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2010 ARMM-WIDE ANNUAL OPERATIONAL PLAN FOR HEALTH

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CONTENTS Executive Summary I. Introduction – Exploring the Features of the ARMM

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II. Situation Analysis of Health

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A. General Health Status

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B. Public Responsiveness of the Health System (Service Delivery)

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C. Distribution of Health Expenditures (Financing)

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D. Regulation

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E. Organizational Set-up of Health System in ARMM (Governance)

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III. Analysis of Gaps and Deficiencies

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A. Health Service Delivery

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B. Health Regulation

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C. Health Financing

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D. Health Governance

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IV. Strategies and Interventions

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Vision, Mission, Goals and Objectives

A. Health Program Interventions B. Systems improvement or cross cutting interventions

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1. Service delivery

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2. Effective Health Regulation

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3. Efficient and Equitable Health Financing

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4. Good Governance on Health

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V. Critical Goals and Targets

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VI. Critical Investment Activities

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VII. Proposed Implementation and Management Arrangement

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VIII. Proposed Budget and Source

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IX. Monitoring and Evaluation Scheme

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References

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EXECUTIVE SUMMARY

Major health reforms in the ARMM are necessary to bring the health condition of the people up to a level at par with the rest of the country. As the region undergoes the reform process, it has to face major challenges, to wit: a) the magnitude of health problems is huge in both scale and scope, hence it is critical to focus on interventions that are of public health significance and have the most impact; b) developing the management capacities of a resource-poor health system like in ARMM is as vital as addressing its actual health problems; c) the health situation in the region is unique due to a confluence of factors, e.g. geographical isolation, chronic armed conflict and extreme poverty, thus necessitating a health system tailored to the prevailing situation and needs in the region; d) resources need to be allocated based on the ARMMâ€&#x;s health direction; even if the region has a centralized health system, some health resources have been devolved to the LGUs and these need to be tapped; and e) given the numerous funding agencies and local support, there is a need for the region to rationalize and govern the inflow and utilization of these resources to prevent duplication and wastage of efforts.

Major health problems or issues A. Health or disease-based problems Overall health status in ARMM is much worse than the rest of the country. Infectious diseases, tuberculosis in particular, are the leading causes of morbidity. Other prevalent infectious diseases include diarrhea, respiratory infections, malaria, dengue and STIs. The lack of environmental sanitation facilities and poor practice of sanitation contribute significantly to these diseases. Chronic diseases, particularly cardiovascular diseases, cancer, cerebrovascular diseases and hypertension are the predominant leading causes of death. The overall life expectancy at birth in ARMM is 55.5 years for males and 59.3 years for females, both lower by >10 years with national averages. The health status of women and children in ARMM is particularly low compared to other regions of the country as shown by high maternal, infant and child ratios, compounded by high malnutrition rates. The leading causes of maternal deaths are post-partum hemorrhage, sepsis, and pregnancy-induced hypertension, which account for 94% of all maternal deaths in ARMM, all three of which are preventable with existing interventions and technology. The threat of Avian Influenza in ARMM looms high because of its proximity to Southeast Asian countries where AI cases among poultry and humans, including deaths from H5N, have occurred The existing health programs and available health services in ARMM attain limited reach and coverage, and a big proportion of the population have poor access to the available health services. Antenatal, delivery and post-partum services reach a small proportion of pregnant women, who prefer to deliver at home. Child care interventions such as immunization, micronutrient supplementation, and other nutrition interventions have low coverage and reach. The TB control program is marked with low case detection and cure rates. Overall, there is poor health-seeking behavior among target population groups due to low awareness, cultural beliefs and practices, geographic isolation, difficult transportation and extreme poverty.

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B. Health systems or cross cutting problems Health resources. There is an absolute lack of health human resources in ARMM. The available plantilla positions for health workers is much lesser than what is ideal for the standard health manpower to population ratio. Health facilities are also lacking, and access to the limited number of basic health facilities is hampered by uneven distribution especially in the remote areas, land-locked and island provinces. These facilities usually function at a level below the specified DOH standards. This is not surprising given the very limited funding available for operations.

Health regulation. Existing health regulations, policies and guidelines need to be modified to take into account the condition and local set-up in ARMM. Local legislation in support of national policies are barely existent and no policy advocacy measures have been instituted to lobby for health sector reforms among Local Chief Executives. Access to quality and affordable drugs is severely restricted given the low number of drugs stores, many of which are not licensed.

Health financing. The benefits of social health insurance in ARMM is not optimized because of low enrolment in PhilHealth, which in turn is due to low incentive for LCEs to enrol their indigent constituents and the lack of PHIC accredited facilities where enrollees could avail of benefits and services. There is no financing framework in ARMM to guide policy makers and program managers on how to mobilize resources and augment funds for health.

Health governance. The absence of clear governing policies like implementing rules and regulations that crystallize the type of health system in ARMM somehow affects the operational efficiency for health operations. Roles of the LGUs in health are not clearly defined. The institutional arrangement for public and private sector partnerships for health is not visible in ARMM, resulting into minimal coordination between public and private sectors in delivery of health services in the whole region.

DOH-ARMM is dependent on funds coming from the national government with minimal amount directly generated at the regional level. This is combined by an inadequate amount of contribution from the LGUs. Despite the bigger amounts ARMM LGUs received (from IRA and from share on internal revenue collection in ARMM), most LGUs have low expenditures for health since health has not been devolved to their level.

The referral system is fragmented despite the fact that in ARMM, the district health system is still in place. People seek basic health care directly from hospitals and other higher levels of health care instead of going to outpatient primary health care facilities because the latter are not adequately manned and equipped. Due to lack of maternal health workers, many traditional birth attendants (TBA) attend to majority of deliveries, and their practice is not regulated given the absence of clear-cut policies on TBAs.

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Aside from the shortage of health workers in ARMM, the existing crop of health workers have weak capacities and are further limited in delivering services due to lack of resources for operations.

Information needed to improve management of health programs in ARMM is of inadequate and of poor quality due to an ineffective health information system (HIS). There is a no institutional communication and marketing for DOH-ARMM and a unified Communication for Behavior Change and advocacy plan for all health program is ARMM.

Procurement and Logistic Management. The DOH-ARMM procurement and logistics system has a low level of efficiency and responsiveness to address the demands of the core helath programs and to improve access to low-cost quality essential drugs. In view of these gaps and deficiencies, strategies and interventions will be geared towards strengthening the public health programs complemented with interventions to improve the health systems along the four F1 pillars. The thrust is empowering the region for better health outcomes. Goals, critical interventions, expected outputs, and outcomes. The over–all goal of DOH-ARMM is to improve the final health outcome of its populace, especially the marginalized, deprived, disadvantaged, underprivileged and poor, for the next five years and beyond in congruence with the FOURmula One Health System Goals and Medium-Term Philippine Development Plan (MTPDP) 2004-2010 Goals. Its objectives are anchored on the National Objectives for Health (NOH) health performance indicators, including the Millennium Development Goals.

A. Health Program Interventions

1. Disease Free Zone Initiatives – The burden of infectious diseases (rabies) will have to be reduced if not eliminated by improving the quality of public health work, capacity-building, health promotion, and disease surveillance. 2. Intensified Disease Prevention and Control - The incidence of infectious diseases (Tuberculosis, malaria, schistosomiasis, filariasis, leprosy, dengue and STD/HIV/AIDS) will have to be reduced by improving the quality of public health work, capacity-building, health promotion and disease surveillance. The threat on avian influenza from neighboring countries will have to be deterred by preventive measures coupled with active surveillance on the ports of entries in close coordination with Department of Agriculture and other key players.

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3. Maternal and Child Health and Nutrition (including Family Planning and Dental Health) - The survival, health and development of mothers and children will have to be ensured specifically to address leading causes of mortality and morbidity of mothers (postpartum hemorrhage, sepsis, and pregnancy-induced hypertension) and children (pneumonia, diarrhea, etc.) which are highly preventable through cost-effective interventions. 4. Chronic Diseases and Health Risk Management – The leading causes of mortality and morbidity due to chronic diseases will have to be pared down by comprehensive and integrated action within the framework of public health and primary health care such as healthy lifestyle promotion and population-based risk management, individual and mass screening activities, early detection coupled with cost effective interventions, capacity enhancement and provision of basic equipments, laboratory reagents and supplies. On the other hand, at the hospital level, health service providers handle primary and secondary cases depending upon its capability otherwise referral system to tertiary levels should be strengthened. 5. Environmental Sanitation and Hygiene – Morbidity and mortality on water and food-borne diseases attributed to poor environmental sanitation and hygiene will have to be thwarted by strengthening environmental sanitation and hygiene program through increasing households‟ access with safe water supplies, sanitary toilets, and increasing the compliance to food establishments with sanitary permits and food handlers with health certificates. 6. Disease Surveillance and Epidemic Management System - The number of deaths and illnesses due to disease outbreak will be managed by establishing or strengthening the Disease Surveillance and Epidemic Management units at all levels from regional down to municipal levels. 7. Disaster Preparedness and Response System – The pitfalls on health emergencies during disasters will have be minimized if not prevented through training packages, provision of logistics, ambulance, drugs and medicines, establishing a functional operation center with complete communication facilities, public awareness programs, and financial resources,and a well coordinated and collaborative effort with different line agencies and stakeholders. B. Systems improvement or intertwining interventions

1. Health service delivery - The strategies and activities in service delivery systems will address the issues on distribution of health facilities and services, improving the referral system and enhancing service delivery modes. The overall goal is to improve accessibility and availability of basic and essential health care for all especially the poor. Underlying this main goal is to ensure that the delivery of health services is sensitive to local culture and practices. 2. Health financing - The overall goal of health financing is to secure increased and sustained investments in health, and ensure efficient utilization and equitable distribution of resources. This will improve health outcomes, especially of the poor. Outlined under this component are activities on establishing local health accounts, diversification of financing resources and expanding health insurance coverage.

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3. Health regulation - Strategies and activities under this component will address issues on licensing and accreditation and availability of affordable medicines. The main goal is to assure access to quality and affordable health commodities, facilities and services especially those commonly used by the poor. 4. Health governance - The objective of good governance strategies and activities is mainly to improve health systems performance in the region and at the local levels. Interventions under this component will address issues on health human resource, partnership arrangement and coordination with stakeholders, strengthening management capacities, health information system and monitoring and evaluation. Policy advocacy to localize nationally initiated policies and promulgation of health code. Likewise, promulgation of local policies. Major investment items: Given the amount of financial requirements of the AIPH for five years and the limited resources, there is a need to prioritize which investment activities should be implemented first. Coordination of all health activities is critical to avoid duplication of efforts and to ensure complementation of interventions. Facility mapping, assessment and rationalization are crucial in determining how many facilities will have to be refurbished and/or created. On the other hand, an effective public finance management system and a system of health accounts will ensure that resources are used efficiently, monitored easily, and that policy and program interventions are sound and evidenced-based. The following are the major investment in:

Service Delivery

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Maternal health care Child health care Environmental sanitation and hygiene Disaster preparedness, HEMS & ER

- FP - Infectious disease control - Healthy lifestyle - Surveillance

Health Systems

- Health Facilities Development - Regulation Selected Investment Proposals

- Governance - Financing

The AIPH shall be financed through internal and external funds. The internal funds are those sourced out from the funds of the Office of the Regional Governor. (In ARMM context, LGU refers to regional government and not on its component provinces and municipalities, which derive its financial resources from ARG itself). Internal funds also includes DOH-CO releases some subsidy funds for the implementation of a centrally-managed health programs and projects. The external funds will come from other funding agencies

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operating or will operate in the region. Currently, the DOH-ARMM is a recipient of USAID technical assistance on health. This funding support had been factored into the budget. It has also specifically identified other funding institution like EC, which had already sounded off their proposed support. Where specific donor agencies are not identified, DOH-ARMM could other support e.g. WHO, UN Agencies, Islamic States, and other development partners, including NGOs.

The total cost of the ARMM-wide investment for health is about PhP 6.246 billion spread across several sources (Tables 20 and 21). About PhP 1.798 billion (28.8%) will come from DOH-ARMM allocation from the regional government. The major items of expenditures under this source are mostly for the salary of newly hired helath personnel and development of health facilities. The LGUs will shoulder about PhP 0.716 billion, which will be in the form PhilHealth premium contributions (the same amount will be counterparted by PhilHealth). The DOH-Central is proposed to assume about PhP 2.550 billion (40.8%) in the forms of drugs, medical supplies, upgrading of BEMONCs/CEMONCs and various training. The remaining Ph 1.181 billion will come from development partners e.g. USAID, EU, WHO, UNICEF, JICA and others. The development partners will take on some form of capital outlays (construction of hospitals), technical assistance (training and consultancies), drugs and medicines.

The medium-term investment on health, which is about PhP 6.246 billion, is extended over a 5-year investment period, 2008 – 2012 (Tables 22 and 23). The investment spending will progressively increase starting at about PhP 0.157 billion (2.51%) outlay in Y1. Year 1 expenditures are mostly technical assistance to establishment of the AIPH Management Team (including managerial capacity building), carrying out baselines studies and critical trainings, procurement of drugs and remittances for PhilHealth premiums of LGU-enrolled indigents. Major capital investments and hiring will start in Y2. Beginning in Y2, the average annual investment is P1.522 billion.

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INTRODUCTION The implementation of health reforms in the Autonomous Region in Muslim Mindanao (ARMM) builds on the lessons and experiences of major health reform initiatives foremost of which are the Health Sector Reform Agenda (HSRA) and Fourmula One (F1). In 1999, the HSRA was formulated to provide general directions for reforming the health system in the country. The HSRA became a reference in the development of the first ARMM Strategy for Health Improvement (ASHI), a strategic framework intended to scale up efforts on health improvement initiatives in the ARMM. However, both the HSRA and ASHI were strategic frameworks that did not provide operational handles and details. In 2003, the Department of Health Central Office (DOHCO) then came up with the implementation frame called the F1 focusing on critical health interventions to jump start the reform, backed by effective management and financing arrangements. For DOH-CO, F1 became its implementation framework.

The formulation of the AIPH initially began in February 2007 through consultations with the provinces in ARMM. The provincial health officers were tasked to develop and complete their own province-wide investment plans for health (PIPH). The consolidation of the PIPHs of the six provinces into a single ARMMwide investment plan started in June 2007. This AIPH takes off from the lessons of the ASHI and will be guided by the F1 but will take into account the uniqueness of the region.

Major health reforms are necessary to bring the health of the people in the ARMM up to a level at par with the rest of the country. As the region undergoes the reform process, it has to deal with the following challenges: a) the magnitude of health problems is huge in both scale and scope, hence it is critical to focus on interventions that have the most impact or of public health significance; b) developing the management capacities of a resource-poor system like in ARMM is as vital as addressing the actual health problems; c) In spite of ARMM expansion with centralized health system, some health resources are still devolved to the LGUs and need to be tapped; d) the health situation in the region is unique due to a confluence of factors, e.g. non-contiguous geographical setting, extreme poverty, chronic armed conflict, and presence of various ethno-linguistic groups, thus necessitating a health system tailored to the prevailing situation and needs in the region; and e) given the numerous funding agencies and local support, there is a need to rationalize the inflow and utilization of these resources to prevent wastage and duplication of efforts.

This ARMM Investment Plan for Health (AIPH) aims to present the operational framework for reforming the health system in the ARMM in the context of F1. It provides critical strategies to improve the capacities of DOH ARMM in effecting better health outcomes and it brings forth a common health agenda that need to be supported by both the DOH-ARMM and the DOH-CO. It is intended to guide health managers, donors, LGUs, NGOs, the private sector and other stakeholders in undertaking collaborative work with the region.

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I. Exploring the Features of the ARMM A. History and Legal Mandate For the most part of the Philippine history, the region and most of Mindanao have been a separate territory, neither subjugated nor culturally assimilated to mainstream Filipino society, enabling it to develop its own culture and identity. The region has been the traditional homeland of Bangsamoros since the 15th century even before the arrival of the Spaniards. Arab missionaries Sheikh Karimul Makhdum arrived in Tawi-Tawi in 1380, followed by Shari'ful Hashem Syed Abu Bakr in Sulu in 1450, and later followed by Shariff Kabunsuan in mainland Mindanao who started the propagation and spreading of Islam into the native Moro population. In 1457, the Sultanate of Sulu was founded and not long after, the sultanate of Maguindanao was established. At the time when most of the Philippines was under Spanish rule, these sultanates maintained their independence and regularly challenged Spanish domination of the Philippines. The armed resistance against the Spaniards lasted over 350 years, until the Spaniards were defeated by the Americans in the 1898 Spanish-American War. The Treaty of Paris which transferred sovereignty over the Philippines from Spain to the United States included Mindanao, Sulu and Palawan (MINSUPALA) as part of the Philippine territory. When the Philippines was granted independence by the U.S. on July 4, 1946, the Bangsamoro homeland was incorporated into the Republic of the Philippines without the approval of the Sultanates. Sulu Province was created from the Department of Mindanao and Sulu (July 23, 1914). Marawi City (former Dansalan City) was created under Commonwealth Act 592 on August 19, 1940 but was inaugurated only on September 30, 1950. On June 16, 1956, Dansalan City was renamed Marawi City under Republic Act No. 1552 and later, on April 15, 1980, Resolution No. 19-A was passed and adopted by the Sangguniang Panglunsod, renaming Marawi City as Islamic City of Marawi. Lanao del Sur from Lanao (on May 22, 1959 by RA 2228), Tawi-Tawi Province from Sulu (on September 11, 1973 through PD 302) and Maguindanao province from former Cotabato (through PD 341 on November 22, 1973). Basilan province was created out of Zamboanga del Sur by virtue of PD 356 on December 27, 1973. Recently created (October 28, 2006) was the province of Shariff Kabunsuan from Maguindanao through Muslim Mindanao Autonomy Act No. 201. Article 10 of the 1987 constitution mandated the Congress to create the ARMM. In 1988, the Regional Consultative Council was formed and tasked to draft the Organic Act for Muslim Mindanao which was signed into law (RA 6734) by the then President Aquino on August 1, 1989. On November 17, 1989, a plebiscite was conducted in the proposed areas of ARMM and provinces of Maguindanao, Lanao del Sur, Tawi-Tawi and Sulu opted to join the area of autonomy. The first set of ARMM officials elected on February 17, 1990 formally operated on July 6, 1990 following the oath taking of Atty. Zacaria A. Candao as its first Regional Governor. After the signing of the 1996 Peace Agreement between the Government of the Philippines and the MNLF, the Special Zone of Peace and Development (SZOPAD) and Southern Philippines Council for Peace and Development (SPCPD) were created by virtue of Executive Order No. 371 signed by President Ramos on October 21, 1996. Governor Misuari was named SPCPD Chairman. To sustain peace and development efforts in Mindanao and as part of the commitment to the Peace Agreement, President Arroyo supported the 2001 plebiscite for the ratification of Republic Act 9054, expanding the area of autonomy to include the province of Basilan and Marawi City.

B. Government and Political System

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ARMM is the only region in the Philippines that has its own government holding executive, legislative, and judicial branches of governance. Its regional government is headed by a Regional Governor and a Regional Vice-Governor directly elected by the people. It has a unicameral Regional Legislative Assembly (RLA) composed of assemblymen and assemblywomen that has the power to pass legislation with local as well as region-wide enforcement. Its officials are elected every three years separately and not in conjunction with the national and local elections in the country. The seat of the regional government is in Cotabato City, although this city is outside of its jurisdiction. ARMM governs within a large-scale government system with elected members of the congress or the lower house also represents the different congressional districts in areas of autonomous region that can actually influence and shape the health service delivery in the area. Under Executive Order No. 133, series of 1993, the mandate, tasks and functions of the DOH were partially transferred to ARMM. Its mandate is to promote, protect, preserve or restore the health of the people through the provision and delivery of health services through regulation and encouragement of providers of health goods and services. Specifically, it shall be primarily responsible for the formulation, planning, implementation and coordination of policies and programs for health. DOH-ARMM is directly under the administrative control and supervision of the Office of the Regional Governor. The Regional Health Secretary, a position that is coterminous with the Governor, heads the health department. Under the regional health secretary are the different provincial and city health officers.

