laboratory and dental clinics need renovation and equipment upgrade; the nurses dormitory and doctors quarters need repair. It has a Family Planning room that is not fully equipped as a Womens Clinic; several comfort rooms need to be repaired. Basic equipment such as Infant incubator, suction machines, nebulizers and oxygen gauges are badly needed too.

All hospitals need ambulance too for timely referral. Mabinay Medicare Hospital, a 10-bed facility, with an average utilization

rate of 15.2 per cent bed occupancy, located within the MaMaBaTaPa district, is also in need of a new autoclave sterilizer.

The 25-bed capacity Congressman Lamberto L. Macias Memorial Hospital

(CLLMMH) of SiaZam district has a service utilization rate of 58.3 per cent. This is one of the hospitals with high referrals to other health facilities because of the limited capability of diagnostic services. Aside from this, the hospital lacks medical equipment for infant care and cardiovascular disease management. Other problems the hospital needs to address are those of prescriptions which are mostly filled outside the hospital pharmacy. It has not implemented the clinical practice guidelines yet.

CLLMMH is a DOH-licensed secondary hospital, but PHIC downgraded it to

a primary facility because it lacks surgical capability as the resident physician who was trained in surgery transferred to a rural health unit in the province. The hospital does not have space for conference and trainings. Neither does it have a supply room or a stock room. Thus, conferences and trainings are held either at the mess hall or at the hospital garage. The hospital construction is only 50 per cent complete.

Bindoy District Hospital is standing on a swampy area near the shoreline in the middle of a thick mangrove where sea water intrusion in the building area may have caused the early deterioration of the hospital structure as well as its equipment. To sustain the quality of its services and eliminate the dangers to its occupants and clients, the facility needs rehabilitation, equipment upgrading and maintenance especially in the laboratory, emergency room and dental services. Core logistics in the delivery of health services and the strengthening of the referral system are also among the priority needs of the hospital. C. HEALTH FINANCING

Hospital income is derived from professional fees, accommodation, laboratory examination fees, and other users fees, all of which are held in trust at the Office of the Provincial Treasurer. The hospital income held by the Provincial Treasurer is utilized to fund portions of hospital operations in a form of supplemental budget based on the approved work and financial plans of the individual plans as approved by the Sannguniang Panlalawigan.

Public health financing like the Free Hospitalization Health Care Plan, although slowly gaining ground, remains isolated in identified LGUs and funds are insufficient as yet. The same is true with the community-based health financing scheme. An innovative approach of this community management, the PESO for Health, is the experience of the four municipalities in the catchment area of


Guihulngan District Hospital of the first Congressional District and of the two (2) municipalities and one (1) city of Bayawan District Hospital of the 3rd congressional district.

Public health and the community-based health financing still need to be made acceptable and implementable. The benefits given by these two plans have yet to be supplemented. Some concerns still need to be addressed by the provincial government such as the lack of compulsory insurance plan to address the increasing cost of medical care; limited population coverage, limited service coverage, and low level support; medicare is applicable only to those who have stable jobs of which majority of our people do not have; untapped Health Maintenance Organizations (HMOs) since these are not common in the province yet; under registration/under reporting of births and deaths.

Based on the previous analysis the following are the gaps and deficiencies identified which likewise serve as the bases in the selection of the overall strategic objectives and interventions to undertake in initiating financial reforms.

National Health Insurance Program

o Low coverage in NHIP (15% of total households) o Premium scheme for 3rd class and up municipalities and cities not

sustainable o Non inclusion/participation of non-formal sector in the HIP o Lack of information campaign pertaining to NHIP o Lack of ordinances ensuring continuity of the NHIP o Political bias in selection of indigents o No capitation for IPP and sponsored enrolees (no incentive for

advocacy) o Absence of enrolment desk in most facilities o Lack of local support for strengthening NHIP in the LGU to make it

compulsory and universal o Capitation fund is not adequate in some LGUs (3rd Class up &

Cities) o Delayed PhilHealth reimbursement in hospital expenses o Lack of counter-parting scheme of the different sector to lighten

the premium burden o Lack of an objective means of identifying the poor (political

indigents) o Promotes indigency

Community-based Financing Initiative

o Limited portability, benefits and coverage (Affordable compared to NHIP)

o Competition between local initiative and NHIP in some ILHZ o Assessment and evaluation of community based health insurance

Local Government Unit Health Financing

o Inadequate LGU budget to support health implementation o Limited LGU financing for MOOE and Capital outlay for health o Health investment is only 125 pesos per capita (10% of average

annual cost of health per capita per year) o Non institutionalization of health program o IRA dependent LGUs, limited income