C. Geographic Characteristics ARMM is located at the southwestern fringes of Mindanao (Figure 1). It is also strategically located in the Brunei Darussalam-Indonesia-Malaysia-Philippines East ASEAN Growth Area (BIMP-EAGA). Its proximity to avian-flu afflicted Indonesia poses threat to the region and the country in general. It is mainly divided into contiguous mainland provinces and non-contiguous Island provinces. The mainland provinces are further sub-divided into Lanao del Sur, Maguindanao, and Shariff Kabunsuan, and the Islamic City of Marawi while the Island provinces are Basilan (including Lamitan City), Sulu and Tawi-Tawi. The difficult geographic condition in the ARMM, characterized by large expanses of mountainous areas in the mainland provinces and the geographically isolated island provinces, imposes a big burden on the ARMM‟s health system which is not felt in the other parts or regions of the country (WB, HD for peace and security, 2003). The region has a total land area of 13,435.26 square kilometers which is about 4.5 percent of the country‟s land area. It has a total of 113 municipalities which is subdivided into 2,504 barangays. There is frequent subdivision of municipalities to create new municipalities. This in turn affects the health service delivery both in the old and new municipalities.

Aside from the advantage of ARMM‟s location, a cache of investment opportunities can be found amidst its natural wealth. Lake Lanao is the biggest source of hydroelectric power in Mindanao. In spite of this, it is sad to note that it is catering electricity outside the region. ARMM boasts for its abundant marine, mineral, agricultural and forest resources which include banana, coconut, mangosteen, lanzones, durian, fish, seaweeds, abaca, basalt, chromites, manganese, gold, silver and copper. However, bananas and abacas are the common habitat of filariasis vector.

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While ARMM has vast water resources like lakes, springs and streams, it is the most disadvantaged region in terms of access to safe water. Only one third of families in ARMM use water from community systems or piped wells, in contrast to 96 percent of families in Central Luzon. Three in every ten households draw water for drinking and/or cooking from spring, lake, river or rain. Residents in Sulu and Tawi-Tawi have to cross the seas to get supply of potable water in Jolo and Bongao paying Php 0.50 to Php 5.00 per container aside from transportation cost. Onslaught of water borne diseases in most areas of ARMM is evident.

D. Demographic Characteristics 1. Population and Distribution Rate

In 2007, projected population showed that ARMM had reached 3,508,632 (RPDO-ARMM). In 2006, the region has a total population of 3,318,032 which is 3.15 percent of the countryâ€&#x;s total population. Maguindanao had the highest population (924,691) while Marawi City had the lowest (162,173) Projected population for the rest of the provinces are as follows: Basilan - 4,207; Sulu - ,337; Lanao`del Sur - 9,184; and Tawi-Tawi - 396,440.

2. Population Growth Rate and Density Figure 1. Average Population Growth Rate, 2000-2005

Based on 2000 Census of Population and 2005 projected population, the regionâ€&#x;s average annual population growth rate is 3.86 percent which is higher than the national average population growth rate of 2.05 percent (Figure 1). As of 2006, the population density in the region is approximately 252 persons per square kilometer (FHSIS-ARMM).

4 3.5 3

3.0 5

3.6 1

3.2 2

2.5

3.5 1 2.7 9

2.4 2

2. 8 National Average

2 1.5 1 0.5 0 ARMM

Marawi City

Basilan

Lanao

Maguin

Sulu

TawiTawi

Source: NSO

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3. Population Pyramid

About 57 percent of the population in the region (excluding Marawi City and Basilan) belonged to the productive ages or economically active persons (15 to 64 years old). On the other hand, the young dependents (aged 0 to 14 years) accounted for about 41 percent while about two percent were elderly dependents (aged 65 years and over). The overall dependency ratio in 2000 was 74 meaning that for every 100 economically active persons (15-64 year olds), there were about 74 dependents. ARMM had a median age of 18 years, and the sex ratio was recorded at 97 males per 100 females. The population-age structure of ARMM shows a very wide base.

E. Socio-Cultural Indices 1. Religious Affiliation

Majority of the total household population in the ARMM are Islam (90.52%) while the rest are Roman Catholic, Philippine Episcopal Church, Evangelicals, Iglesia ni Cristo, and other religions (Source: NSO, 2000 Census of Population and Housing). Islam is one of the major vital determinants of the Filipino Muslims‟ attitude and behavior toward health. Muslim religious leaders play a major role in influencing healthy behaviors, and have been recognized and tapped by earlier UNFPA and USAID-supported health projects in the ARMM for communication and health education particularly on Family Planning programs and the MCH in general but it was not sustained after the projects end.

2. Ethnographic Groups

Muslim constituents in the region are versatile ethnographic groups that share the same religion but they have different local vernaculars from province to province and city to city. The major local Languages and dialects spoken include Maguindanaon (Maguindanao), Iranon (Shariff Kabunsuan), Maranaw (Lanao del Sur and Marawi), Tausug (Sulu), Sama (Tawi Tawi) and Yakan (Basilan). Filipino is also spoken extensively, and serves as the “common” language.

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3. Social Behavior

While Islam is the common religion of most people in the region, they are a people apart with their own customs, traditions, values, and ways of thinking. They are greatly influenced in varying degrees by the intermingling of indigenous culture with clan and tribal dynamics, as well as local economics and politics. It is also noteworthy that the patriarchal system is predominant in decision-making as regards the family (An In-Depth Inquiry into Muslim KABP in the ARMM, 2004). The Muslims‟ understanding of family and community dynamics is to a large extent, filtered through ethnographic lenses – their being Maranao, Maguindanaon, Tausug, Sama, Yakan, Iranon, etc.

Health approaches and strategies that have worked in the past were culturally and socially sensitive and responsive, having taken into consideration the integration of Islamic values and teachings as well as traditional modes of healing into “modern” preventive and curative health care.

4. Literacy and Education

As for literacy and education, the indicators are no better. In 2003, simple literacy rate in ARMM (70.2%) was the lowest in the nation. The national average was 93.4 percent. More noteworthy is the fact that ARMM‟s 2003 literacy figure is actually lower than its 1993 literacy rate (73.4%). ARMM‟s provinces have the lowest participation and enrollment rates, as well as the highest drop out rates. National data revealed that high IMR is noted among infants of mothers with no education, no antenatal and delivery care, and mothers aged below 20 and above 40 years (NOH). About 53 percent of Madaris (an Arabic term for schools) are located in the ARMM. Past projects in the region have tapped these Madaris as channels to help disseminate information on the national and local fatwa (religious edict) on family planning, and other health issues.

F. Environmental Hazards and Vulnerabilities Human vulnerability to natural disasters is growing in the region with the increasing population density and environmental degradation. Although the region is generally spared from typhoons, Maguindanao municipalities surrounding Liguasan Marsh and Sultan Kudarat particularly, have been hit by recurrent flash floods and landslides caused by deforested watersheds and illegal logging activities. Big waves have hit the island provinces of ARMM. Basilan, Tawi-Tawi and in coastal areas in Maguindanao have experienced tsunami in the past. These calamities destroyed properties and livelihood, damaged public infrastructure, disrupted the education of school children and worsened public health services (Figure 2).

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Figure 2. The ARMM Regional Hazard Map

LEGEND Armed conflict/civil strife/terrorism

Mount Kalantungan Earthquake/Volcano eruption/Flashflood

Marawi City

Disease Outbreak/food poisoning

Mount Musuan Tornado/Tsunami/strong wind/Flood

Lanao Sur

Vehicular accident/ Sea mishap Fire MINDANAO FAULT LINE

T L

Mount Ragang

H ZAMBOANGA CITY

Mount Matutum

Maguindanao

Basilan

U

E TR

U

E

C

O AT

Mount Makaturing

H NC

S

R

N

B TA CO

Nevertheless, the major man-made hazard is the long years of armed conflict in the region. The continuing armed-conflict between government troops and separatist groups and terrorists, and to some extent, hostilities between clans/tribes have contributed to the prolonged difficulties of affected communities. It has led to unstable communities and the high mobility of health claim holders and providers made transaction costs higher and health services harder to deliver.

Sulu Mount Parker

Tawi-Tawi

G. Support Infrastructure and Transportation Facilities Essential infrastructure support facilities have not been adequately put in place in the region making it difficult for people to access the already limited available health facilities in the region. There are less roads, unpaved roads and more isolated communities and thus, it is more difficult to provide services from fixed points. Road density in ARMM is only 0.44 of road length per hectare of land compared to 0.61 nationwide and only 8.2 percent of these roads are paved compared to 20.8 percent nationwide. (Source: Mindanao Social Assessment and Joint Needs Assessment, World Bank). H. Poverty Incidence The region is endowed with rich agricultural and marine resources but it is confronted with low production and poor quality of agri-fishery and aquaculture products. The low productivity contributed partly to lack of employment opportunities and lower incomes for most of poor families in the area. ARMM has consistently ranked as the poorest region in the country in 1997 and 2000. Worse, the poverty incidence rose from 50.0 (1997) to 57.0 (2000), the incidence was almost twice the national figure of 28.1 in 1997 and 28.4 in 2000.

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II. Situation Analysis A. General Health Status 1. Life Expectancy The life expectancy at birth in ARMM is far below the national average. In 2000, the figures in the region are 55.5 years for males and 59.3 years for females while the national averages are 66.3 years for males and 71.6 for females (NSO). This means that people in ARMM will likely die ten years younger than people in the country in general. In 2004, life expectancy in the region is 59.3 years, the lowest among the regions, while the national average is 70.2 years (Philippine Statistical Yearbook, 2004). In 2005, the Philippine Human Development Report showed that the ARMM had the poorest health situation, in terms of life expectancy (bottom 5 among all provinces). 2. Burden of Disease a. Leading Causes of Morbidity Six of the reported leading causes of illnesses in ARMM are infectious and preventable in nature. However, it should be noted that these data are facility-based and there may be more cases not actually seen nor treated in any health facility (Figure 3).

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b. Leading Causes of Mortality On the other hand, four out of the ten leading causes of mortality or 41 percent of deaths are due to chronic diseases (CVD, cancer, CVA and hypertension) followed by communicable diseases (36%) while the rest are distributed among trauma, gunshot wound and undetermined causes (23%). Cardiovascular diseases are reportedly the leading causes of deaths with a total of 11.9 per 100,000 population. This was followed by

pneumonia and diarrhea (Figure 4). However, there is an issue on the accuracy of data and correctness of diagnosis. Though there were trainings in ICD-10 conducted among the health personnel in ARMM, not all were trained and given the International Classification of Disease (ICD 10) reference manual resulting to limited implementation of this reporting system. The health statistics for the district and provincial hospitals are also not reflected in the FHSIS. Some cases of malaria are not reflected in the ARMM data as these cases are reported to CHD 9. 3. Crude Birth Rate and Crude Death Rate Crude Birth Rate in 2006 is reportedly highest in Marawi City (25.68/1000 pop) and in Maguindanao (25.08/1000 pop) while lowest in Basilan province (10.85/1000 pop). One of the concerns is the poor registration of birth in almost all areas in the

ARMM-wide Investment Plan for Health

Lanao Sur

Sulu

Marawi City

55


region hence the immediate need to address under reporting (Figure 5).

Source: FHSIS-ARMM

Crude Death Rate is reportedly highest in Tawi-Tawi(1.89/1000pop) and lowest in Marawi City (0.58/1000 pop). Again, under reporting is very common among provinces. Also, majority of the deaths were not attended by physicians lending the accurate reporting of the causes of reported deaths as another major concern.. 4. Maternal Mortality A high number of women in ARMM die of causes related to or aggravated by pregnancy, childbirth and its management. As many as 135 maternal deaths are estimated in 2007 (MMR of 132/100,000 live births, MFHSIS DOH-ARMM 2006). Women commonly die of post-partum hemorrhage, sepsis, and pregnancyinduced hypertension, which account for 94% of all maternal deaths in ARMM.

The slow rate of decline in MMR, which reflects womenâ€&#x;s basic health status, access to health care and the quality of care that has been provided, indicates that many maternal deaths will still occur in ARMM over the upcoming years (Figure 7). The same figure indicates that the National Objective for Health (NOH) target of 90 per 100,000 live births by 2010, and the Millennium Development Goal (MDG) target of 52 per 100,000 live births by 2015, may not be attained in ARMM.

Figure 7. Trends in Maternal Mortality Ratio, ARMM, 2001-2006

250

MMR per 100,000 LB

200 150 100

NOH Target MDG

50 0

2001

2002

2003

2004

2005

2006

Source: FHSIS-ARMM

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There is wide disparity in MMR among the provinces in the region, ranging from 60 in Maguindanao to a high of 380 in Basilan (Table 1). The causes of maternal mortality across the provinces and city of ARMM are similar – post-partum hemorrhage, sepsis and pregnancy-induced hypertension. In the entire ARMM, only 42% of the women who died of maternal causes (maternal deaths) receive medical attendance (NSO 2004). Table 1. MMR by province, per 100,000 live births Given that the health of mothers is inextricably linked to the health of their newborns, it is understandable that a significant proportion of children dying in ARMM occur during the neonatal period. It is during this period when 44% of all child deaths under 1 year of age in ARMM occur (NMR: 18 and IMR:41, NDHS 2003).

The reported leading causes of maternal deaths directly reflect the poor maternal health care received by the pregnant women. Access to maternal health services appears is restricted as reflected by poor maternal care indices.

Province / City

2005

2006

Basilan

300

380

Sulu

230

140

Tawi-Tawi

190

250

Lanao

120

110

Maguindanao

60

60

Marawi City

70

170

ARMM

130

132

Philippines

-

162

Source: DOH-ARMM MFHSIS, 2005-2006

5. Infant Mortality Rate

Figure 8. Trends in Infant Mortality Rate, ARMM 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Figure 9. Under-Five Mortality Rate, 2001 2002 2003 2004ARMM 2005

IMR per 1,000 LB

The infant mortality rate (IMR) per 1,000 live births in the region has been generally declining through the years (Figure 8). However, this is an underestimated value considering the common practice in the area of burying the dead within 24 hours without documentation and the lack 120 Source: FHSIS-ARMM of interest in the filing of death certifications. Besides, ARMM has the Per 100 least percentage (14.4 %) of deaths 1,000 80 attended by health professionals. On LB the other hand, the reported rate is 60 higher among surveys conducted in the region. 40

98

2006

ARMM Philippines

72

Source: FPS 2006

55 42

45 31

20 ARMM-wide Investment Plan for Health

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0 NDHS 1998

NDHS 2003

FPS 2006


6. Under-Five Mortality Rate

Although there was a series of decline in under-five mortality rate from 1998 to 2003 and 2006 in the region, it has to sustain its efforts to continuously bring down the figure to meet the NOH as well as the MDG targets. Latest FP survey showed that ARMM had 45 per 1,000 live births which is significantly higher than the national average of 31 per 1,000 live births (Figure 9). Tawi-Tawi (178) and Basilan (137) have the highest deaths under five years of age while Maguindanao (56) registered the lowest among ARMM provinces.

The observed major causes of infant deaths (Table 2) invariably reflect the poor health seeking behavior for child health care services. High infant mortality rates could be reduced if not eliminated if proper infant care services are provided and availed of early.

Table 2 . Leading causes of death before one year of age, 2006 Causes of death % Pneumonia

41

Diarrhea

22

Prematurity, congenital anomaly, asphyxia, birth injury

16

Neonatal tetanus 6 The childhood mortality rates in 6 ARMM are almost double the Malnutrition national rates. The leading causes Other infectious diseases (malaria, meningitis) 6 of underfive mortality and morbidity remain to be infectious in nature. Source: 2006 FPS Pneumonia is the leading cause of infant mortality (41%) and while data show 96% of children seeking treatment are given appropriate care, a large number still do not get to access health services as reflected in the mortality data. Deaths due to diarrhea is highly preventable and FHSIS data show that life saving ORS sachet is not available to children in the ARMM making diarrhea (22%) to remain in the top ten causes of infant mortality .

An interplay of several factors greatly contributed to this situation. Some of these factors are poor environmental sanitation, undernutrition, cultural and traditional beliefs and practices leading to poor health seeking behaviors. The lack of health personnel, especially midwives and the difficult terrain contribute to the difficulty of providing neonatal and child health services in every barangay. Data in 2006 show that only 66 % of newborns were given newborn care.

Diarrhea as a major cause of infant mortality can be attributed to poor sanitation and waste disposal practices (only 40 percent of mothers in ARMM dispose of the childâ€&#x;s stool properly) and poor healthseeking behavior (only 42 percent seek help from a health facility of whom majority are advised ORS, ARMM-wide Investment Plan for Health

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recommended home fluids or increased fluids (NDHS 2003 p143). Children with diarrhea who are severely dehydrated are not properly treated due to lack of equipment for intravenous fluid therapy, . Furthermore, only 80 percent of mothers in ARMM have knowledge of ORS packets as treatment for diarrhea, the lowest among the regions. Consistently, a big proportion of mothers (like teenage mothers, those with no education and mothers in the poorest quintiles) are the least likely to know about ORS packets.

Neonatal tetanus can understandably be expected as one factor for infant mortality since 52.5 percent of mothers in ARMM did not receive any tetanus toxoid injection and 24.1 percent only had one injection, a combined 76.6 percent of mothers who are inadequately covered for tetanus. The recommended immunization is at least two or more injections during their first pregnancy.

7. Nutritional Satus of Children Both acute and chronic energy malnutrition are high among 0-5 year old children, with estimates that are highest or among the highest across regions. (Underweight: 23.7%; stunting or underheight: 37.7%). Aside from the increasing trend in the prevalence of underweight among 0-5 year old children in the region from 2003 to 2005, figures in ARMM (Table 3) were higher than the national average and those reported in other Mindanao regions. Table 3. Proportion of underweight 0-5 year old children

Latest available data on Vitamin A Deficiency showed 40.5 % prevalence among 6 months to 5 years old children (NNS 1998). Only 58% of children 6 months to 5 years old in ARMM received Vitamin A supplementation (FPS 2006).

8.

Total Fertility Rate

Region

2003

2005

ARMM

34.0

38.0

Zamboanga Peninsula

32.7

33.9

CARAGA

31.5

24.3

Northern Mindanao

24.9

25.4

Southern Mindanao

22.6

23.1

Philippines

27.6

24.6

Source: Food and Nutrition Research Institute

The Total Fertility Rate (TFR) in the region or the average number of births that a woman in ARMM would have at the end of her reproductive life is 4.2, much higher than the national average of 3.2 (NFPS). Strong emphasis is given on greater spacing between births as a way to improve the health of mother and child rather than limiting the number of children as far as the Fatwa on Family Planning is concerned.

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9. Infectious Diseases a. Tuberculosis Tuberculosis remains a regional priority inasmuch as it is still a major public health problem. Data shows that the region has a 75 percent Case Detection Rate (CDR) which is higher than the national average of 70

Table 4. Case Detection Rate (CDR) and Cure Rate (CR), by Province, 2006 Province/ City

CDR (%)

CR (%)

percent; however, the Cure Rate (CR) of 73 percent is below the national rate of 85 percent. Table 4 shows that except for Maguindanao and Basilan, the rest of the provinces and Marawi City have CDR and CR below the national target of 70 percent and 85 percent, respectively. There is also a high variation of performance among the individual Rural Health Units (RHU) resulting to pockets of infection in many areas despite the seemingly good performance region-wide.

Basilan

113

80

Lanao del Sur

72

76

Maguindanao

85

78

Marawi City

60

NR

Sulu

61

52

Tawi-Tawi

65

68

Average

75

73

Source: DOH-ARMM 2006 NTP Annual Report

b. Avian Influenza (AI) While the Philippines remains free from avian influenza (AI), ARMM is at greater risk largely because of its proximity to Southeast Asian countries where AI cases among poultry and humans, including deaths from H5N1 avian influenza virus persist. Not a single area in ARMM was identified as AI-critical areas in the 20 priority sites previously acknowledged. Apparently, the identification of critical areas where based primarily on the presence of migratory bird sanctuaries. ARMM health and agriculture officials however, acknowledged that it has numerous high risk areas for AI. Foremost of these is the countryâ€&#x;s backdoor in Tawi-tawi where undocumented migrants and smuggling of birds, poultry and poultry products from infected Asian countries are observed all over the province, aside from the migratory bird sanctuaries in several island municipalities. Similarly, a big part of the Liguasan Marsh where there are migratory birds are observed is under Maguindanao. Several Sulu and Basilan municipalities were identified as smuggling routes of poultry products and undocumented individuals from neighboring countries with endemic AI infection. The USAID-supported AI project in ARMM in 2004 included activities that effect the creation of Regional Avian Influenza Task Force, orientation at provincial levels (Basilan, sulu, Tawitawi and Maguindanao) on AI and the Management/Preemptive Approach of Animal Disease Outbreak, training on surveillance and sample collection, actual collection of avian blood samples for testing, production of reading materials (leaflets & tarpaulin) and radio plugging on AI public awareness.

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Currently, health personnel at the local level do not have the capacity to identify the associated signs and symptoms of the disease in the field, conduct laboratory sero-surveillance for both animal and human cases and unaware of the protocols to respond in the event of infection. The signs and symptoms of the AI disease among fowls are closely associated with New Castle disease. Local farmers or households who are raising fowls believe that mass deaths of chickens are regular events as season changes. The most common poultry raising method in the regions, free-ranging, increases the risk of infection. Similarly, AIinfected humans exhibit symptoms analogous human influenza. As a result, individuals exhibiting influenzalike symptoms are complacent about the danger. In ARMM, the absence of sustained awareness and information campaign on the importance of the AI exacerbates the risk of spreading the disease.

c. STI/HIV/AIDS The prevalence of HIV/AIDS in the region cannot be determined since no surveillance among the most-atrisk population has ever been conducted in the ARMM. Data from the DOH-ARMM FHSIS 2006 report shows that there is under-reporting of STI. Certain areas such as Bongao and Jolo have been identified as home to undocumented aliens and migrants which may include female commercial sex workers (CSWs). In Basilan, there are also women suspected to be working as CSWs in neighboring countries. However, the DOH-ARMM has no capacity at the moment to closely monitor these areas. Also, the proximity of General Santos City to the ARMM makes the region highly vulnerable to HIV/AIDS.

d. Malaria Malaria remains endemic in ARMM (Figure 10) with Tawi-Tawi and Sulu consistently registering the highest number of confirmed cases. Based on the National Malaria Control Programâ€&#x;s stratification method done nationwide to prioritize areas according to the burden of the disease, there are nine provinces that belong to Category A (province with more than 1,000 malaria cases per year) and two of these are in ARMM namely, Sulu and Tawi-Tawi. Basilan, Lanao Sur and Maguindanao belong to Category B (provinces with more than 100 but less than 1,000 malaria cases per year). The 2006 survey via records review done under Global Fund reported that Tawi-Tawi and Sulu ranked 2nd and 3rd respectively, in terms of confirmed malaria cases, with the highest reported incidence rate all over the country.

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Figure

10.

Philippine

Malaria

Morbidity

Rate

by

Region

Source: FHSIS 2004

e. Other Infectious Diseases Schistosomiasis is endemic in Lanao del Sur and Maguindanao having a combined infection rate of 82 percent but there could still be cases of underreporting in the other provinces. On the other hand, Leprosy is prevalent in Sulu, Tawi-Tawi and Basilan (>1%/10,000 pop) but it may also be underreported with some provinces reporting cases of deformities but not being properly recorded and investigated for lack resources. Regarding Lymphatic Filariasis (LF), ARMM has the second highest prevalence rate in the country at 2.3 cases per 1,000 population (DOH 2003). Filaria cases are found to be highest in Sulu with prevalence rate of 10.8, followed by Maguindanao with 2.5, Basilan with 2.2, Lanao Sur with 0.5. Tawi-tawi and Marawi City have no data to support that Filariasis is endemic in the area. There is also a reported 30 percent increase in the cases of Dengue Fever (DF) in the region in the first halves of 2005 and 2006. For cases of animal bites seen, Tawi-Tawi reported the highest number among provinces in 2006 (184) while Marawi City registered the least number (47). From 2000-2007, twelve human rabies cases have been reported in Maguindanao and Sulu with 58% case fatality rate. However, post-exposure immunization coverage is low regionwide due to limited supply of anti-rabies vaccines.

f.

Chronic Diseases (CDs)

In ARMM, there is neither data on the prevalence nor survey conducted on CDs. The lack of data on the prevalence and other indicators of CDs can be attributed to the existing FHSIS which is not comprehensive enough to include indicators on the risk factors, utilization of health facilities and other performance indicators relative to CDs. CDs such as cardiovascular diseases, cancers or malignant neoplasm, chronic obstructive pulmonary diseases, chronic liver diseases and cirrhosis, diabetes mellitus and bronchial asthma are not part of target client list (TCL) being reported by health service providers. Only the program

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impact or the final outcome indicators particularly morbidity and mortality are included in the FHSIS. Moreover, no studies and survey were conducted specific for ARMM to analyze the magnitude of CD problems. Based on FHSIS-ARMM 2006, diseases of the heart is the number one cause of death and is the tenth leading cause of morbidity, malignant neoplasm is the sixth leading cause of death while hypertension is the eighth leading cause of morbidity (Figures 4 and 6). National data shows that the prevalence of smoking is 34.8%, hypertension is 22.5%, while obesity is 4.9 %. These risk factors contribute to the incidence of CDs.

At present, CDs prevention and control (formerly known as non-communicable diseases, degenerative diseases then lifestyle diseases) is almost dormant for more than a decade due to the cessation of program fund sub-allotment from the national DOH after the devolution took place. Healthy lifestyle promotions like Tobacco-Free and Sports were no longer done region-wide. The “Tiya Kulit / Iwas Sakit Diet” (low salt, low fat, high fiber diet) launched by the National DOH was not felt at the grassroots.

B. Public Responsiveness of the Health System (Service Delivery)

1. Medical attendance at births

Figure 11 shows that 50 percent of total deliveries at birth in the region were attended by “Hilots” of which 39% are trained while 11% are untrained.

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Source: FHSIS-ARMM

2. Maternal Health Care Services Home-based deliveries are Table 4. Selected Maternal Health Care Service Indices, 2006, ARMM mostly attended by traditional 2006 birth attendants. Birth Maternal Health Care Indices deliveries attended by health 60 professional accounted for Pregnant women with 3 or more ante natal visits (%) 49% of all deliveries. This Pregnant women with 2 or more injections of tetanus toxoid (%) 59 brings into question the capacity and quality of Pregnant women with iron supplementation (180 tabs) (%) 17 deliveries assisted by 88 traditional birth attendants Home Deliveries (%) (TBA). Home deliveries Deliveries attended by health professionals (%) 49 account for about 88% (Table 4). While TBAs Postpartum with at least 1 PP visit (%) 66 complement the inadequate 64 number of professional Postpartum initiated breastfeeding (%) health workers in ARMM, their lack of training, the Source: DOH-ARMM MFHSIS, 2006 infrequent supervision and the lack of overall regulation over their activities by health authorities, may have contributed to the high MMR. A clear cut policy on TBA practice is not available in ARMM. Low program coverage of supplements and vaccines. While there is high percentage of pregnant mothers with anemia (60%), only 17% of pregnant women were given a complete dose of iron supplements. Only 59% of pregnant women have at least 2 shots of tetanus toxoid (Table 4). The poor iron supplementation in all of the provinces is mainly due to budgetary constraints and lack of supplies from the DOH-Central. Vitamin A supplementation for pregnant women not taken place as a regular activity given that s there is basically no Vitamin A capsules (10,000 IU) available in the RHUs. Low pre-natal and post-partum visits. Nearly 80% of women in ARMM received postnatal care at home, of which 59 percent received it within the first week after delivery. The type of postnatal care given seems to be more geared on the baby than on the mother, focusing more on baby check up, baby care advice and breastfeeding advice. Internal and abdominal examination, breast examination and family planning advice are often neglected. (NDHS 2003). Pregnant women with 3 or more ante natal visits reached only 60% and there are only 66% of mothers with at least 1 postpartum visit (Table 4).

Table 5. Family Planning Methods

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Predisposing factors to maternal mortality. It has been proven that early pregnancy and short birth intervals are risks for maternal complications. About 32 percent of women in ARMM aged 15-24 years are already mothers or pregnant with their first child. ARMM also has the shortest birth interval at 21.6 months among all the regions.

Method

ARMM

National

Any Method

20.0

50.6

Modern Method

14.2

35.9

14.0

35.7

Artificial

Natural 0.2 0.2 Contraceptive Prevalence Rate (CPR) and Unmet Need for Family Planning (FP). Diverse cultures with indigenous and Traditional 5.8 14.8 religious beliefs weigh heavily against contraceptive use in ARMM. In 2006 FP survey, the Contraceptive Prevalence Source:FPS-2006 Rate is only 20% against the national average of 50% (Table 5). CPR is highest in Maguindanao (33%), area regarded as having better health facilities and systems, as compared to Tawi-Tawi (24%), Sulu (21%), Lanao del Sur (14%) and Basilan (13%).

The Family Planning Method Mix in ARMM favors modern family planning methods very much like the national preference. Note the high figure for “No method� (80%) in ARMM compared to the national average of 49.4%. Table 6. Source of FP commodities The main source of FP commodities remains the public sector led by the RHUs and the DOH-retained hospitals (Table 6). The EnRich survey also shows that Marawi City has a slightly lesser dependence on the public sector for FP commodities as compared to the other provinces. This could be attributed to the relatively urban nature of the area with a portion of the population having the financial capacity to buy FP commodities from commercial pharmacies in the city.

Province/City

Public (%)

Private (%)

Maguindanao

99.2

1.6

Lanao del Sur

98.1

9.4

Tawi-Tawi

97.1

4.3

Basilan

96.8

20.6

Sulu

94.4

8.3

Marawi City

78.0

28.0

ARMM

97.7

8.0

Source: EnRICH Project Integrated Health and Nutrition Survey, 2006

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3. Child Health Care Services

As mentioned earlier, the causes of observed infant deaths customarily mirror the poor health seeking behavior for child health care services (Table 7). These are deaths or illnesses which could have been avoided if the available child health cares services are availed of on time.

Table 7. Selected Child Health Care Service Indices, 2006, ARMM Child Health Care Indices

%

Proportion of newborns given essential newborn care

66

Proportion of newborns initiated to BF within 1 hr after birth

64

Proportion of 0-11 months that had EBF for the first 4 months of life

81

Child Pneumonia cases seen and given appropriate treatment

96

Child diarrhea cases seen and given ORS

6

Vitamin A supplementation coverage 58 The prevalence of underweight among 0-5 Source: DOH-ARMM MFHSIS, 2006; FPS 2006 years old in ARMM is higher than the national average and the figures reported for neighboring regions in Mindanao. Further, underweight prevalence in the same age group even increased from 2003 to 2005 in contrast to the decreasing trend at the national level.

There are no recent estimates for specific micronutrient malnutrition indicators for ARMM. The 2003 National Nutrition Survey (NNS) revealed that Vitamin A Deficiency (VAD) and anemia continue to be a major public health problem among infants, 1-5 years old children, pregnant and lactating women. Latest available data on Vitamin A Deficiency showed 40.5 % prevalence among 6 months to 5 years old children (NNS 1998). This may still be the situation at this time since only 58% of children 6 months to 5 years old in ARMM received Vitamin A supplementation (FPS 2006). Vitamin A supplementation coverage was 56.9 % among 6-11 m0nths. Marawi City registered the lowest accomplishment at 24.23 percent followed by the other poor performing provinces of Basilan (53.82%), Tawi-Tawi (51.31%), and Sulu (55.97%). Maguindanao and Lanao del Sur registered accomplishments of 100.56 percent and 71.57 percent, respectively (figure 12). This could be attributed to the lack of supplies for the routine supplementation among the target group. The VAS coverage in ARMM is consistently lower than the national rate and the rates in other regions in Mindanao; however, the VAS coverage in ARMM has been consistently increasing for the past six years. There is low coverage ( 25.5%) of VAS among post partum women given vitamin A (NDHS 2003). This may be due to the lack of supply for this target group since the DOH is only providing the supply for the universal supplementation and the inability of mothers to visit the health center for post natal care.

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The same survey (NNS 1998) showed that Iron Deficiency Anemia affects 76.8% of infants from 6 months to less than one year of age and 48.3% among 1-5 years old. The situation may still exist if not worsen since there is no supply of iron supplements for these target population regionwide. Figure 12. Year 2006 1st Round GP, Children ( 6-71 months ) given VAC, ARMM 120 100 80 60 40 20 0 Lana o 86

Magu in. 101

Sulu

' 6-11 mos.

Basila n 81

'12-59 mos.

78

91

101

89

'60-71 mos.

91

88

105

90

90

Tawi2 x 95

Mara wi 98

ARM M 94

97

99

93

105

104

96

Source: DOH-ARMM 2006 GP Report 4. Deaths from all causes attended by medical or health professionals The number of deaths from all causes attended by medical or health professionals was 35.6 % of total deaths in 2000 at the national level. ARMM has the least percentage with only 14.4 % of deaths attended by medical practitioners.

5.

Utilization of Health Facilities

In ARMM, 94.2 percent of women had at least one of the following problems in accessing health care: lack of or no money for treatment; having to take transport; distance to health facility; not wanting to go alone; concern that there may not be a female provider; getting permission from partner to go for treatment; and not knowing where to go for treatment. Poverty, cultural milieu and means of access to health facilities are a prime concern in ARMM. a. Distribution and Functionality of Health Facilities in ARMM A total of fifty hospitals are operating in ARMM. Twenty four of these are government hospitals under the DOH-ARMM through the Provincial and District Health Offices, four are DOH retained hospitals, two are military hospitals and one is financed thru a congressional development fund while nineteen are privately owned (Table 8).

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At present, there is no existing regional hospital in ARMM and no provincial hospital in the provinces of Basilan and Lanao del Sur. Amai-Pakpak, a DOH-retained hospital is located in Marawi City and can cater to the constituents of Marawi City and nearby Lanao del Sur municipalities. Table 8. Health Facilities Provincial / City

DOHARMM

DOHRetained

Military

Lanao del Sur

5

-

Maguindanao

3

Shariff Kabunsuan

CDF*

Private

Total

-

-

1

6

-

-

-

1

4

2

1

1

1

1

6

Basilan

-

1

-

-

-

1

Sulu

8

1

1

-

-

10

Tawitawi

5

-

-

-

1

6

Marawi City

-

1

-

-

14

15

Lamitan City

1

-

-

-

1

2

TOTAL

24

4

2

1

19

50

Hospital

Source: DOH-ARMM

Table 9. Number of RHUs & BHSs per Municipalities & Barangays, 2000 Population

# of

# of

# of

As of 2006

Municipalities

RHU

Barangays BHS

HNPs

Maguindanao

924,691

33

28

466

163

239

Lanao del Sur

789,184

39

28

1,068

88

6

Sulu

731,337

18

18

410

44

54

Tawi-Tawi

396,440

12

11

203

41

O

Basilan

314,207

10

8

261

58

4

Marawi City

162,173

1

1

96

5

3

ARMM

3,318,032

113

94

2,504

399

306

Province / City

ARMM-wide Investment Plan for Health

# of

# of

68


Source : DOH-ARMM; based on 2000 Census There are 14 district hospitals and 9 municipal hospitals in ARMM. Most of these district hospitals function as Level 1 instead of the ideal Level 2 function. Only a total of 640 hospital beds serve a population of 3,318,032. Based on the DOH standard ratio of 1 hospital bed for every 1000 population, the present ratio in ARMM is very far from ideal to adequately serve the entire population. Hence, there is a felt need to cope up the 2,685 hospital beds shortage. In terms of public health facilities, only 90 out of 113 municipalities have Rural Health Units in ARMM with one CHO in Marawi City and 2 CHOs in Lamitan City (Table 9). There are about 20 municipalities that have no RHUs. There are 399 Barangay Health Stations (BHS) that serve 2,504 barangays (Table 5). Maguindanao has only 163 BHS while provinces of Sulu and Tawi-Tawi have 44 and 41 respectively. A total of 306 Health and Nutrition Posts has been established and made operational in the whole region. Most of these structures are community initiatives to augment the inadequacy of BHS in the region. It has to be noted that Maguindanao and Sulu have the highest number of health nutrition posts which could be attributed to UNICEFâ€&#x;s assistance through the Sixth Country Programme for Children. b. Status of Hospitals and Public Health Facilities Table 6 shows that out of the 94 RHUs/CHOs, only 32 are Sentrong Sigla Certified while 31 are PhilHealth Accredited. For the period July to December 2006, there was a dramatic increase from 4 to 59 in the number of PhilHealth accredited RHUs. In the entire region, there is only one facility which met the standard on CEmONC while 11 facilities met the standard on Bemoan.

Table 6. Status of Facility per province Province / City SS MCP OPB

PhilHealth

Lanao Sur

2

1

2

2

Maguindanao

21

4

21

21

Sulu

5

-

5

5

Tawi Tawi

3

-

3

3

Basilan

1

-

-

-

Marawi

-

-

-

-

ARMM

32

5

31

31

Source: DOH-ARMM

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6. Environmental Sanitation and Hygiene

The total household in ARMM with access to safe water is only 55.3 % (Table 7). The very low coverage in Marawi City has to be noted. Table 7. Proportion of Households In ARMM With Access To Safe Water, 2006 Province / City

Total House- HH with Access to Safe Water (%) hold Level I Level II Level III

Total HH with Access to Safe Water

Basilan

47,904

16.9

23.4

11.0

51.3

Lanao del Sur

125,202

29.9

20.0

1.8

51.7

Maguindanao

155,217

52.9

4.5

2.8

60.2

Sulu

121,890

23.1

12.7

21.0

56.8

Tawi-tawi

33,800

55.2

5.0

12.9

73.0

Marawi City

26,009

4.0

5.8

9.6

19.5

ARMM

510,022

34.4

12.1

8.7

55.3

Source: FHSIS ARMM

Table 8. Households with Access to Sanitary Toilets, 2006 No. of Households Province / City

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Total

With Sanitary Toilets (%)

Basilan

47,904

22.36

Lanao del Sur

125,202

35.01

Maguindanao

155,217

45.90

Sulu

121,890

10.91

Tawi-tawi

33,800

68.58

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The percentage of household with sanitary toilet facilities is only 34.5% (Table 8). Note the low coverage in Basilan and Sulu at 22.36% and 10.91%, respectively.

Marawi City

26,009

51.52

ARMM

510,022

34.45

The percentage of food establishment with sanitary permit is only 48.5% with Lanao del Sur registering a low 3.64% coverage (Table 9). Food handlers with health certificates comprise only 33.1% with Sulu showing a very low 1.1% coverage. Table 9. Number of Food Establishment and Handlers with permit, 2006 Food Establishment Province / City

Food Handlers

Total

With Sanitary Total Permit (%)

With Health Certificates (%)

Basilan

508

35.43

644

13.04

Lanao del Sur

2,034

3.64

2,348

11.03

Maguindanao

3,629

59.47

4,898

51.88

Sulu

545

21.47

1,394

1.08

Tawi-tawi

724

66.16

760

57.76

Marawi City

1,403

91.38

4,968

32.83

ARMM

8,843

48.53

15,012

33.11

Source:FHSIS ARMM

7. Disaster Preparedness and Health Emergency Management ARMM has always been at risk to invariable disasters because of its environmental hazards and vulnerabilities. Since the establishment of the Health Emergency Management in ARMM in 1994, environmental hazards such as landslide, El Nino, flash flood, disease outbreak, among others were recorded. It is also the site of perennial armed conflict and family feud. Internally Displaced Population due to Armed Conflict. Hundreds of thousand of non-combatants had been internally displaced as a result of perennial armed conflicts. Basilan and Sulu provinces are the provinces that experience internal population displacement that is due to armed conflict between government troops and secessionist and terrorist groups. While the timing of armed encounters is unpredictable, the threat is always present. During armed conflict the community suffers direct deaths, injuries and violation of basic human rights. Conflict-driven population displacements create temporary disruptions of livelihoods, forced

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migration, education, and the disintegration of social functions and temporary collapse the health system, which results pockets outbreaks of infectious diseases. Damage on health facilities further deteriorated the health service delivery in the region and further widened the gaps to be at par with other regions. Mostly displaced are marginalized women and children who often seek refuge in neighboring barangays or in other hubs and temporarily sheltered in evacuation centers. Displaced children are reported to constitute 60 to 70 per cent of the IDPs, and exposed to ailments such as flu, skin disease, coughing, measles, diarrhea and typhoid fever (RESU-ARMM). This high incidence of ailments and deaths secondary to infectious diseases are primarily due to overcrowding and congestion inside the evacuation centers and problems on water and environmental sanitation. Host LGUs, communities and families suffer equally as the displaced population as their resources become over burdened. In the short run, while the LGUs in conflict areas and host communities face the burden as the stream of IDP swell, they are able to cope well with the added pressure on their resources. The advantage of central setup like DOH-ARMM, allow other sectors of the autonomous government to provide synchronized response to the complex disaster.