Hospital Financing

o Inadequate supply of drugs to provide for admitted NHIP members o Prescription of non essential and non generic drugs which is not

reimbursed by PHIC o Lack of standardized users fee for hospital care and services o Lost opportunity for income due to inadequate laboratory

capabilities o Delayed reimbursement of PHIC claims o Stopping of sub-allotment in hospitals which delays purchases of

emergency needs

ILHZ Common Fund Financing o Non compliance of agreed annual contribution for the pooled

fund o Lack of uniformity or guidelines in the use of the Common Health

Fund o Lack of trust between LGUs in entrusting funds in the ILHZ due to

various factors o Lack of follow up for the collection of the funds and sanctions for

non-compliance o Non functional ILHZ

Congressional Development Fund o Strong political bias in the awarding of CDF o Irregular source of financing o Dependent on politician whims and caprices

External Factors - Out-of-Pocket

o Over-reliance on dole outs and free medical services and goods o Lack of appreciation for savings for health or insurance system

Grants

o Specific programs and project, limited scope o Lack of information dissemination for other LGUs to avail o Short to medium term o Too many technical requirements for compliance o Counter- parting bias to the higher income LGUs which could

afford it

D. GOVERNANCE

There are three major essential external factors that hamper the efficiency, effectiveness and relevance of the provincial health system. They are (1) low priority and low allocation of resources for health; (2) the negative impact of the devolution of health services as mandated by the Local Government Code (LGC); and (3) the general lack of health consciousness among the people.

One of the major deficiencies of the hospital system in the province is the non-operational Provincial Health Information System. Health personnel have limited skills in computer programming and are still illiterate in the software application. In addition, there are no computers, servers, and other necessary hardware and software components.


Another gap is the non-functionality of some structures. There is a need to reorganize and strengthen the different hospital committees which include among others, the Therapeutics Committee, Infection Control Committee, Quality Assurance Committee, Waste Management Committee and the Disaster Control Committee. Trainings of the committee members are likewise needed to effectively implement the programs under the control and supervision of their respective committees. Activities of the above-mentioned committees are evaluated by concerned government agencies for accreditation and licensing purposes so that budgetary support is a must.

Administrative issues and concerns which can be considered under the governance reform are the limited employment opportunities and unfavorable working conditions common among rural health workers. Other issues are the non- full implementation of the Magna Carta of Public Health Workers and the Salary Standardization Law in many LGUs. The devolution of health services is not well explained and understood by health workers. Arbitrary change in the positions and assignments is perceived as politically mitigated.

Another deficiency is that most of the health personnel lack training on service areas particularly on Clinical Practice Guidelines, Referral System, Disease Surveillance System, Newborn Screening, Management Information System with Information Technology, Comprehensive FP for nurses and midwives, Non-scalper Vasectomy for Physicians, Maternal Care and Partograph, IMCI, Health Lifestyle Training, Procurement System, Medical Records Management and all SS-related trainings.

Other issues, concerns, gaps and deficiencies identified are presented below:

1. Management Structure

- failure to identify a regular official representative to the District Health Board and or Technical Management Committee meetings

- District Health Boards are not updated on health and health related issuances

2. Financial Management

- no local ordinance supporting the budget allocation of the LGU counterpart for the Common Health Fund

- some participating LGUs have not allocated their counter part fund for the Common Health Funds in their respective ILHZ

- no written guidelines for the utilization of the Common Health Fund

3. Management Support System

- ILHZ plan cannot be implemented due to non compliance of LGU counterpart for the Common Health Fund

4. Health Management Information System

- no computer hardware for the implementation of the Philippine Local Health Information System

- HOMIS not functional in Bayawan and Canlaon District Hospitals

- HOMIS not installed in the Provincial Hospital and the rest of the District Hospitals

- Lack of training of PESU, CESU, DESU and MESU on disease surveillance and outbreak response protocol

- Lack of resources for training of BHWs on CBMIS - Lack of logistics for reproduction of forms for


CBMIS (maternal mortality review, under five mortality review, new born screening)

5. Monitoring and Evaluation

- no active community participation on monitoring and evaluation of plans and projects within the ILHZs

- lack of budget allocation for monitoring activities as proposed in the ILHZ plans

- no feedback mechanism on monitoring and evaluation results

6. Health Human Resource Development

- lack of coordination with the Center for Health Development Central Visayas on the provision of technical assistance and capability building e.g. health leadership and management program

- no committee to track the implementation of re-entry plans of trainees

- loss of opportunity for study grants/fellowships for LGU health personnel

- missed opportunities for career path - lack of recognition for health and health related

community designed training modules - limitation for hiring additional health workers

because of the 45% ceiling on personnel service 7. HealthCare

Financing - no inventory of community based health care

financing schemes - master list of indigents in all ILHZs have to be

validated and updated - users fees in government hospitals are

obsolete and unrealistic - sustainability of endowment and medical

assistance fund from SP/SB - lack of training on financial management e.g.

disbursement of funds

E. REGULATION

Long and tedious process in drug procurement, temerity in assuring safety and efficacy of medicines, high cost of medicines, unavailability of medicines in government facilities, poor prescription of generic drugs by doctors, substandard drugs of fly-by-night suppliers, and difficulty of doctors in memorizing the long list of generics drugs are the issues that confront the health care system in the province.