9. Health Emergencies due to natural disasters: While ARMM is generally considered typhoon-free, it is not spared from flooding, soil erosion, and even landslides as experienced in mainland provinces. For example, the Sultan Kudarat flashflood in 2003 caused 6 deaths and displaced 115,725 individuals. As a consequence, survivors and IDPs are at health risk as a result of dislocation and disruption of normal everyday lives. Oftentimes, IDPs contracted infectious diseases URTI, diarrhea, measles and pneumonia including skin diseases (Table 10). Table 10. Recorded Population Displacements during Emergencies in ARMM, 2000, 2003 and 2006 2000 Disease

2003 (Boliok Complex)

2006

# of Cases

# of Deaths

# of Cases

# of Deaths

# of Cases

# of Deaths

URTI

1313

0

1243

0

92

0

Diarrhea

1352

68

489

7

19

0

Measles

1087

83

36

9

0

0

Pneumonia

95

31

17

2

0

0

Total

3,847

182

1785

18

111

0

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C. Distribution of Health Expenditures (Financing) 1. Source of Funds a. ARMM Regional Government (ARG) Allocation The Department of Health–ARMM mainly operates out of ARG allocation through the Government Appropriation Act (GAA). Table 11 shows that there is no significant increase in the operating budget of DOH-ARMM Regional Office across years. Budget for capital outlay is also minimal. Table 11. Breakdown of DOH – ARMM Budget (Million Pesos)by Operation, 2006-2010 2006 Actual

2007 Current

2008 NEP

2009

2010

Proposed

Proposed

20,230

19.272

19.396

23.464

23.464

Maintenance and Other 26.375 Operating Expenses (MOOE)

30.308

30.934

70,840

70.840

Capital Outlay

1.000

1.000

TOTAL

47.605

50,580

50,330

94,304

94,304

OPERATION Personal Services

b. DOH Central Office sub-allotment for ARMM There is no fixed amount intended for DOH-ARMM in support to line programs. Special allotments are very minimal and intended only for specific activities which are mostly advocacy and capability building initiatives. In 2007, the region received an amount of PhP1.316 million to support Knock Out Tigdas , Measles Elimination Campaign, REDCOP and GP.

Table 12. Comparison of Budget Lines (Million Pesos) Mindanao Regions, 2002 PARTICULARS

CHD IX

1. General Administrative Support 7,041

CHD X

CHD XI

CHD XII

CARAGA ARMM

2,487

9,509

9,019

4,113

-

Regional Office

-

-

-

-

-

9,698

IPHO/Hospitals

-

-

-

-

-

74,632

4,766

3,194

4,421

2,525

343

2. Support to Operations

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3. Operations

117.415

162.990

72.914

107.170

80.788

TOTAL

129.222

168.671

186,844 118.714

85,244

84,330

Table 12 shows a comparison of ARMMâ€&#x;s budget allocation with the other Mindanao regions in 2002. While ARMM had no funds allocation for operations and support to operations, it has a budget of around PhP 84 million for its regional office and IPHO and hospitals. c. Expenditure by Use of Funds An annual average of Php 22 million or about 1% percent of total expenditures of the provinces and city is spent for health, nutrition and population.

Table 13. Total Health Expenditure in ARMM in relation to Total Expenditures (in million Pesos) Indicators

2002

2003

2004

Average

Total Expenditure

3,465.28

1,841.06

1,969.94

2,425.43

Health Expenditure

3.30

31.18

32.95

22.48

1.69

1.67

0.93

Percent Share of Health 0.10 Expenditure

Source: 2004 Statement of Income and Expenditures, Bureau of Local Government Finance, DOF

Table 13 shows the percentage of health spending of the provinces relative to total spending. In all provinces except Basilan, the amount allocated to health, nutrition and population services is less than 5 percent of their respective total expenditures. The health allocation in Basilan is slightly bigger than 5 percent of its total expenditures because health was a devolved function in this province (Table 14).

Table 14. Health Expenditure in ARMM, by province/city (million PhP) Province/City

Total Expenditures

Health, Nutrition Health Expenditures on Health, and Population Nutrition and Population Expenditures Total Expenditures Ratio (%)

Basilan

263.12

14.18

5.39

Sulu

297.48

4.39

1.48

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Tawi-Tawi

236.99

0.79

0.33

Lanao del Sur

525.51

0*

-

Maguindanao

438.36

8.80

2.01

Marawi City

208.49

4.77

2.29

Total

1,969.95

32,93

1.67

Source: 2004 Statement of Income and Expenditures, Bureau of Local Government Finance, DOF *Lanao del Sur in 2004 opted to infuse more funds on social services and infrastructure

d. Health Insurance Table 15 shows varying trends in the number of PhilHealth-enrolled families among provinces from 2003 to 2005. While Basilan and Tawi-tawi registered decreasing figures, the rest of the provinces performed otherwise. The dramatic increase in enrollment from 2003 to 2004 could be attributed to the massive distribution of PhilHealth cards during elections in 2004.

At present, processing of claims are being done at the PhilHealth Regional Offices (PROs) in Zamboanga for BASULTA, and Marawi City for Maguindanao and Lanao del Sur.

Table 15. Sponsored Program Enrolled Families (2003-2005) Province

2003

2004

2005

Basilan

27,698

50,987

8,605

Sulu

160

52,072

392

Tawi-Tawi

2,349

20,014

0

Lanao del Sur

23,446

88,057

45,955

Maguindanao

2,940

109,917

9,440

Marawi City Source: PhilHealth – ARMM

D. Regulation Almost all health-related laws and guidelines were formulated by the National Government. Most of these laws and policies were applied by ARMM but not reviewed by the Regional Legislative Assembly (RLA) and not adjusted to suit the needs and conditions of the region. The Regional Licensing and Regulation Division is operating without the plantilla position for regulatory officers (medical regulatory officers, nurse regulatory officers, medical technologist, engineer, licensing clerks, food and drug regulatory officers). At present, there are four staffs manning the division. Heading the division is a trained doctor, with one trained nurse, one clerk, two engineers and one newly appointed Food ARMM-wide Investment Plan for Health

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and Drug Regulatory Officer (FDRO). All are designates except for the FDRO. Because of the presence of only one FDRO in ARMM, the BFAD regulatory functions of the island provinces (Sulu, Tawi-Tawi and Basilan) are still under CHD IX. Many facilities remain unlicensed (Tables 16-17).

Table 16. Status of Hospitals and Laboratories in ARMM, 2007 DOH Licensed HF Facility

Unlicensed

Government

Private

Level 1

Level 2

Level 1

Level 2

Hospitals

14

6

8

1

Laboratories

1

4

2

2

Public

Private

7

10

Source: DOH-ARMM : DOH-ARMM Hospital Licensing

Table17 . Number of Licensed and Unlicensed Pharmacies and Botika ng Barangay Pharma

Total

Licensed

Unlicensed

Hospital pharmacy

23

10

13

Botika ng barangay

25

5

20

Private retail drugstores

167

78

89

Botika ng Bayan

0

0

0

Health Plus

0

0

0

E. Organizational Set-up of Health System in ARMM (Governance) ARMM has a distinct organizational set up. While the rest of the country operates under a devolved set up, wherein LGUs are responsible for health services (as enshrined in Local Government Code 1991), ARMM has a centralized set up. Health services are operated by DOH-ARMM through its regional, provincial, district, municipal and barangay health units. The Regional Health Office exercises over-all supervision of all provincial and district health offices in terms of technical, administrative and financial aspects. The RHO

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serves as the central office of the health sector in ARMM. The Provincial Health Offices exercise supervisory function over the district and municipal health offices, administratively and technically. The set up, however, is different in some areas like Basilan and Marawi City, which opted to join the expanded ARMM in 2001 pursuant to Republic Act No. 9054, which up to now still adopts the devolved set up.(wherein health personnel are still receiving salaries from mother LGU). Despite the existence of MMAA 25, an ARMM version of Local Government Code of 1991, the Local Government Units claiming that they are not mandated to support the operation of health units in their areas do not provide nor allocate regular budget for health services. Although it is clear that a portion of IRA is intended for social services that includes health, however, very minimal if there is any support comes from LGUs. The absence of clear governing policies like implementing rules and regulations that crystallize the type of health system in ARMM somehow affects the operational efficiency for health operation. Roles of the LGUs in health should be clarified. Under the current setup, the LGUs in Basilan and Marawi City are both providing and financing health services. In contrast, the LGUs in other ARMM areas are dependent on the DOH-ARMM/ARG for health services. I.

Health Human Resources

The ratio of health workforce to population is far from ideal (Table 19)l. Some of the municipalities are without physicians and nurses. Most of the midwives cover at least 3-4 barangays. Moreover, the prescribed standard are less than ideal because of the geographical spread and poor transportation facilities. The personnel at the regional level have sufficient technical knowledge and skills on the different programs. There is however a general feeling among the current health managers that they need to attend crash courses to address deficiencies in their managerial skills. These staff will concurrently serve as the AIPH Management Team to oversee its implementation.

Table 19. Health Workforce and Ratio to Population, ARMM Health Personnel

Number

Ratio to Standard Population

Physicians

166

1:19,988

1:10,000

Dentists

31

1:107,033

1:50,000

Nurses

279

1:11,893

1:20,000

Midwives

515

1: 6,443

1:5,000

Medical Technologists

58

1: 57,207

1:20,000

Sanitary Inspectors

123

1:26,976

1:20,000

Engineers/

Although ARMM is governed by the district health system, the referral Source: FHSIS-ARMM 2006 system is fragmented and uncoordinated. There is no facility in ARMM serving as tertiary referral center strategic in location to service both the mainland and island communities. Amai Pakpak Medical Center (DOH-retained) serves Marawi City and Lanao; Cotabato Regional and Medical Center (DOH-retained) serves Maguindanao; patients from the island provinces of Basilan, Sulu and Tawi-tawi are referred to Zamboanga City Medical Center. In emergency and/or complicated cases, people access the health services of private facilities in cities outside of the ARMM. Currently, the role of community health volunteers like BHWs in the referral system remains undocumented

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and not harnessed properly. People seek basic health care directly from hospitals and other higher levels of health care instead of going to outpatient primary health care facilities because the latter are not adequately manned and equipped. DOH-ARMM does not have baseline information on what skills are needed by its health service providers. Past government- and donor-supported projects have invested heavily on training and coaching activities to capacitate the limited health staff to adequately deliver services. It was reported that more than 60% of midwives in ARMM have attended trainings in various family planning courses but fewer consider themselves as highly competent. This is reflected in the regionâ€&#x;s performance where it consistently has the lowest CPR compared to the rest of the regions in Mindanao (Source: Surveys for ENRICH Project). Global Fund for AIDS, Tuberculosis and Malaria (GFATM)) maintains personnel for malaria program in Sulu and Tawi-Tawi (Category A) and none for Category B provinces (Maguindanao and Basilan). Given the severity of malaria cases in these areas, there is a need to put in place health personnel on a sustained basis.

2. Public-Private Partnership Businesses operating in ARMM are dominated by micro-enterprises with few large agri-based corporations. These large companies implement health programs for their employees including the immediate family and the communities where they operate. There is not much in terms of the number of private health facilities and private health service providers in ARMM. Some of the private health facilities operate without license from DOH-ARMM. Midwivesâ€&#x; organizations and other local health associations exist in Tawi-tawi, Basilan and Maguindanao. There are also NGO that address health issues in the region. The private transport operators likewise have not been organized and mobilized for a concerted effort in partnership with DOH-ARMM and their LGUs during calamities and during disease outbreaks. There are at least 140 Community-based Health Organizations that were organized all over ARMM during the EnRICH Project. These CBHOs have multiple functions that support local health service providers. They are volunteers from across different community sectors/groups and geographic parts of the community, including religious leaders. The members were equipped with relevant knowledge and simple tools to assist in health service delivery and negotiate with target community groups to try new, improved and feasible healthy behaviors.

3. Monitoring, Supervision and Evaluation The monitoring of health programs is mainly passive and relies on the reports from the health information system (HIS). While frontline field health workers require frequent and regular visits by their supervisors for, this is constrained by three main factors: lack of funds/vehicles for monitoring/supervisory travel, limited supervisory skills of health supervisors, and lack of the necessary monitoring/supervisory softwares/tools. Frequently, monitoring and supervisory plans are not prepared. When monitoring and supervisory visits are conducted, usually these are done for individual programs and not for all the health programs being implemented. Program implementation reviews are not conducted regularly due to lack of funds.

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The existing HIS in ARMM involves the collection of four subsets of reports, namely: 1) the reports on the Modified Field Health Services Information System; 2) the non-FHSIS program reports; 3) Hospital Statistical reports; and 4) the Disease surveillance reports. At best, the present HIS can be described as weak and fragmented. The modified FHSIS is limited to reporting public health program activities and accomplishments of the field health service, as well as vital events; however, it does not include reports on new health programs particularly the non-communicable diseases health programs (Cardiovascular Disease Prevention and Control Program, Health Education activities, Primary Eye Care, National Voluntary Blood Services Program, Cancer Prevention and Control, and others). Separate reports are prepared for these programs. Activities and accomplishments (using hospital indicators like admission rates, bed occupancy, causes of admissions and discharges, etc) of the hospital services are separately prepared by all hospitals, consolidated at the Provincial Health Offices and submitted to the DOH-ARMM. Disease surveillance reports, on the other hand, are collected by Designated Surveillance Officers at the Provincial Health Offices and selected Reporting Hospitals. These reports are submitted to the Cotabato Regional Medical Center, which is the designated sentinel hospital for the ARMM. Information from the current HIS is not of high quality given that the health workers who collect the data have not been updated/re-oriented on changes/modifications of the HIS guidelines. Recording and reporting forms for these four types of reports are not always available, and analysis of the data generated at different levels of the health system rarely happens. Information generated through the existing HIS is hardly used to inform management and improve performance of programs 4. Health Promotion and Advocacy The DOH-ARMM has conducted a variety of activities on health promotion and education (including advocacy) particularly aimed at consumers / clients to boost demand for service delivery. Lately, it is shifting to strategies that focus on changing behaviors (BCC) not only of consumers / clients but also of health providers and volunteers. There are also singular, separate attempts to conduct health promotion and education to influence processes and systems on governance, regulation and financing primarily aimed at local officials. These efforts, however, have not been as consistent as activities related to boosting demand. The ARMM‟s current communication and marketing strategies can be summed up under the following characterization:  Increasing consumer / client demand for health services. Efforts are limited to monthly thematic campaigns targeted to a “general public”. There is no unified, regional health promotion, advocacy and BCC plan for all health programs. Dependence on the centralized monthly thematic celebrations has raised issues about their applicability to the region‟s and province‟s needs, the variability of the audiences and the need for customization, the systematic use of media and traditional channels. Behavior issues and knowledge gaps have not been directly addressed. Since much of the monthly campaigns are celebratory and fleeting, they did not respond directly to the behavioral issues and knowledge gaps present in each priority technical program for consumers / clients. These issues and gaps have contributed largely to the weak demand for information and health services. ARMM-wide Investment Plan for Health

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 Improving the communication capacity and credibility of health providers and volunteers. Capacity building focus on technical skills for programs and less on communication and advocacy. As a result, messages are not customized to fit specific audiences. Many, too, do not fully engage in advocacy especially because of the lack of confidence in their negotiation skills. Some are hesitant to tackle sensitive topics such as STI / HIV, family planning and abortion either due to their own biases or simply because they are not skilled enough to talk about it publicly. Un-professionalism, biases and other behavioral barriers prevent optimum communication performance. On another level, though highly skilled technically, some health workers themselves discourage people from seeking medical care either by their unprofessional work ethics and attitudes, arrogant attitudes, personal biases or plain indifference.  Improving the capacity and image of the DOH-ARMM and IPHOs as sources of health information. There is no institutional communication plan. Other than the newsletter and thematic celebrations, the DOH-ARMM does not have other strategic activities designed to systematically enhance their image as sources of health information. Without a plan, there is also no marketing component that could have addressed the chronic limited budget for health promotion. HEPOs juggle multi-tasks and need to be capacitated to further improve their skills. Most of the HEPOs while trained on basic health promotion skills (interpersonal communication, public speaking, advocacy, etc.) have not had training on communication program management and on the more specialized skills (lay-outing and packaging, media management, website development, etc.). There is no person designated to handle information communication technology (ICT), thus, the DOH-ARMM currently does not have a website.

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5. Procurement and Logistic Management

Implementation of health programs in the region is partly affected by inadequate logistical supplies (FP commodities, reagents, medicines, etc). Centrally- procured medicine from DOH Central exclude ARMM as recipient citing its autonomous set up. Line item budget for medicines and medical supplies is not properly identified in the GAA in as much as MOOE barely cover mandatory expenses. The public sector, in particular the RHUs and public hospitals, remains the main source of drugs and commodities. There is a need to rationalize the provision of medical supplies and other public health commodities, e.g., contraceptives. There is low level of efficiency and responsiveness of the procurement and logistics systems to address the demands of the core health programs and improve access of beneficiaries to low-cost quality essential drugs. The small budget allocated for district and provincial hospitals can only support hospital operations and there is no line item budget intended to cover expenses for public health services operations, e.g., procurement of drugs and commodities for catchment areas, freight and transport costs. Because of limited budget, the region and its provinces mostly rely on drugs and commodities coming from the DOH-CO and donor agencies. On top of the budget constraints, cases of expiration of drugs and commodities occur: a) at the level of the IPHO when RHUs (catchment areas of district and provincial hospitals) are not able to get their allocations due to huge transport costs involved from the IPHOs to points-of-use (RHUs) especially in the island municipalities and in areas of conflict; and b) at the RHU level when drugs and commodities received from the DOH-CO do not match the needs of the RHUs. In addition, drugs received from DOH CO are near expiring. Forecasting and aggregate planning is done only at the national level but not at the RHU and provincial levels. Drugs and supplies are sent out quarterly from the DOH-CO/ various health programs to DOHARMM/IPHO/RHU even without orders from the next lower level. Coordination and information-sharing is vertical and only within the same supply chain (i.e., DOH-ARMM-province-LGU) but not among provinces and RHUs. There is no timely and regular submission of reports and feed-backing of needs to the highest level. In relation to this, the financing and reporting system in the region needs to be evaluated and areas of improvement need to be identified.

6. Internal Management

Operational costs of the DOH-ARMM Regional Office were solely sourced out from the funds of the Office of the Regional Governor. The DOH-CO at times releases some subsidy funds to the autonomous government purportedly for the implementation of a centrally-managed health programs and projects. DOHARMM receives some financial support from the autonomous government drawn against the revenues collected by the regional treasury of ARMM. The operational budget of the DOH-ARMM undergoes the cycle and processes similar with the regular administrative regions of the national government. Disbursements of public funds are still guided by the Government Accounting and Auditing Manual (GAAM) and other

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circulars, issuances and related memorandums issued by the concerned national government agencies. The agency is not adopting and implementing a centralized procurement process. The regional office, provincial, district and municipal hospitals have their own separate and established Bids and Awards Committee (BAC) responsible for procurements.

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III. Analysis of Gaps and Deficiencies

A. Health Service Delivery

1. Disease Free Zone Initiatives

Rabies

 Coverage of post-exposure vaccination against rabies is low. Anti-rabies vaccines from the DOHCentral Office is not always adequate and available. These are too expensive if bought from private sources and are usually not available in local pharmacies.  Poor health seeking behavior due to misconceptions on rabies and traditional, non-scientific procedure on case management

Muslims usually do not domesticate dogs in their dwellings but stray dogs can be found in almost every Muslim community. Responsible pet-ownership is not enforced strictly in most places of ARMM. Hence, the possibility of rabies cases in ARMM cannot be discounted.

A common misconception in the area is that rabies can be cured through certain non-scientific procedures like „tandok‟. “Tandok” is usually done by traditional healers or quack doctors believed to remove the rabies virus with the use of a piece of stone immersed in oil. This has led to poor health seeking behavior among dog-bite victims such that they do not seek post-exposure vaccination.

2. Intensified Disease Prevention and Control

a. Tuberculosis

 Low case finding in Marawi, Tawi-Tawi and Sulu. There is limited availability of and poor accessibility to laboratory services, which is further constrained by far distance and difficult transportation from hard-toreach areas. Health workers, particularly doctors, are not using sputum microscopy sufficiently to diagnose TB (low 3-sputum exam rate). These health workers favor the use of clinical and radiological means over sputum examination.

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 Weak case holding (low cure rate) in all provinces in ARMM. There are not enough BHWs to supervise treatment of sputum-positive patients. Further, health workers do not strictly comply with the DOTS protocol, contributing further to the low cure rates.  Quality of microscopy services is weak. The quality of the microscopy results is poor leading to missed diagnosis of cases (only 60% of labs under QAS achieved over 95% correct microscopy results). The QAS for sputum microscopy is not in place.  Poor health seeking behavior. Mortality data from cohort analysis (high death rate) suggest the practice of late consultations among patients. There is a need to further determine the other reasons that affect this behavior: access, costs, convenience, awareness of the disease and the available control services, knowledge, etc.  Lack of PHIC TB DOTS accredited facilities. There are only 21 TB DOTS certified facilities in the region and all are in Maguindanao province. However, their PHIC accreditation expired in 2007. These facilities will have to work on the requirements for the renewal of their accreditation.  Irregular monitoring and supervision including EQA feedbacking. There is minimal political support and consequently budget allocations, to support program management activities like monitoring and supervision including EQA feed backing. Hence, the limited visits of health workers in far flung areas.

b. Schistosomiasis

 There is low level of awareness on schistosomiasis in the community. Also, there is no baseline data on schistosomiasis incidence and available reports are inadequate.  No logistical support is given. There is also no Schistosomiasis Control Team in the region. c. Filariasis

 The Filariasis Control Program in ARMM suffers logistical and health human resource problems. Lanao del Sur and Tawi-tawi provinces and the city of Marawi were not included in the Mass Drug Administration because DOH-ARMM is yet to conduct further case investigations on the availability of required logistics and technical staff in the area.

d. Leprosy

 In some provinces there is likely under-reporting of cases due to lack of resources for case detection and investigation.  Assistance from the DOH Central Office is inadequate.  Tracking of leprosy patients is particularly difficult because of mobility of infected population, possibly of Filipinos who are working in neighboring countries.

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e. Malaria

 There is low level of awareness among the general population on malaria regarding its cause, treatment and prevention. Also, private practitioners are not following the WHO-treatment protocol for malaria.  There is low prevention coverage. The use of insecticide-treated mosquito nets has not reached a significant level that will prevent transmission of the disease. The presence of the vector in the BASULTA areas remains a major concern as this could lead to increased rate of infection anytime.  The lack of trained medical technologists in both RHUs and DOH hospitals has hampered diagnosis and monitoring of malaria cases. Complicated cases are often referred to hospitals outside of the region due to lack of trained specialists to handle cases.  Many isolated villages have no malaria field workers and health personnel to provide basic services such as consultation, case identification and blood smear collection and examination.  Equipment, logistics (reagents, slides, etc.) and microscopists are lacking. There are no microscopy centers in far flung islands.

f.

Dengue

 Surveillance of the disease is mainly at the hospital level and RHUs are not able to accurately monitor the presence of DF due to lack of trained personnel.  Drugs and medical supplies to screen, diagnose and treat suspected cases are insufficient.  Majority of the health personnel are not trained in the clinical guidelines and management of dengue.  The general public lacks an understanding of the transmission and preventive measures of the disease. Many breeding sites are found in schools and residential areas with poor drainage system and improper garbage disposal.

g. STI HIV/AIDS

 The exact prevalence of HIV/AIDS in the region is not known. Data from the DOH-ARMM FHSIS Annual Accomplishment Report for 2006 also shows under-reporting of STI.  The level of knowledge on STI HIV/AIDS among the general population is poor with only 75 percent of women and 51 percent of men reported knowledge of STI HIV/AIDS (2003 NDHS).  Health facilities and providers lack capability to perform clinical assessment and management of STI/HIV/AIDS cases.

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h. Avian Influenza  The lack of awareness about avian flu and the absence of preparedness at the local level make the AI mitigation difficult. LGUs basically lack AI preparedness and emergency response plans to address an outbreak. LGUs that claimed to have preparedness plans do not have ordinances that support the implementation of AI program or public health measures to prevent spread of the disease, inter-LGU info sharing and mitigating measures mechanism, personal protective equipment for use during animal stamping out operations, critical anti-viral drugs at strategic facilities, and community-based early warning or surveillance systems for early recognition of animal infection or early detection of human cases.  The community is not aware of the AI risk on their livelihoods and health, unaware of simple prevention measures, and oblivious of the associated signs and symptoms of infected poultry animals and human.  Local health facilities, including that of adjacent provinces, are not capable of handling immediate and appropriate clinical management of AI cases. Health personnel do not have the capacity to do laboratory sero-surveillance for animal and human cases.  A unified communication plan to bring down the critical information to the grassroots level is yet to be developed and rolled out. Despite the fact that ARMM has prepared a regional AI preparedness plan, it is yet to roll it out to the provinces municipalities and barangays.

3. Maternal and Child Health and Nutrition (including Family Planning and Dental Health)

 Access to maternal services provided by professionally trained health workers is generally low in the region. One reason for this is the low awareness among pregnant women about the value of seeking maternal services from professionally trained health workers. There is also a strong cultural preference for traditional birth attendants.  Access to the first level health facilities is constrained also by high poverty rates and the high transportation costs involved.  Finally, many RHUs lack midwives and other professionally trained health workers.

4. Family Planning

 There is low contraceptive prevalence and high unmet need for family planning services in the region, because cultural traditions and religious beliefs weigh heaviliy against contraceptive usage in ARMM.  The situation is confounded by the phase out of USAID-donated FP commodities.  While the ARMM-DOH has crafted a CSR Plan, it has yet to implement the plan.

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5. Child Health and Nutrition The high UFMR, IMR and NMR presently existing in ARMM can be explained by the following:  There are insufficient resources (human, facilities, materials, funds) to provide adequate child health care services in ARMM.  Access to the available child health care services/interventions in ARMM is difficult.  The available child health care services in ARMM are of variable quality, ranging from poor to high across different facilities  Some key behaviors for good child health or to support delivery of quality child health services are not adopted / followed by women, health workers, community members and leaders. 6. Fully immunized children Only 73% of children were fully immunized under the Expanded Program on Immunization, because:    

The delivery of immunization services against measles is hampered by the lack of manpower to cover hard to reach area (1 midwife covering 3 to 5 barangays). Disease surveillance is not fully established at the RHU level. Many of the field facilities lack refrigerators for storage of vaccines and for other areas it has no power supply. Listing of eligible population is not updated in some RHUs. Areas affected by skirmishes, targets for immunizations are missed due to mobility of the population. Regularity of service delivery is also disrupted by conflict.

7. Nutrition

The prevalence in ARMM of malnutrition (particularly micronutrient deficiency of iron and vitamin A) is generally higher than elsewhere in the country. The reasons for this are:  

Lack of awareness among mothers about proper nutrition. Insufficient supply of Vitamin A capsules and iron supplements, confounded by the poor distribution mechanism for the available supply. The poor nutritional status of children in ARMM makes them susceptible to pneumonia and diarrhea, which are among the leading causes of deaths in ARMM.

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9. Chronic Diseases (CDs) and Health Risks Management (cancer, diabetes, hypertension, COPD, cardiovascular disease)  Health service providers are not trained in the latest clinical practice guidelines developed by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.  Many health facilities lack diagnostic equipment for screening and early detection of cases.  Lack of funds to sustain Chronic Diseases Program activities like health awareness, prevention and control .  IEC materials were neither written in the local dialect nor culturally-sensitive and easily understandable (An In-depth Inquiry into Muslim KABP in the ARMM, 2004). There was no integration of Islamic health teachings considering that ARMM is predominantly inhabited by Muslims.

10. Disaster Preparedness and Health Emergency Management  Both the ARMM-DOH and the LGUs do not have the resources and capabilities to prepare for and address calamities, health hazards and other forms of health emergencies. The DOH –ARMM has yet to update its disaster preparedness plan and roll it out down to the provincial level. LGUs do not have the requisite assessment tools to prepare their own plans.  Funds for drugs, supplies and communication facilities to be used during health emergencies are severely restricted.

11. Health Facilities

 Access to basic health facilities is a major problem in ARMM because it is hampered by inadequate, uneven distribution and practically non-existing health facilities especially in remote areas, land-locked and island provinces.  Many of the existing public health facilities do not function in accordance to classification and specified DOH standards. Most RHUs are physically dilapidated and worn out. Most are under-equipped; some are not equipped at all even with the basic equipment like sphygmomanometer and weighing scales.  There is inequitable distribution of rural/barangay health units and nutrition posts in ARMM. Some RHUs/BHS are located in areas not strategically located for maximum community health utilization.  Most health facilities in the region are below the standard requirements for manpower-to-population ratio because even if there are vacancies, there are no takers owing to the high risk the areas pose to health providers.  There are municipalities without RHUs and most of the existing RHUs need major repairs. Many of the district and municipal hospitals likewise need to be renovated.  The current number of BEMOC and CEMOC facilities is not enough to meet the demand for these facilities in the region.

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B. Health Regulation  Overall, health regulation in ARMM is weak due to lack of appropriate regulatory framework and weak regulatory capacity. Building the regulatory framework would require that existing regulations, policies and guidelines that are national in scope must be modified to take into account the conditions and the local health set up in ARMM. Further, additional regulatory policies and laws should be legislated in the region. For example, there is a need to introduce halal considerations in the certification process.  Another possible reason for the weak regulatory framework in ARMM is that the the municipal and provincial local health boards are not functional. As envisioned in the Local Government Code, the local health boards should provide inputs to local health policies, legislations and program implementation. The established local helath boards however do not meet regularly and the members are not aware of their roles and functions. Moreover, there is no equivalent regional-level local helath board that can also provide inputs to the regional government and ARMM-DOH.  Even with the proper regulatorymandates, enforcement in ARMM will be weak because of lack of manpower and insufficient funds for enforcement and monitoring. The income of the DOH-ARMM (renewal fees) is very meager to support the different licensing and regulation activities.  One consequence of the weak regulatory capacity is that several pharmacies in the region are not licensed. As a result, drug prices could be higher or drug quality may be inferior. To facilitate licensing of pharmacies, the one-stop shop guideline of the DOH-CO should be modified to suit local conditions and then fully institutionalized.

C. Health Financing  There is limited knowledge and expertise at the DOH-ARMM level in tracking the sources and uses of health expenditures for policy purposes.  There is no financing framework to guide policy makers and program managers on how to mobilize resources and augment funds.  There are no standard guidelines for local health financing schemes such as user fee schemes, socialized pricing and income retention. The provision of guidelines and technical assistance to these innovative LGUs and facilities will help them avoid common mistakes associated with these financing interventions. There is low enrollment in the PhilHealth indigent program because of the following reasons:

 There is little incentive for LCEs to invest in Philhealth insurance because of lack of PHIC-accredited facilities. LGUs therefore do not benefit from capitation funds.  In areas where there are PHIC-accredited facilities, there is also little incentive for health staff to campaign for enrollment as capitation reverts back to LGU central funds and does not necessarily translate to investments in health, e.g., improvement of health facilities.  There is lack of accredited facilities that will service potential and current members. While DOH-ARMM is responsible for upgrading facilities for licensing and accreditation, its resources are limited. LGUs may have to be tapped to augment resources to facilitate accreditation of facilities.  The people‟s low demand for health care through PhilHealth in some areas could be attributed to lack of awareness and non-prioritization on the benefits of social health insurance. ARMM-wide Investment Plan for Health

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 Philhealth resources for ARMM are inadequate. PhilHealth has yet to put in place human resources, infrastructure and other requirements to institutionalize its operations.  LGUs do not reinvest capitation fund to develop health facilities as stipulated in the PhilHelath rules governing capitation funds. D. Health Governance 1. Sectoral Management  The mechanisms for public and private sector collabaroration in health are weak. Existing collaborations between LGUs and local business or professional groups like mergency/disaster relief operations and medical missions are occasional.  The referral system is fragmented. The protocol for referral is not working and not being followed.  There is a legal to strengthen the legal framework for health in ARMM. This will require the enactment of local laws to support regulatory functions of the DOH-ARMM, enforcement of MMMA 25, adaption national laws to local conditions, to clarify the roles and responsibilities of the LGUs in health, and strengthening of the local health boards.

a. Health Human Resource Management  Health human resource is inadequate. Service delivery is heavily affected by inadequate health human resource complement at the regional down to municipal level especially in the geographically isolated provinces.  Health human resource is inequitably distributed and has weak capacities.  The health staffs have no operational resources to translate their trainings into action; still others need training on basic and refresher courses.  Most health staff have poor incentives and motivation due to the lack of full implementation of the Magna Carta for Health Workers. b. Health Information System  There is weak information management system. The Modified FHSIS only provide limited information, and is poorly implemented because of lack of trained manpower, logistics support and supporting IT infrastructure.  Additional information may have to be collected and analyzed for purposes of monitoring and evaluating programs for policy purposes.  The Modified FHSIS only provide limited information, and is poorly implemented because of lack of trained manpower, logistics support and supporting IT infrastructure.

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c. Health promotion and advocacy  There is a poor health seeking bevaior among the target population because of lack of information.  The health promotion and advocacy strategy is not effective because (i) not based on a clear`understanding of the needs and sensitivities of the target clients, (ii) communication materials and approaches are not adapted to ARMM conditions, and (iii) poorly funded.  Health providers have poor communication/”customer relations” skills.  The DOH-ARMM has no unified behavior change and communication plan and social marketing capability.

d. Devolution framework (legal framework, enforcement/implementation)  There are overlaps, duplication and even competition among the different sources of ODA assistance. Each donor works on its own agenda providing various forms of delivery mechanism that require different modes of participation from the health providers and the community. There is little attempt to coordinate multiple channels of ODA resources and harmonize efforts for efficient and equitable use of available resources for health services. These indicate/include coordination of donor-funded and international NGO-funded projects that is not coordinated at the DOH-CO.  Absence of clear cut policies and or understanding between donors and DOH-ARMM: Donors often direct their interventions to the specific area bypassing protocol. Regional government like the Department of Health is left uninformed. Monitoring and evaluation of activities are not well coordinated. Accountability and responsibility in the management of these projects flapped.  Absence of a clear cut policy or procedures on the relationship between DOH-Central and ARMM-DOH in trems of coordination and investment programming of donor-fund projects, DOH-CO funding support to DOH-ARMM , etc.  Absence of a clear cut policy or procedures on the relationship between DOH-ARMM and the component LGUs of the region in trems of funding support, coordination and delineation of responsibilities.  There also exists a vague policy or procedures on the relationship between DOH-ARMM and its development partners in terms of investment programming, coordination at implementation phase. Donors do not usually coordinate with the regional office, instead they deal directly with component provincial or municipal LGUs.

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2. Internal Management a. Public Finance Management  The tracking of allocation and expenditures for health in the ARMM is ineffective due to weaknesses in internal control, audit, loopholes in procurement procedures, an dlack of transparency and accountability.  Public finance management personnel lack capacities. Personnel involved in public finance management lack the skills and capacities in terms of cash flow forecasting, assessment of investment or debt risks, cash and debt management and other related concerns.

b. Procurement and Logistic Management  There is a weak drug management system leading to inadequate medical supplies and commodities. Implementation of health programs in the region is partly affected by inadequate logistical supplies (FP commodities, reagents, medicines, etc).  There is limited budget for drugs, medical supplies and equipment.  The DOH-ARMM has to strengthen implementation of the key aspects of RA 9184, e.g., linking procurement to actual budget, adopting a unified procurement process to generate price advantages, and use of competitive bidding procedures.  There is a need to promote greater transparency and accountability in public transactions.

IV. Strategies and Interventions Vision

The DOH-ARMM as the Center of Excellence in Health facilitates attainment of optimum health for the people of ARMM by 2012 Mission Ensure affordable, responsive, equitable, accessible, sustainable and quality health care services and systems in ARMM. Goals and Objectives The over–all goal of DOH-ARMM is to improve the final health outcome of its populace, especially the marginalized, deprived, disadvantaged, underprivileged and poor, for the next five years and beyond in congruence with the FOURmula One Health System Goals and Medium-Term Philippine Development Plan (MTPDP) 2004-2010 Goals. Its objectives are anchored on the National Objectives for Health (NOH) health performance indicators, including the Millennium Development Goals.

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A. Health Program Interventions Communicable diseases dominate the leading causes of morbidity while non-communicable and lifestylerelated diseases are the leading causes of deaths. Interventions will therefore focus on preventing and controlling infectious diseases, chronic and degenerative diseases, endemic diseases and improving maternal and child health. Major programs will be strengthened and intensified in pursuit of attaining the Millennium Development Goals.The need to improve capacities of health personnel will be addressed to effectively deliver critical health interventions. Medical supplies and equipment will be procured to ensure sufficient program coverage. Facilities will be upgraded/renovated to cater to the needs of the people. Behavioral Change and Communication (BCC) materials need to be tailored to local culture and practices to be more effective and improve the health seeking behavior of the population.

1. Disease Free Zone Initiatives (Rabies)

 Anti-rabies vaccines will be procured in order to eliminate rabies.  Animal Bite Centers will be established and made operational in strategic health facilities.  Responsible Pet Ownership Program will be promoted to ensure dog vaccination and other rabies preventive activities.  Health promotion and education strategies on timely and proper health seeking behavior will be intensified.

2. Itensified Disease Prevention and Control (Tuberculosis, Dengue, Malaria, STD/HIV/AIDS, Avian Influenza, Schistosomiasis, Filariasis, Leprosy)

 The lack of health care personnel, basic infrastructure (laboratory, and microscopy units and social hygiene clinics ) medical supplies has hampered the diagnosis, treatment and monitoring of the population affected with TB and the other endemic diseases. Laboratory and microscopy units will be created or upgraded and the hiring of additional microscopists will be done based on the facility and human resource rationalization plans. The procurement of medicines specifically for TB and malaria and those needed for mass treatment of schistosomiasis and filariasis will be intensified and distribution systems will be put in place to ensure availability in the communities.  The need to improve capacities of health personnel must be ensured and addressed to effectively deliver health interventions on infectious diseases. The training of regional and provincial program coordinators will focus on achieving basic competency on the management of the infectious disease programs. Health personnel from the hospitals and the RHUs will undergo training to achieve improved capacities on the diagnosis, cure, prevention and surveillance of infectious diseases. The sensitivity on the nature of sexually transmitted infections, HIV/AIDS will be highly considered in crafting the guidelines for case management.