Other deficiencies are in the manner of distribution of medicines, which has been under the control of some local chief executives. It has been observed that some City/Municipal Mayors or their representatives have taken the responsibility for the distribution of medicines.

On drug management system, most medical practitioners do not fully comply with the Generics Act.


Chapter IV

GOALS, OVERALL STRATEGIES AND SPECIFIC INTERVENTIONS

It is the overall goal of the province to improve the health status of its population. Specifically, with the implementation of this plan, it is expected that the province would experience a 25% reduction in the prevalence of morbidity (caused by lifestyle-related diseases and others), 17% reduction in infant mortality rate, 15% reduction in maternal mortality rate, and 5.1% reduction in malnutrition.

To attain such improvement in the health status, this investment plan aims to ensure the following:

1. Access to quality, integrated, comprehensive, continuous, affordable health care services, goods and facilities in partnership with the community. This could be achieved by ensuring that:

a. All RHUs and hospitals are SS certified/PhilHealth accredited;

b. All health facilities have adequate and competent HHR; and

c. All private health facilities and providers are regulated

2. Effective and efficient allocation, generation and, mobilization of resources, whereby:

a. Per capital expenditures would increase by 5% every year;

b. PhilHealth indigent coverage would increase by 25%;

c. PhilHealth capitation would increase from PhP11M to PhP18M;

d. Benefits from Community Based Health Financing scheme would complement (interface with) PhilHealth benefit packages;

e. Socialized users fees are institutionalized in both public hospitals and RHUs;

f. DRF/BnB/HPO are established

3. Improvement in the unified technical direction and operational coordination of all providers at all levels and sectors province-wide, whereby:

a. Sector-wide approach to health is implemented in all components of the local health system; and

b. There is functional organizational structure and systems in the various levels of governance (i.e. Provincial Health Board, Inter-Local Health Zone, Local Health Board, District Health Board)

4. Strengthened regulatory functions at provincial and municipal level through ordinances and legal mandates where:

a. ILHZ Therapeutic Committees are established;

b. There are Policies relative to the detailing of midwives;

c. Outsourcing of doctors are carried out;

d. Compliance to SS Certification and PHIC Accreditation is achieved; and

e. Policies on revenue generation (i.e. users fee, RDF, and others) are adopted through appropriate local legislations


It should be noted that the main strategy of the province to achieve these sets of goals are two pronged: first is ensuring that basic or essential health care is provided to all; and second is the provision of services that goes beyond what is basic.

The primary health care approach where there is partnership among the

community, government and private sector, and non-government organizations which focuses on the importance of community participation in the identification of health related problems and in finding its solutions to improve the socio- economic development of the country shall also be adopted under each reform area. A. HEALTH NEEDS

1. Births and Deaths Each LGU through the RHUs, keeps records of births and deaths in their respective locality. Data are generated by the RHMs from their field of assignment. Consolidation of these data for the whole province is incomplete because not all LGUs share their statistics with PHO. Figures of morbidity and mortality are often underestimated because of unreported cases. Making the FHSIS functional at all levels is the immediate possible remedy to this situation. Massive orientation and trainings on the FHSIS, encoding and decoding of data, and high awareness on the systems features should be highlighted to give emphasis to it being a management tool. To this effect, all LCEs and Barangay Captains will formulate a workable and doable policy legislation that will capture and store all information on health indicators. Advocacy on local policy to decision makers therefore is the initial step to be followed by hands-on training on the system prior to procurement and acquisition of the necessary software and hardware. Actual and factual report of the causes of morbidity and mortality are important in identifying appropriate options for health care initiatives. To avert the increasing number of CVD cases, more particularly on the direct and indirect effects of smoking, massive IEC activities should be conducted.

2. Maternal Mortality

Adequate training on the management of emergency obstetrical cases and provision of equipment can help in the reduction of maternal mortality rate. Also, most midwives are serving two to three barangays so that they are not residing in one specific area. One midwife should therefore cover only one barangay, and the Reside or Resign policy should be enforced to make available services of midwives 24 hours. However, it should be considered that even if services of midwives are made available round the clock, the possibility of high maternal death rate is still possible if pregnant mothers themselves refuse to undergo prenatal check up. Other strategies that should be considered are a strong advocacy on Safe Motherhood and Family Planning Program, capability building on Maternal Care Partograph, upgrading of health facility for Maternity Care Package, upgrading the capability of health personnel, revitalization of the MDR, provision of ambulance for immediate/timely transport of referral cases, provision of quality


prenatal care, additional hiring of qualified health workers and networking of NGOs.