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 Behavioral Change and Communication (BCC) materials that are sensitive to local culture and practices will be developed and activities will be done aimed at reaching the majority of the communities.

a. Avian Ifluenza (AI)

The goal is to keep the country from AI infection. Preparedness for implementing mitigation measure when the country becomes infected or when pandemic occurs are complex tasks that require involvement of all levels of government and all segments of society. Community-based intervention strategies will require definite undertakings by individuals, families, and other sectors of the community. Creating a foundation for collective preparedness is critical. The need for AI preparedness plan at all levels in the region is to mitigate the spread of the disease and lessen the impact on health, livelihoods and the economy as a whole. The specific objectives of the intervention are as follow: 1) To establish a multi-sector AI task force at all levels of the regional government to put into effect a sustained collaborative early warning system and response mechanism; 2) To advocate for LGU support for sustained AI program and inter-LGU collaboration on mitigating measures; and 3) To sustain increased awareness of individuals and community about AI infection symptoms on birds and humans and potential danger. The target is to establish AI Preparedness Plans at the regional level, 5 component provinces, 2 cities and 105 municipalities. The identified high-risk municipalities will take precedence over the less-risk areas. At year 1 of implementation (2008), preparedness planning at regional and provincial levels as well as in identified high risk areas will be undertaken. On year 2, all other areas will be targeted for preparedness planning. The routine activities that will be implemented throught the investment period are on awarenessraising campaigns, surveillance and update meetings with different levels of task forces.

Implementation Strategy: - Establishment or review of AI preparedness plan of the LGUs (region, province, municipalities, barangays) which is consistent with the current national program protocols and practices. The characteristic of the preparedness plan will have the following elements: a) coordination with stakeholders: multi-agency/sector task force at all levels of LGUs; Provincial/Municipal Disaster Coordinating Councils; partnership with the private sector; b) prioritized areas (municipalities, barangays); c) with community-based early warning system and defined reporting and response mechanism; d) with defined mechanisms to promote inter-LGU information sharing and AI-mitigating measures; e) LGU support (ordinances, budgets,) ; and f) provision for simulation exercises to test AI readiness at all levels - Determining strategically situated health facilities that should be made AI-ready. The preparedness of the health facility may consider the following elements: a) defined essential resources to address AI cases adequately identified (personnel, equipment, supplies); b) defined procurement plan for essential equipment and supplies; c) provision for capacitating health personnel to address AI-related cases; and d) defined protocols for referral of AI cases to other facilities/provinces/region. - Formulation of Behavioral Change Communication (BCC) or Advocacy Plan for AI awareness and prevention which should be part of the unified ARMM BCC Plan.

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- Defined management structure to implement AI program b. TB Control

The lack of health care personnel, basic infrastructure (laboratory, and microscopy units and social hygiene clinics ) medical supplies has hampered the diagnosis, treatment and monitoring of the population affected with TB and the other endemic diseases. Laboratory and microscopy units will be created or upgraded and the hiring of additional microscopists will be done based on the facility and human resource rationalization plans. The procurement of medicines specifically for will be intensified and distribution systems will be put in place to ensure availability in the communities.

The need to improve capacities of health personnel must be ensured and addressed to effectively deliver health interventions on infectious diseases. The Training of regional and provincial program coordinators will focus on achieving basic competency on the management of the infectious disease programs. Health personnel from the hospitals and the RHUs will undergo training aimed at achieving improved capacities on the diagnosis, cure, prevention and surveillance of infectious diseases.

Behavioral Change and Communication (BCC) materials need to be tailored to local culture and practices to be more effective. BCC materials that are sensitive to local culture will be developed and activities will be done aimed at reaching the majority of the communities.

 Strengthening the political support to TB Control. Increased political support allows the generation or mobilization of resources for TB control particularly at the local level. A favorable political environment including formalizing support to the TB program through local issuances and/or budgetary support from the LGUs will facilitate initiatives that can improve the conduct of TB control activities and management functions such as planning, monitoring and supervision, recruitment and retention of staff, and organizing; strengthening the leadership to bring in more partners in DOTS implementation; improving and exploring financing opportunities, such as PhilHealth enrollment, accreditation of facilities, user fees, tapping local government/civic groups/donor support for TB control. Institutionalizing the participation of the other national agencies and private groups in the TB control program through the Comprehensive and Unified Policy for TB (CUP) will expand ARMMWide support for TB Control.  Strengthening TB control program management. Strengthening the capacity of the managers at all levels is necessary to ensure that activities are implemented properly given the local difficulties in the region. It is also important that program managers are provided with an enabling environment to perform their functions. The autonomous character of ARMM should be reflected in the types of managers it needs for the program. This includes having systems and management skills for centralized heatlh systems. The management approach should likewise be sensitive and adoptive to the local culture and practices.

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The managers‟ skills in monitoring, supervision, evaluation, data analysis, planning, and even in providing feedback need to be enhanced. Data-based decision-making is important for effective and efficient TB Control program implementation. Experience in other areas has shown that effective supervision can raise the quality of performance at the treatment unit. At the RHU level, health unit managers should be able to perform the appropriate management skills by improving the capacities of local staff through TA and training. In addition, the available health staff should possess the basic clinical skills for TB case diagnosis and management.

 Improving the quality of existing DOTS services . The current performance of ARMM‟s DOTS services is generally poor. Case detection and treatment outcome results are below the targets. To improve the performance of the existing DOTS facilities, the following elements should be in place: (1) local government commitment to the TB control program, (2) quality assured microscopy services, (3) capacity to provide directly-observed treatment, (4) regular supply of drugs and other logistics, (5) a recording and reporting system. Cure rate need to be increased through the reduction of failures, defaulters, and transferred cases will reduce complications and deaths, and will prevent the development of future MDRTB cases. Quality of case finding will be improved through: ensuring the quality of microscopy service; adequate use of sputum microscopy for diagnosis and follow-up; evaluation of case finding results to plan for improvements. Strengthening case management through efficient and functional referral system, including improvement in the communication capability will be a priority. Networks among DOTS providers in the region and with neighboring provinces outside ARMM shall be created and or strengthened. Across all the interventions identified in the provision of quality DOTS services, the referral system and creation of networks of DOTS providers seem to be the most feasible strategy. Increasing the number of DOTS-certified and PHIC-accredited facilities will provide a good opportunity for sustainability of the TB control program in ARMM through a comprehensive review and revision of some DOTS policies and protocol specific for ARMM. An example is the family member being allowed to be a treatment partner and which can be included TB DOTS accreditation providerbenefit package.  The network of DOTS providers need to be expanded to make services more accessible particularly to population groups isolated because of geography, and social or cultural barriers . Increased availability of DOTS services in underserved areas with high prevalence by engaging / creating partnerships with health providers in other sectors (other public, private, and NGOs) to provide, or to support DOTS services. This may involve strengthening CUP implementation, establishing publicprivate collaboration in providing DOTS services, and institutionalization of DOTS implementation in selected areas. Alternative ways of providing DOTS services to difficult areas are to be developed and should be supported through a more structured approach. The itinerant or mobile microscopy laboratories is one of the more effective ways of expanding diagnostic services. The particular needs of conflict areas and indigenous groups should be addressed through a special program approach. Good practices will be documented and shared for replication.

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 Increasing community involvement in TB Control. The TB control program has, in general, insufficient support from the community. Widening the base of community support will facilitate in improving awareness which leads to improving the health seeking behaviour. Educating patients and health service providers on TB improves treatment outcomes. A BCC program tailored to the local culture and practices is the main approach to achieve this.

3. Maternal and Child Health and Nutrition (including Family Planning and Dental Health)

A continuum-of-care concept (based on the assumption that the health and well-being of women, newborns, and children are closely linked and should be managed in a unified way) will be adopted as a guiding principle in the selection of strategies to attain the goal to improve maternal and child health in ARMM. The interventions will address problems related to adequacy of health care for mothers, the sub-causes of which are traced to the leading causes of maternal morbidity and mortality. These pertain to factors leading to health conditions such as post-partum hemorrhage, sepsis, and pregnancy- induced hypertension for mothers. The package of interventions for MCH will ensure the survival and health and development of mothers. In particular, these interventions will aim to upgrade identified critical facilities and their personnel to provide basice/essential and emergency services, enhance the capacities of both trained and traditional health workers in the communities and improving health seeking behavior of mothers and families through the development of locally sensitive health promotion activities.

a. Improving skills of health care providers

 The quality of prenatal, delivery and post natal care is inadequate. Capacities in the provision of maternal and child health care, nutrition and dental health including family planning will be strengthened through various basic and refresher training courses for health personnel and traditional health workers in the communities. Training on antenatal care services will be undertaken to prevent complications where possible and ensure that complications of pregnancy are detected early and treated appropriately. Likewise, training will be conducted on clean and safe delivery to ensure that all birth attendants have the knowledge, skills and equipment to perform a clean and safe delivery and provide postpartum care to mother and baby. To ensure that essential care for high-risk pregnancies and complications is made available to all women who need it, health workers will also be trained on essential and emergency obstetric care.

b. Strengthening the health system to deliver maternal/neonatal health services

There is poor performance in terms of maternal health program indicators in ARMM with nearly all the provinces in ARMM reporting more than 80 percent of deliveries at home and maternal deaths

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remaining high. Better coverage with maternal health care services necessitates strengthening of the ARMM health system.  Strategically located health facilities will be renovated and/or upgraded to ensure availability and accessibility of basic and comprehensive emergency obstetric care. These facilities will be equipped with the critical equipment and medical supplies needed to manage obstetric emergencies adequately.  To address the high unmet need for FP in ARMM, a commodity security plan will be put in place and implemented to ensure availability of FP commodities. Aside from FP supplies, the commodity security plan will include essential medical supplies and medicines (micronutrient supplements like Vitamin A capsules, iron tablest, syringes, vaccines, etc.).  Maternal and newborn recording and reporting system will be strengthened as part of the health information system in order to monitor and track progress towards achieving the goal for maternal and newborn health. Maternal death review will be introduced and implemented in the areas of ARMM that are not practicing this.  The provision of ongoing technical support for the frontline maternal health workers will be strengthened through supportive supervision. Local health supervisors (RHPs, PHNs, Supervising Midwives) will be trained to upgrade their supervisory skills, and resources will be made available to allow them to support the field maternal health care workers attain better maternal health services coverage and reach. c. Improving Family and Community Practices

 The utilization of maternal care services is not only dependent on the availability of the services, but also on the behaviors of the mothers themselves as well as those of their family and other members of the community. Communication techniques will be utilized to achieve appropriate behavior change consistent with prevailing values and cultural practices and which will improve maternal health and reduce maternal mortality in ARMM.  Current behaviors of women, families, health workers and leaders, that influence the utilization of and/or support the provision of maternal health services, will be identified through the review of previous behavioral studies. Further, a behavioral study will be conducted to fill in information gaps regarding behaviors that are relevant to reducing maternal mortality in ARMM. The results of the study will allow the identification of existing behaviors that are amenable for modification towards better maternal health practices, as well as identify the communication strategies to best attain the change in behaviors desired.  Specifically, BCC will be geared towards encouraging pregnant women and mothers in ARMM to seek antenatal, delivery and postnatal care including child health care and nutrition. Furthermore, responsible parenthood and/or family planning will also be promoted as a strategy to protect the health of women and children and ultimately the whole family.  Communication strategies will be utilized to promote community awareness and knowledge on pregnancy and childbirth, danger signs, role of family and community in birth preparation and transportation in case of obstetric emergencies. The DOH-ARMM will lead community-based health organizations in transforming this awareness and knowledge to take positive actions towards ensuring safe motherhood and delivery.  Community groups for health will be organized and capacitated to work with the field health workers (RHMs) as support group for the community level planning for and delivery of basic maternal health services. These multisectoral community health groups may include community and religious leaders

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(e.g. Muslim Religious Leaders), volunteer health workers, women groups, etc., who will be under the technical supervision of the RHM in their respective barangays.

d. Improving the enabling environment

 The implementation of national health laws related to maternal health services can be facilitated by the passage of local legislation. The DOH-ARMM will advocate to the ARMM Regional Government, as well as with Provincial and Municipal LGUs for the enactment of appropriate local laws that allow establishment /improvement of local maternal health services as well as better access of women to the available health services.

4. Chronic Diseases (CDs) and Health Risks Management

Preventive and curative interventions will be adopted to curb the incidence of chronic and lifestylerelated diseases, such as cardiovascular diseases, renal illnesses, substance abuse, smoking, alcoholism among others,  Preventive interventions will focus on addressing the population-based risk factors and regular screening activities for the eligible populations. Basic equipment to be used for screening will be provided. Promotion of health lifestyle will be intensified.  Hospital interventions will be directed on early detection of chronic diseases and therapeutic lifestyle change. Tertiary cases will be referred to tertiary or specialty hospitals through established networking and referral system.

5. Environmental Sanitation and Hygiene

 The environmental sanitation and hygiene program will be strengthened through increasing households‟ access to safe water supplies, sanitary toilets, and increasing the compliance of food establishments to have sanitary permits and food handlers with health certificates.

6. Health Facilities and Development

 Health facilities will be developed and/or improved through the following activities: a) lobby to ORG, RLA, LGUs and other stakeholders for fund support; b) technical assistance for health facility rationalization process; c) rationalization of facilities including mapping and services; d) strengthening health facilities services through construction/renovation of hospitals, RHUs and BHS including provision of equipment, medical supplies, logistics to increase accessibility of services and meet the

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SS, PHIC, BEmONC/CEmONC, DOTS and other specified DOH standard; e) provision of health human resources; and f) strengthening two-way referral system.

7. Disease Surveillance and Epidemic Management System

 The number of deaths and illnesses due to disease outbreak will be managed by strengthening the Disease Surveillance and Epidemic Management. This will include: strengthening of epidemiology and surveillance units at all levels; and public and private partnership and collaboration with various sectors.

8. Disaster Preparedness and Response System

 Training packages on health emergency management among health human resources such as public health and mass casualty responders,( the medical team, epidemiology and surveillance units, psychosocial team) and paramedics at all levels. Regular simulations and drills on health emergencies among health service providers.  Provision of logistics such as medical kits and gadgets, assorted medicines, vaccines, chlorine, water testing kits, compact foods, and other pertinent supplies and materials  Provision of land ambulance at the regional level and additional ambulance at the provincial, city and district levels  Provision of financial resources for mobilization and coordination expenses and emergency procurements of drugs and medicines  Establishing communication facilities in areas not covered by mobile phones  Public awareness and education on health emergency policies, guidelines protocols especially among high risk areas for certain disasters  Early detection, reporting, management and documentation of communicable diseases that has potential to cause outbreak or epidemic

B. Systems improvement or crosscutting interventions

1. Service delivery

The strategies and activities in service delivery systems will address the issues on distribution of health facilities and services, improving the referral system and enhancing service delivery modes. The overall goal

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is to improve accessibility and availability of basic and essential health care for all especially the poor. Underlying this main goal is to ensure that the delivery of health services is sensitive to local culture and practices.

 A facility rationalization study will be undertaken. This involves mapping of facilities to assess the condition of health facilities, PHIC accreditation requirements, among others. This will be the basis for upgrading of facilities, renovation, or construction of new ones and strengthening of the referral system.  Innovative service delivery modes will be identified such as: establishing floating clinics, sea ambulance, itinerant teams, among others. Inter-LGU collaboration will also be advocated for an effective and efficient referral system. Policies and guidelines will be formulated for adoption and enforcement in the region once referral networks have been identified.  Partnership arrangements with the following sectors will be formulated: private companies/industries, NGOs (both profit and non-profit), Muslim leaders, tribal leaders, community-based organizations, among others. DOH-ARMM may be able to use its current resources to leverage participation from these possible partners once policy mechanisms are in place.

2. Effective Health Regulation

 Enforcement of and compliance to National Health Legislation and Standards. Not all health facilities meet the standards for licensing requirements. To ensure quality of health services in the region, all health facilities (both public and private) including pharmacies will have to be licensed. To facilitate licensing, and accreditation, current requirements will be assessed. Efforts to streamline processes will also be pursued and phased or provisionary accreditation will be encouraged in complying with licensing requirements. In addition, program standards and health facilities operational standards that are appropriate to the conditions in ARMM will also be formulated.  Legislation of Health-related Laws at the Local Level . In order to synchronize over all operational efficiency for health, ARMM regional government should craft and pass into law through Regional Legislative Assembly a health code or a regional administrative order that will serve as blue print of operation. Policy advocacy to local government units should be addressed also to facilitate enactment of local ordinances supporting health program implementation in the area. 

Improvement of Access to Low Cost Quality Drugs / Commodities. To ensure access to affordable and quality medicines, mechanisms for procuring commodities from other sources (local or foreign) will be explored including other essential commodities necessary in the delivery of public health programs (syringes, vaccines, FP commodities, among others). This may include facilitating the establishment of more Botika ng Barangays (BnBs) or similar initiatives in strategic areas.

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3. Efficient and Equitable Health Financing

The overall goal of health financing is to secure increased and sustained investments in health, and ensure efficient utilization and equitable distribution of resources. This will improve health outcomes, especially of the poor. Outlined under this component are activities on establishing ARMM health accounts, diversification of financing resources and expanding health insurance coverage.

 In order to track financing resources (both domestic and international) and monitor expenditure levels, an “ARMM health accounts” needs to be established. This activity includes collecting expenditure data and analyzing the spending pattern on health and determining the various sources and uses of health financing, namely: family out-of-pocket spending, national budget for health, NHIP/PHIC, LGU spending for health, and FAPS/SDAH/management of external support for health. In particular, this will involve developing the system, estimation and capacity building. The ARMM health accounts will provide program and policy directions especially in terms of allocation and use of resources.  To ensure sustained financing and augment the limited resources for health, there is a need to diversify financing sources such as: income-retention policy, cost-recovery mechanism, pricing policy guidelines, user fees, etc. Technical assistance will be needed in studying various revenue-generating schemes and identifying the most appropriate one given the conditions in ARMM.  Philhealth enrolment in ARMM, specifically the Sponsored Program is low. In order to increase and sustain efforts in enrolling indigents in the Sponsored Program, IEC and advocacy efforts will be intensified to encourage LCEs/LGUs and other local officials to enroll their constituents in Philhealth and provide counterpart contribution. The assistance of Philhealth will be needed in promoting benefit packages and accreditation of health facilities, and in orienting health providers on capitation fund management. The strategy to expand the Sponsored Program should be linked to a referral strategy and phased accreditation plan to ensure that members have access to PhilHealth supported care. In addition, means-testing will be carried out to ensure targeting of indigents and mechanisms will be put in place to ensure easy processing of claims.  Institutionalize income retention scheme and user fees in rural health centers pursuant to ARMM local revenue code by allowing rural health centers to charge minimal operating cost on services rendered as provided under the revenue code. Fees may also be collected from the following: BFAD licensing, GMP accreditation, sanitary permit issuances, health and medical certification.  Public enterprises and other health revenues will also be explored to augment current resources. These public enterprises may include establishment of: One Herbal Pharmaceutical Processing and Manufacturing Plant; Halal Science Laboratory and Testing Center per province or city; Drug Testing Laboratories among hospitals or where it is appropriate.  Provincial hospitals in ARMM must be assisted and accredited in order to be tapped as a training school for nurses and midwives (Sulu Provincial Hospital; Datu Halun Sakilan Memorial Hospital; Maguindanao Provincial Hospital)

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4. Good Governance on Health

The objective of good governance strategies and activities is mainly to improve health systems performance in the region and at the local levels. Interventions under this component will address issues on health human resource, partnership with stakeholders, strengthening management capacities including health information system, and monitoring and evaluation and policy advocacy to target local chief executives, regional legislators, members of provincial boards, Sangunian Panglungsod and Sanggunian Bayan.

 Institutional arrangements of programs and projects, especially those with external funding, are poorly coordinated. To address this, the following activities need to be in place: a) establishment of an effective management team and/or coordinating body to coordinate all programs and policies for health putting in place a functional and structural relationship with ARG, RLA, DOH-CO and CHDs, LGUs, and development partners; b) formulation of a policy instrument to institutionalize the functions of the management team; and c) conduct of a regular multi-sectoral forum to encourage development partners and other agencies to complement DOH-ARMM‟s efforts in health.  Partnership arrangement with local government units in ARMM will be put in place through: forging of a memorandum of understanding on health implementation in their localities through the Department of Interior and Local Government in coordination with leagues of municipal mayors, provincial governors and city mayors; and review of local legislation and operationalization of local health boards in their areas.  Most guidelines, policies, and procedures/standards are national in scope. It is important that these policies and guidelines be reviewed, localized and tailored to the ARMM setting. An “ARMM Health Code” will be formulated which contextualizes health laws and provides the implementing guidelines for the Organic Act in terms of the health sector in the region. Consultations with various stakeholders will be undertaken.  The inadequacy of health human resources (HHR) in the region is further aggravated by inequitable distribution. This complex issue shall be addressed through the following: a) formulate a comprehensive human resources development plan; b) develop health facilities rationalization plan; c) additional plantilla positions of rural health physicians; additional Plantilla positions for Medical Technologists, Rural Health Midwives; plantilla positions in Basilan and Shariff Kabunsuan Provincial Offices and Parang Iranon Hospital as well as Marawi and Lamitan City Health Offices; d) increase Cash Disbursement Ceiling for RHM ; e) locally funded hiring of midwives and nurses institutionalized in ARMM local fund budget; f) collaboration with NGOs, academe and CBOs, professional organizations and foreign funding agencies organized; and g) nationally- initiated programs like DTTB, LHP , Pinoy MD and other grants established in ARMM  In order to strengthen public finance management (PFM) capacities, an assessment of current PFM systems and procedures will be conducted and a PFM plan will eventually be developed, taking into account government accounting, budgeting and auditing regulations. An assessment of the following will be conducted: number and skill levels of the current PFM personnel, financing and reporting system, cash and debt management practices and procedures, procurement procedures (including identifying areas of corruption, leakages and wastages), internal and external audit controls, performance evaluation system, and others. Based on assessment, capacity-building activities will be implemented to include financial management (internal audit and control), formulation of periodic procurement and logistics plans, forecasting commodity requirements, among others. Mechanisms to

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improve PFM will also be proposed including possible legislation. A procurement and logistics systems will eventually be installed including a distribution system. (DOH ARMM to identify specific unit/agency that needs PFM capacity development/technical assistance).  An overall behavior change and communication (BCC) and advocacy plan and approach will be adopted in order to influence the behavior of the community and to encourage participation from local leaders and various stakeholders to provide and demand quality health services. A unified regional advocacy and BCC plan sensitive to local culture and practices will be developed for all health programs (MCHN including FP, infectious diseases, and chronic diseases, NHIP, among others) and disseminated to catalyze corresponding investments and immediate interventions, thereby improving the health seeking-behavior of the community. Furthermore, parallel efforts will be pursued to motivate health workers and to enhance the communication and advocacy skills of health workers in the delivery of health services. A comprehensive set of social marketing plan/activities essential to encourage RLA, local leaders/LGUs, Philhealth, NGOs, private sector, tribal leaders, religious leaders, development partners, among others, to invest in health will also be developed and implemented.  Information management systems will be strengthened in coordination with DOH-National Epidemiology Center. There will be a region-wide enhancement on data management. Consultative conferences and planning workshops will be done in order to start drafting the required documents for the ARMMspecific Health Information System such as the Manual of Procedure, recording forms, reporting forms, consolidation tables and tools for data analysis. Roll out trainings will be planned out and implemented. Monitoring and supervisory checklists will also be formulated. There will also be provision of adequate equipment and logistics. On the job training and coaching will be done at all levels. A major intervention to improve hospital statistical reporting system will also be prioritized. There will be an interfacing of the hospital statistical reports with that of the field health services information system. Data analysis will be strengthened at all levels, both in the field health service and hospital service. Workshops on data analysis and utilization will be planned out and conducted at all levels. To achieve an effective surveillance system, an assessment of current reporting systems will be conducted and eventually modified to suit the needs of ARMM. Other activities to improve surveillance include: provision of reporting tools, software, hardware, among others.  A monitoring and evaluation (M&E) plan/system will also be put in place to track the progress of AIPH implementation. There is also a plan to draft a scheme to improve reporting system in ARMM through the use of the World Wide Web and integrated network system of computers on file sharing, data transfer and information exchange both in the regional level and in the provincial level.  To improve the local health systems especially in the delivery of health services in Marawi City and Basilan, an interim arrangement will be initiated. Policy dialogue with Basilan and Marawi City local leaders will be undertaken, and policy options will be studied to explore the best mechanism to integrate Basilan and Marawi City in ARMM. A policy advocacy to expedite preparation and passage of regional laws, implementing rules and regulations that would integrate fully Marawi and Basilan in the mainstream of ARMM  In order to strengthen coordinative mechanism among non-government organizations, people organizations, and privately owned enterprises engaging in health service, a partnership alliance will be developed on resource sharing and health activity complementation. Partnership fora and memorandum of understanding will be developed to strengthen collaboration among stakeholders such as the Muslim Mindanao Certification Board, ARMM Business Council, United Islamic Health Professionals of the Philippines, etc.  Muftis and Muslim scholars and community health organizations will be encouraged to participate in policy, guideline and operating procedure development and formulations giving credence to ARMM‟s culture and tradions and unique set-up. A training package will be instituted per province in order to provide updates on health issues. Da‟wah Team will be formed to conduct advocacy caravan viz a viz ARMM-wide Investment Plan for Health

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health workers. BCC will be launched at selected radio stations in ARMM. An Islamic fatwa on health in modular form will be developed. The health sector and Islam will interface and work on common agenda.  Develop self sustaining mechanism in barangay health stations among Barangay Health Workers in order to institutionalize BHWs role in community health services. Policy shall be adopted pursuant to Barangay Health Workers Act. Encourage consumer cooperative and other income generating endeavors. Develop, educate and train BHWs as health frontliner in their barangays.  Develop referral mechanism that would address inequality of health manpower and health facility distribution in the region. Adopt system that integrate/ cluster areas through facility mapping and manpower rationalization and deployment  Develop inter agency coordination in program implementation on environment and sanitation, rabies elimination, avian influenza with Department of Environment and Natural Resources and Department of Agriculture. Department of Education on expanded Program on Immunization, Nutrition, TB control and dental health. Department of Social Welfare and Development of disaster response, etc.  To resolve these dilemmas on TBAs, the region will have to strategize and implement interventions to bring down the MMR. Policy guidelines will have to be crafted for the TBA‟s roles in attending to deliveries. Continuous capacity enhancement for TBA‟s will be conducted Training packages on safe deliveries should also include newborn and child health care.

5. Health Promotion and Education, Advocacy and Behavior Change Communication (BCC) strategies (cross-cutting):

The region intends to develop a unified BCC plan that will cater to the communication needs of its program and DOH-ARMM as a whole. As such, the necessary information about the different taget audience will be analyzed and provide capacity building activities for its staff. The CBC training package for health providers will capacitate them to translate highly technical information into practical talking points anchored on what current behaviors can be changed. It will include the conduct of workshops to address the biases and behavioral barriers of health providers, and to follow up on behavioral commitments and reinforce behavior changes. Health providers will be equipped in initiating and handling sensitive messages in the face of their being perceived as taboo and anti-Islam, and denials from LCEs, religious leaders and others that cases like these exist among Muslims.

a. Increase consumer / client demand for health services through systematic and strategic planning and implementation of a regional health promotion and education, advocacy and BCC plan

 A unified regional health promotion and education, advocacy and BCC plan will be developed which will reflect provincial variabilities, ethnographic nuances and Islamic sensitivity considerations. Strategies and approaches will be based on the following evidences: current behaviors of particular target audiences per health program, mapping of available media and stakeholders‟ analysis. These

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evidences will form the baseline from where monitoring schemes will be based. IEC materials will be produced (or existing ones modified) depending on the needs, behavior and cultural and religious sensitivities of the target audiences. The plan will also discuss how the monthly thematic celebrations of the DOH-CO will be treated (including the level of modification or change of centralized IEC materials), depending on their applicability to the ARMM. The health promotion and education, advocacy and BCC plan will complement and be linked with the DOH-ARMM‟s institutional communication and marketing plan (discussed below), and vice-versa. Documentation of existing exemplary practices within the region or beyond its boundaries should be done as additional evidences or be developed as advocacy and promotional materials. Activities include: Completing the evidence gathering: validation of current behaviors and beliefs, media mapping, stakeholders‟ analysis; Provincial consultations; communication needs assessments ; Actual write-shops; Operationalization of the regional plan which includes the development, production and distribution of materials.  Current approaches and messages will be tailored to address behavior and knowledge gaps for major priority programs (Maternal Health/Family Planning, Child Health, Tuberculosis, Malaria and CardioVascular Diseases). Health promotion, advocacy and BCC efforts will be focused on interpersonal and group communication and the use of traditional channels (such as the pagbi-at or pre-nuptial counseling) and maximization of local entertainment forms (music, theatre, etc.) to reinforce the generic informational forms. Media and the use of IEC materials will be reinforcing channels to the interpersonal and group communication formats. Messages will be focused on addressing the specific behavioral issues rather than on merely translating centralized technical messages. Approaches will be developed to prioritize the hardest to reach and lowest performing areas. Activities include the conduct of a behavior study for each technical program with a layer of analysis on the influence of ethnographic nuances on behaviors. The conduct of the following activities will be based on the results of the behavior study: a) Individual and group counseling – regular facility counseling, Family Health Action Sessions (FHAS), “3 in 1 (FP, malaria and TB),” bench conferences; b) Community assemblies; c) Blocktimer radio programs that are province-specific specific provinces or centralized broadcasts simulcast to other areas; radio plugs; d) Channeling of messages through the khutbah and other Islamic fora; e) Traditional channels (such as the pagbi-at, etc.); e) Support group meetings and public testimonials; f) Popularization and invoking of the regional and provincial fatwa – specific for family planning packaged with maternal and child health messages

b. Increase the capacity and credibility of the communication channels (health providers and volunteers) through building their capacity to communicate and advocate, and manage communication activities and overcome their individual behavioral barriers

 Capacity building activities will be conducted to enhance the communication and program management skills of HEPOs, health providers and volunteers. On the short term, with the lack of HEPOs tasked and dedicated only to implement health promotion work, health providers and volunteers will be tapped to augment the force and implement activities. HEPOs can be trained as managers of communication programs.

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Activities include: a) the conduct of communication needs assessment to determine training gaps; b) Mapping of HEPOs, health providers and volunteers who can benefit most from specialized training; c) Completion of a 1) basic health promotion, education, advocacy and BCC training package; 2) communication management package; 3) specialized communication package; 4) communicating sensitive topics; d) Roll-out of training packages; e) Deployment and teaming  Workshops and public recognition schemes will be conducted to address individual behavioral barriers and lack of motivation, and reward good performance. Activities include: a) the conduct of public service excellence workshops to float and respond to individual barriers and biases; b) Launching of Healthy Na Ok Pa (HEAP HOP) program which includes regular consultations with health personnel and providing of public recognition for innovative and good performing providers  Community-based health groups will be organized where none exists, and the activities of existing ones will be coordinated; Individual champions and influentials will be recruited to be members of the groups Activities include a) Mapping of existing community-based groups; b) Mapping of potential individual champions and influentials and their interests (to build communicators‟ pool for each technical program so they can “specialize”); c) Training of champions and influentials on effective communication and advocacy depending on their “specialization”  Advocacy approaches for local officials and private groups and individuals will be customized. Activities include a) the conduct behavior mapping of local officials and private groups and individuals to determine their interests and best channels by which to approach them; b) Development of information packages designed to respond to the needs, interests and behavior of local officials (i.e., short, brief, not text-heavy, popular not technical, etc.) and private groups and individuals; c) Development of training packages for health providers and volunteers on policy advocacy

c. Increase the communication capacity and enhance the image of the DOH-ARMM and IPHOs as source of health information through the efficient operationalization of a regional institutional communication plan

 An institutional communication plan will be developed to include a marketing component that will detail how internal and external resources can be leveraged to cover health promotion, advocacy and BCC activities for sustainability. Activities include a) the conduct of write-shops with provincial consultations to develop institutional communication plan; b) Development of DOH-ARMM website; c) continued radio plugging; tie-up with the Bureau of Public Information-ARMM will be maximized; d) sustaining the conduct of media briefings and coverages; e) continued production of bi-monthly newsletter with sections allotted for IPHOs

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V. CRITICAL GOALS AND TARGETS

A. Service Delivery a. Increase the number of health personnel 1. Field Health Services  Doctors from 78 to 115  Nurses from 114 to 196  Midwives from 459 to 1750  Medical Technologists from 37 to 115 2. Hospital Services    

Doctors from 70 to 167 Nurses from 73 to 184 Midwives from 63 to 215 Paramedics from 70 to 450

b. Improve Health Facilities    

Construction of 2 Hospitals, 41 RHUs and 854 BHS Upgrading of 23 Hospitals, 45 RHUs and 199 BHSs. Renovation of 49 RHUs to meet SS, PHIC and others Facilitate establishment of 600 BnBs in strategic areas

c. Maternal and Child Health  To reduce maternal mortality rate by at least 40% from baseline by the end of 2012. - Increase in coverage of pregnant women with 4 or more prenatal visits to skilled providers from 60% in 2006 to 80% in 2012. -

Increase in coverage of pregnant women immunized with TT+ from 59% in 2006 to 90% in 2012.

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Increase in coverage of pregnant women with Vitamin A 10,000 IU or multiple vitamins with Vitamin A to 90% in 2012.

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Increase in coverage of pregnant women provided with complete dose of iron supplementation from 17% in 2006 to 85% in 2012.

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Increase coverage of deliveries attended by skilled health provider from 49% in 2006 to 80% in 2012.

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Increase coverage of deliveries in accredited health facilities from 12% in 2006 to 50% in 2012.

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Increase coverage of postnatal visits from 66% in 2006 to 90% in 2012.

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Increase in coverage of women with complete dose of iron supplementation to 80% in 2012.

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Increase contraceptive prevalence for modern FP methods from 20% in 2006 to 35% in 2012.

 To reduce child mortality rates: Under-five and Infant Mortality Rates by at least 50%, and Neonatal Mortality Rate by at least 40%, by the end of 2012. - Increase in the percentage of children achieving Fully Immunized Child Status from 73% in 2006 to 95% by end of 2012. -

Increase in the proportion of newborns protected at birth against neonatal tetanus from 59% in 2006 to 90% in 2012.

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Increase in the coverage of newborns given essential newborn care from 66% in 2006 to 90% in 2012.

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Increase in the coverage of newborns initiated to BF within 1 hour after birth from 64% in 2006 to 90% in 2012.

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Increase proportion of infants who are exclusively breastfed (EBF) for the first six months of life to 80% in 2012.

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Increase the proportion of child pneumonia cases seen and given appropriate treatment (antibiotics) from 96% in 2006 to 100% in 2012.

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Increase the proportion of child diarrhea cases seen and given ORS from 6% in 2006 to 70% in 2012.

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Increase in VAS coverage among all target child groups (6-11 mo, 12-71 mo) from 58% in 2006 to 95% 2012.

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Increase in iron supplementation coverage among targeted children from 34% to in 2006 to 85% in 2012.

 To achieve Philhealth accreditation of all existing RHUs for Maternity Care Package and Out Patient Benefits by end of 2012.  To provide training and capability building for all health service providers to deliver quality maternal and child health services at the end of 2012.  To increase enrollment of households to PhilHealth from 59% % to 80%.  To establish midwife-traditional birth attendant partnerships (TBAs) with all 1,532 TBA d. Nutrition    

Reduction in the prevalence of underweight children (0-5 years old) from 38% to 10% in 2012 VAS coverage among 6-71 months old children increased from 58% to 95% in all provinces by 2012. VAS coverage among post-partum women increased from 25.4 % to 50% in all provinces by 2012. Complete Iron Supplementation coverage among pregnant women increased from 17% to 30% by 2012  Improved KAS of health personnel on Nutrition Program Management

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e. Family Planning  To increase the contraceptive prevalence among women and their spouses from 20% to 50%  To strengthen management and implementation capabilities for FP and RH through training of service providers at all levels of health care  To expand the provision of FP and RH services through upgrading of facilities and provision of equipments and commodities to conform with the minimum quality standards in health facilities at all levels  Increase awareness and support for FP and RH and improved FP practices through intensified IEC and advocacy activities  To institutionalize the FP and RH program as a priority program of ARMM through its inclusion in the regional comprehensive development plan with corresponding budgetary appropriations. f.

Human Rabies Elimination Program

    

To reduce animal bite cases by 50% from the baseline at the end of 2012 To increase coverage of post-exposure immunization to 100% from the baseline at the end of 2012 To strengthen IEC campaign on rabies case management and preventive measures To intensify advocacy activities and promotion of Responsible Pet Ownership Program To be declared rabies free region at the end of 2012

g. National Tuberculosis Control Program

 To reduce TB mortality and morbidity by 25%  All provinces to have achieved :  Case detection rate of 70%  Cure rate of 85%  To strengthen capacity for management and delivery of quality DOTS for all MHOs, PHNs, and RHMs, Medical Technologists and microscopists  To upgrade all existing microscopy centers  To establish new microscopy centers at identified critical and strategic sites  To increase the number of DOTS certified and accredited RHUs by 80% from the baseline at the end of 2012  To facilitate organization of community support groups for TB in all municipalities  To train community volunteer health workers as treatment partners in every municipality

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h. Malaria Control Program

     i.

Leprosy Prevention and Control Program

    j.

Reduce API in ARMM by 20% To organize Regional Malaria Control Team To strengthen capacity of all provincial Malaria Coordinators as program managers To strengthen the capacity of RHU staff of all endemic areas on malaria case management To facilitate establishment of Community Based Malaria Control Programs in all endemic areas

To establish baseline data on the prevalence of Leprosy in ARMM To strengthen the capacity of RHU staffon Leprosy case management To ensure adequate and regular supply of antileprosy drugs for all identified cases To advocate LGU support in the Leprosy Elimination Campaign

Schistosomiasis Control Program

   

To establish baseline data on the regional prevalence rate for Schistosomiasis To reduce schistosomiasis infection rate by 30% from the baseline at the end of 2012 To establish a schistosomiasis regional center To strengthen capacity of RHU staff in high prevalence areas on Schistosomiasis case management  To ensure adequate and regular supply of Schistosomiasis drugs and supplies  To advocate for LGU support on mass treatment programs in identified endemic areas k. Filariasis Control Program

   

To establish baseline data on the prevalence of Filariasis in ARMM To identify the Filariasis endemic barangays in the ARMM To strengthen the capacity of RHU staff in high prevalence areas on Filariasis case managem,ent To be able to train a provincial medical technologist for the Filariasis control program

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l. Dengue Control Program     

To reduce the incidence of dengue cases by 80% from the baseline at the end of 2012 To intensify Information and Education Campaigns on dengue prevention and control To be able to train one sanitary engineer at the DOH-ARMM in Dengue Control To strengthen the capability of the Regional and all Provincial Coordinators as program managers To strengthen the capability of the district and provincial health offices to respond to dengue outbreaks

m. STI, HIV/AIDS Control Program  To draft a culture sensitive operational guidelines on STI,HIV/AIDS Control Program  To strengthen institutional and general public prevention interventions  To strengthen prevention interventions targeted at identified highly vulnerable groups in certain provinces  To increase public awareness on STI, HIV/AIDS  To establish social hygiene clinics at strategic areas n. Avian Influenza  To establish preparedness plans and AI Task Force by 2008  Regional level = 1  Provincial level = 6  To establish municipal preparedness plans in most high risk areas by 2008  Plans in most high risk municipalities = 50  AI Task Force in most high risk municipalities = 50  Municipal Ordinance in support of AI program = 50  Community-based Early Warning Systems (CBEWS) in all barangays  To establish preparedness plans (including AI Task Force, Muncipal Ordinance, and CBEWS) in the rest of the municipalities/cities by 2009  To equipped at least 1 health facility , including facility personnel, in each of the province to handle AI cases  To stockpile adequate amount of critical drugs and supplies (anti-viral drug, personal protective equipment) in each province/municipality o. Chronic Diseases 1. To improve in five years the health indices concerning the chronic diseases in ARMM as follows: A. Mortality from Chronic Diseases is reduced by 2 % annually per 100,000 population based on WHO target or whichever is lower, specifically:

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a. Mortality Rate from diseases of the heart is reduced to less than 13.379.1 deaths (PHS, 2003) b. Mortality Rate from diseases of the vascular system is reduced to less than 5.9 deaths (PHS, 2003) c. Mortality Rate from diabetes mellitus is reduced to less than 3.314.1 deaths (PHS, 2003) d. Mortality Rate from all forms of Malignant Neoplasm is reduced to less than 47.7 deaths (NOH) e. Mortality Rate from chronic obstructive pulmonary disease to less than 20.8 deaths (NOH) f.