3. Infant Mortality All hospitals should perform newborn screening. Likewise, newborn screening should be part of the requirements of standard hospital facilities or services for accreditation. This is necessary to prevent and avert inflection of metabolic diseases if detected and managed much earlier. Vaccines for all types of communicable diseases should be made available and affordable to provide children full immunization. Complementing this is the conduct of IEC activities for parents, teachers and the community on the importance of full immunization, particularly on infectious or communicable diseases.

4. Malnutrition High profile information and education campaign on proper nutrition and massive training on food fortification are basic initiatives to control or eradicate malnutrition. Exclusive breastfeeding of babies for at least six months or even up to two years should be sustained by mothers, thus massive information on this practice should be a daily task of the service providers who come in close contact with mothers or both parents. B. SERVICE DELIVERY

Generally, public health programs need to be intensified in order to

achieve the targeted improvements in health outcomes. Advocacy and health promotion, training among health personnel, networking with stakeholders as well as ensuring continuous supply of drugs and medicines are activities identified common to strengthen public health programs.

In terms of hospital investment strategies, the province can take various directions. These may range from the conversion of primary/community hospitals to provide hospital outreach services or its development into centers for specialized health services (i.e. birthing homes, TB DOTS Center). They can also serve as self-help reinforcement centers or as extension of the core hospitals while the provincial hospitals remain as main providers for secondary and tertiary care. While these serve as preliminary proposals to guide hospital investments, a rationalization study has been proposed to provide an objective assessment on how the health facilities within the province should be developed.

Offhand, stringent policies on the admission and referral of patients from other provinces and other hospitals in the province to the NOPH are not observed. It is imperative that a referral system should be operational to address the problem of overcrowding in this hospital.

The Referral system must be put on the ground and should take off the soonest time possible. To carry out this effectively, appropriate and adequate


time should be set aside to orient and understand the referral procedures and policies, which should be universally adopted. While the ethical and moral mandates of hospital facilities is that of open admission, quality service and accommodation are of equal concern. All district hospitals must be improved and upgraded so that referrals to the tertiary facilities can be minimized. Improvement and upgrading are not limited to buildings and structures but must include facilities, equipment and materials. All hospitals will be asked to submit program of work and estimates for civil works for areas subjected to improvement and upgrading. Further, manpower capability enhancement is a way by which manpower gap can be filled in. Upscaling of technical, managerial, and field health supervision come high in these agenda. To enhance capability, medical books, updated medical and nursing journals should be made available at all times in a medical library. Continuous upgrading and human resource development especially in ensuring adequate supply of health workers should also be given importance, not only through the DOH or CHD-prescribed trainings and seminars but also through professional involvement of various professional groups in their annual conventions and seminars.

Capability enhancement trainings for health personnel need to be conducted and refresher courses should follow regularly after training sessions.

Lakbay Aral in other provinces to gain or exchange best practice experiences and attendance in national conventions on special areas can help increase practical approaches to health service delivery and realize reforms in the critical areas of the health sector, thus these should be encouraged.

On the other hand, prognosis and diagnosis sometimes appear slow and reach at some point of inaccuracy due to the depreciating and outmoded equipment of the hospitals. Furthermore, situation analysis on the delivery of health care services emphasizes the need to improve the quality of health care given to the community. Quality health care is ensured in the SSII certification and PHIC accreditation. Thus, the major strategy proposed by the province is to make all health facilities SSII certified and PHIC accredited. Compliance with SSII accreditation for RHUs/ CHOs and DOH licensing standards for hospitals fill in the identified gaps and correct the deficiencies of manpower shortage, facility and equipment upgrading, supplies and medicines shortages, logistics and management system. The public notion of government hospitals having substandard or poor quality service is sometimes concealed true and real. But, this notion can be dispelled with the modernization, upgrading and facelifting of hospital structures, facilities and equipment. A uniform policy should be adopted and enforced without let up. To identify flaws and bottlenecks, a regular monitoring and evaluation must be part of the hospital system operation and administration.


C. HEALTH CARE FINANCING As one of the major components of HSRA, financing of health is the most tangible indicator on the sincerity of LCEs in putting their hearts where their mouths are. Health as a primary social service is often considered as a priority of many LCEs. While this may often be the case, budget for health in each locality points otherwise. Per situationer, the average investment for health per capita is only P125.00 per year. Apparently this is short of the need for health care, given the current rate and prices of essential drugs

Documents

Negros PIPH[1]