Mortality Rate from liver disease to less than 1.2 deaths (PHS, 2003)

B. Morbidity from diseases of the heart and vascular system is reduced (per 100,000 population) a. Morbidity rate from diseases of the heart and vascular system is reduced to less than 65.7 cases b. Morbidity rate from hypertension is reduced to less than 522.8 cases (2006 FHSIS, Phil) c. Prevalence rate of hypertension is reduced to 13.9% from 22.5 % C. Risk factors associated with chronic diseases are reduced . D. Prevalence of adults with high FBS is reduced to 2.1 % from 3.4 % E. Prevalence of tobacco smoking among the general population is reduced to less than 34.8% a. Adolescents aged 13-15 years reduced to less than 15.0% b. Adult male reduced to 40 % from 56.3 % c. Adult female reduced to 8.6 % from 12.1 % F. Prevalence of alcohol intake among: a. Adolescents reduced to less than 30% b. Adults reduced to less than 46% c. Older Persons reduced to less than 22% G. Early Detection and Screening for Chronic Diseases are increased. a. Proportion of women of reproductive age and older who practice monthly breast self exam increased to 50% from 40% b. Proportion of women 35-40 years old who have breast examined by a physician every 1- 3 years increased to 20% from 5% in their lifetime c. Proportion of males aged 50 years and older submitting to DRE at least every 3 years increased to 20% by 2%

2. To increase awareness-raising campaign on chronic diseases a. Increase awareness on cancer from 75.3% to more than 94.2% (NDHS, 2003)

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b. Increase awareness on diabetes from 88.6% to more than 94.8% (NDHS, 2003) 3. To have regional and provincial coordinators trained in the Chronic Diseases Programs 4. To have all provincial and municipal governments implementing physical activity in their units. 5. To have all provinces and municipalities implementing policies and legislation aimed at Tobacco Control and Cessation in 5 years. 6. To have all RHUs advocating Healthy Lifestyle Promotion gram at the end of 5 years 7. To have all RHU health personnel trained in the Chronic Diseases Program especially knowledge and skills in early screening methods 8. To have Pap Smearing facilities available at the RHU, provincial and district hospitals as part of the SS and Philhealth accreditation 9.

To have Health personnel at the district and provincial hospital competent on performing DRE examination at the end of 5 years

10. To increase the number of Botika ng Barangay in 5 years 12. To have at least one physician per district or provincial hospital trained in managing Chronic diseases 13. To have all Provincial and Municipal Governments allocate counterpart funding for medicines used for Chronic diseases ( mainly anti- hypertensives, and OHAs) in their annual budget for use in their provincial/district hospital and RHUS in 5 years 14. To conduct baseline survey on chronic diseases

B. Regulations

 To operationalize self-sustained regulatory functions by 2009;  To facilitate issuances of applicable laws by RLAs that would address the gaps in the implementation of existing regulatory mandates;  Rationalized distribution of health facilities, goods and services across ARMM  Issuance of licenses to all health facilities in ARMM by 2010  To facilitate SS certification of RHUs from 23% to 61%(56/94) by 2012;  Increase the no. of licensed BnBs from 20% to 100% (25/25);  All existing food manufacturers are licensed by 2008

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C. Governance

 A draft ARMM Health Code by last quarter of 2008  Implementing Rules and Regulations on the devolution of Marawi and basilan through Regional Executive Order by third quarter of 2008  Regional Executive Order on users fee and income retention policy by second quarter of 2008  Promulgated local health code by first quarter of 2009  MEMORANDUM OF UNDERSTANDING by and between RDOH ARMM and LGU in support to health sector reform by second quarter of 2008  MEMORANDUM OF UNDERTAKING by and between DepEd, DA, DSWD DENR on coordinative mechanism in the implementation of rabies elimination program, avian influenza SARS, expanded program on immunization, dental service, disaster management environmental and sanitation by first quarter of 2008  A fully functional ARMM-specific Health Information System comprehensively designed to encompass field health service and hospital services by last quarter of 2008

VI. CRITICAL INVESTMENT ACTIVITIES Given the amount of financial requirements of the AIPH for five years and the limited resources, there is a need to prioritize which investment activities should be implemented first. Coordination of all health activities is critical to avoid duplication of efforts and to ensure complementation of interventions. Facility mapping, assessment and rationalization are crucial in determining how many facilities will have to be refurbished and/or created. On the other hand, an effective public finance management system and a system of health accounts will ensure that resources are used efficiently, monitored easily, and that policy and program interventions are sound and evidenced-based. The following start-up investment activities are recommended for year 1: 1. 2. 3. 4. 5. 6. 7. 8.

Institutionalization of AIPH management team Crafting of Operational Guidelines for the AIPH Facility rationalization and upgrading of existing health facilities to attain accreditation ARMM health accounts Public Finance Management assessment Plan for capacity building ARMM Health Code ARMM-specific Health Information System

Based on the priority setting tool, other critical activities to improve coverage of priority programs and crosscutting interventions will be identified. These activities will lead to:

1. Reduced maternal, newborn and child deaths

ARMM-wide Investment Plan for Health

115


2. Increased contraceptive use among MWRAs 3. Increase CDR and CR for TB 4. Increased malaria detection and treatment

VII. PROPOSED IMPLEMENTATION AND MANAGEMENT ARRANGEMENT A. This initiative attempts to provide practical and sustainable management arrangements that shall strategically oversee implementation of the AIPH. This management arrangement shall also take the monitoring and evaluation of the health investment packages proposed in the plan. This is one of the key initiatives that should be prioritized in year 1. ARMM-DOH management shall take the lead in defining the arrangements for managing the implementation of the AIPH, taking into account its unique situation. B. The operational guidelines for the AIPH implementation should be crafted and agreed upon by the management team. This should be presented to and deliberated by key officials of the DOH-ARMM. C. This management arrangement shall specify functional relationships with the following critical units important in the implementation of AIPH: (1) ARMM-DOH, (2) ARG, (3) DOH-central and DOH-FICO; (4) CHD IX, X, and XII; (5) RLA; (6) component LGUs; (7) donors or development partners; and the DOHâ€&#x;s JAC. D. The type of arrangement shall also specify composition, number and levels of functional units that shall actively take on their specified roles. E. For institutionalizing the preferred management arrangements, different organizational meetings or workshops shall be undertaken to define its basic specifications in consultation with the different stakeholders. F. To support institutionalization of the management arrangements, management tools shall be developed such as capacity building plan and a monitoring and evaluation system which shall be specified for the AIPH. VIII. PROPOSED BUDGET AND SOURCE The AIPH shall be financed through internal and external funds. The internal funds are those sourced out from the funds of the Office of the Regional Governor. (In ARMM context, LGU refers to regional government and not on its component provinces and municipalities, which derive its financial resources from ARG itself). Internal funds also includes DOH-CO releases some subsidy funds for the implementation of a centrally-managed health programs and projects. The external funds will come from other funding agencies operating or will operate in the region. Currently, the DOH-ARMM is a recipient of USAID technical assistance on health. This funding support had been factored into the budget. It has also specifically ARMM-wide Investment Plan for Health

116


identified other funding institution like EC, which had already sounded off their proposed support. Where specific donor agencies are not identified, DOH-ARMM could other support e.g. WHO, UN Agencies, Islamic States, and other development partners, including NGOs. The total cost of the ARMM-wide investment for health is about PhP 6.246 billion spread across several sources (Tables 20 and 21). About PhP 1.798 billion (28.8%) will come from DOH-ARMM allocation from the regional government. The major items of expenditures under this source are mostly for the salary of newly hired helath personnel and development of health facilities. The LGUs will shoulder about PhP 0.716 billion, which will be in the form PhilHealth premium contributions (the same amount will be counterparted by PhilHealth). The DOH-Central is proposed to assume about PhP 2.550 billion (40.8%) in the forms of drugs, medical supplies, upgrading of BEMONCs/CEMONCs and various training. The remaining Ph 1.181 billion will come from development partners e.g. USAID, EU, WHO, UNICEF, JICA and others. The development partners will take on some form of capital outlays (construction of hospitals), technical assistance (training and consultancies), drugs and medicines. The medium-term investment on health, which is about PhP 6.246 billion, is extended over a 5-year investment period, 2008 – 2012 (Tables 22 and 23). The investment spending will progressively increase starting at about PhP 0.157 billion (2.51%) outlay in Y1. Year 1 expenditures are mostly technical assistance to establishment of the AIPH Management Team (including managerial capacity building), carrying out baselines studies and critical trainings, procurement of drugs and remittances for PhilHealth premiums of LGU-enrolled indigents. Major capital investments and hiring will start in Y2. Beginning in Y2, the average annual investment is P1.522 billion. Of the P6.234 billion, about P3.898 billion (62.40%) will go to Service Delivery and P2.348 billion (37.60%) will go to Health Systems. Maternal Health Care (25.91%), Child Health Care (29.92%), and Health Facilities Development Program (25.33%) get the bulk of the expenditure share.

The major expenditure items by type of expenditure are buildings and other structures outlay (17.48%), personnel services (25.94%), andn supplies (including drugs and medicines (38.09)

The following are the critical assumptions during the costing exercises:

1. There is a unified BCC program for ARMM with three sub-components: 1) Maternal/Child/Family Planning/STI/HIV-AIDS, (2) Infectious Diseases (TB, Malaria, Schistosiamis, Filariasis, Dengue, AI), and (3) HERMS/ER/Healthy Lifetsyle. 2. PhilHealth enrollment rate would grow from 30% in Y1, 50% in Y2, 70% in Y3, 90% in Y4, and 100% in Y5. LGU fund commitment will increase significantly with the changes in the target enrollment rate. 3. 100% coverage of the total population for Vitamin A supplementation for mothers and children, tetanus toxoid, FIC, malaria, filariasis, and TB. The coverage for FP commodities, iron supplementation and schistosomiasis will only for about 60% of the total population (57% poverty incidence). ARMM-wide Investment Plan for Health

117


4. Major capital investments: a. New construction: 2 provincial hospitals (at P100 million each); 41 RHUs (P1 million each), 854 BHS (at P0.3 million each). b. Renovation: 49 RHUs (at P0.25 million each) to meet SS/PHIC standards. c. Upgrade: 13 CEMOCS (at P2.4 million each), 17 BEMOCs (at P1.2 million each); 23 hospitals (at P5 million each), 45 RHUs (at P1.5 million each), 199 BHS (at P0.25 million each). d. Equipment: for 13 CEMOCS (at P10 million each); 17 BEMOCS (at P1 million each). 5. The total investment to pay the salary of new hires is P1.620 billion pesos, a. For field health services: 37 MDs, 82 RNs, 1291 RHMs, 78 medtechs. b. For hospital services: 97 MDs, 111 RNs, 152 RHMs, 380 paramedics. 6. A training budget of P3 million is set aside for establishing 800 BnBs. The total seed capital (in drugs) worth P20 million will come from the DOH Central Office. 7. No allowance for contingency.

ARMM-wide Investment Plan for Health

118


Table 20. ARMM-Wide Investment Plan for Health Cost by Component and funding Source (in million PhP), 2008 - 2012

Local Counterpart Component

DOH ARMM

ARG/ LGU

National Government DOH CO

Development Partners

PhilHealt h

EC

WHO

Service Delivery

1,222.36 0

0.283

1,949.19 9

-

152.167

4.857

Maternal Health Care

1,115.10 0

-

268.003

-

147.000

-

0.444

-

11.090

-

31.104

-

1,643.38 5

-

-

-

59.402

-

11.335

-

-

-

1.000

-

1.900

-

-

-

Family Planning Child Health Care Infectious Disease Control Environmental Sanitation and Hygiene/ Disease Free-Rabies Healthy Lifestyle

ARMM-wide Investment Plan for Health

-

-

Global Fund 10.715 10.715

-

Total

UNFPA

PRIME X

USAID

11.090

2.610

1.260

-

-

-

11.090

-

-

-

-

-

-

-

-

-

-

-

-

61

As % of Total

Others

Cost

543.053

3,897.593

62.40

88.200

1,618.303

25.91

1.800

24.423

0.39

194.282

1,868.772

29.92

190.440

271.892

4.35

23.000

25.900

0.41

33.488

33.638

0.54


Disaster preparedness, HEMS & ER Surveillance

Health Systems Health Facilities Development Program Governance Regulation Financing

-

-

0.150

-

-

-

5.750

0.283

10.832

-

3.667

3.353

2.504

-

1.500

1.504

3.650

-

-

9.560

575.748

716.21 6

600.484

564.198

50.000

579.000

-

3.150

-

1.500

-

0.500

-

-

-

8.974 1.366

0.050

19.984

1.210

666.16 6

-

0.700

-

0.700

-

-

-

-

-

-

-

-

-

-

-

-

-

2.610

1.260

-

-

4.650

-

-

3.150

-

-

1.500

-

-

-

-

-

-

6.233

30.118

0.48

5.610

24.548

0.39

446.910

2,348.358

37.60

382.830

1,582.328

25.33

58.030

70.504

1.13

4.400

25.800

0.41

1.650

669.726

10.72 0.00

Grand Total As % of Grand Total

1,798.10 8

716.49 8

2,549.68 3

0.700

28.79

11.47

40.82

0.01

ARMM-wide Investment Plan for Health

155.817

4.857

2.49

0.08

10.715 0.17

11.090

2.610

5.910

0.18

0.04

0.09

62

989.963

6,245.950

15.85

100

100.00


Table 21. ARMM-Wide Investment Plan for Health Cost by Type of Expenditure and Funding Source (in million PhP), 2008 - 2012

TYPE OF EXPENDITURE

LOCAL COUNTERPART

NATIONAL GOVERNMENT

DOH – ARMM

ARG/ LGU

DOH CO

50.000

605.067

-

-

604.800

-

-

Development Partners

PhilSHIELD Health

EC

WHO

50.667

1.433

Capital Outlay

-

Buildings and Other Structures Outlay

-

Machineries and Equipment Outlay

-

-

0.267

-

-

48.167

Motor Vehicles Outlay

-

-

-

-

-

IT Equipment and Software Outlay

-

-

-

-

-

0.504

-

Personnel Services

50.000

1,619.468

ARMM-wide Investment Plan for Health

Total

Global UNFPA PRIMEX USAID Fund

Others

Cost

As % of Grand Total

-

-

-

-

483.471

1,290.638

20.66

-

-

-

-

434.250

1,091.550

17.48

1.433

-

-

-

-

21.421

171.288

2.74

-

-

-

-

-

-

24.000

24.000

0.38

-

-

-

-

-

-

-

3.800

3.800

0.06

-

-

0.504

-

-

-

-

1,620.476

25.94

2.500 -

63

-


Maintenance and Other Operating Expenses

176.915 666.498 1,945.837

Supplies (including drugs and medicines)

103.761

-

54.202

Repairs and Maintenance Communication

4.390

Consultancy – Studies/TA

6.030

PhilHealth Premium

GRAND TOTAL As % of Total Cost

-

5.150 2.920

10.715

11.090

2.610

1,942.622

-

-

1.000 1.000

10.715

11.090

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

0.500 -

-

-

1.350

-

0.715

0.200

-

-

-

-

1.260

-

1.500

0.500

-

3.650 -

-

-

-

666.166

-

-

-

-

-

-

-

-

-

-

1.000

-

-

-

-

-

-

-

-

-

Consultancy – Training, Workshops, Meetings

Other Operating Expenses

0.700

-

0.333

8.532

1,796.383 716.498 2,551.407 28.76

11.47

ARMM-wide Investment Plan for Health

40.85

0.700 0.01

0.00

1.920

155.817 4.857 2.49

0.08

10.715

11.090

0.17

0.18

64

2.610 0.04

5.910

506.492

3,334.836

53.39

309.022

2,379.209

38.09

54.202

0.87

1.850

3.700

0.06

1.260

47.410

57.488

0.92

4.650

108.910

125.240

2.01

666.166

10.67

48.832

0.78

6 989.963 ,245.950

100

5.910 0.09

-

39.300

15.85

100


Table 22. ARMM-Wide Investment Plan for Health Cost by Component and Year, 2008 - 2012

COMPONENT

SERVICE DELIVERY

COST BY YEAR (in million PhP) 2008

2009

82.931 1,101.964

Maternal Health Care

TOTAL COST

As % of Total

2010

2011

2012

865.302

921.148

926.248 3,897.593

62.40

366.402 1,618.303

25.91

-

542.151

339.015

370.735

3.744

5.012

4.513

5.789

Child Health Care

68.812

429.145

442.695

456.760

Infectious Disease Control

2.825

82.518

57.490

66.026

63.033

271.892

4.35

Environmental Sanitation and Hygiene/ Disease Free-Rabies

5.000

5.225

5.225

5.225

5.225

25.900

0.41

-

18.910

4.910

4.910

4.910

33.638

0.54

2.550

13.242

4.192

5.942

4.192

30.118

0.48

-

5.762

7.262

5.762

5.762

24.548

0.39

73.586

629.638

511.091

553.911

580.132 2,348.358

37.60

Health Facilities Development Program

8.330

466.497

369.167

369.167

369.167 1,582.328

25.33

Governance

7.630

42.506

6.156

6.606

7.606

70.504

1.13

Regulation

1.400

24.400

-

-

-

25.800

0.41

Financing

56.226

96.235

135.768

178.138

203.359

669.726

10.72

Family Planning

Healthy Lifestyle Disaster preparedness, HEMS & ER Surveillance

HEALTH SYSTEMS

GRAND TOTAL

As % of Grand Total

156.517

2.51

ARMM-wide Investment Plan for Health

5.365

24.423

0.39

471.360 1,868.772

29.92

1,731.602 1,376.393 1,475.059 1,506.380 6,245.950

27.72

22.04

23.62

24.12

100.00

100

65


Table 23. ARMM-Wide Investment Plan for Health Cost by Type of Expenditure and Year, 2008 - 2012

COST BY YEAR (in million PhP) TYPE OF EXPENDITURE

2008

2009

2010

2012

235.522

236.972 1,290.638 20.66

231.775

231.775 1,091.550 17.48

2.550

578.572

Buildings and Other Structures Outlay

1.750

392.975

Machineries and Equipment Outlay

0.800

159.247

Motor Vehicles Outlay

-

24.000

-

-

IT Equipment and Software Outlay

-

2.350

-

-

Personal Services

-

405.119

Maintenance and Other Operating Expenses

155.392

748.361

Supplies (including drugs and medicines)

72.556

564.465

Repairs and Maintenance

-

2.016

Communication

-

0.925

1.610

29.082

Consultancy – Studies/Technical Assistance

21.210

45.830

PhilHealth Premium

55.016

94.635

5.000

11.408

Consultancy – Training, Workshops, Meetings

Other Operating Expenses

GRAND TOTAL

As % of Total Cost

157.942

1,732.052

2.53

27.73

ARMM-wide Investment Plan for Health

233.275

3.747

3.747

405.119

734.252

561.703 2.016

0.925

4.032

19.250

135.518

10.808

COST

As % of Grand Total

2011

Capital Outlay

237.022

TOTAL

3.747 1.450

171.288 2.74 24.000 0.38 3.800 0.06

405.119

405.119 1,620.476 25.94

834.418

862.414 3,334.836 53.39

580.405

600.080 2,379.209 38.09

25.960

24.210

54.202 0.87

0.925

0.925

3.700 0.06

18.732

4.032

57.488 0.92

19.700

19.250

125.240 2.01

177.888

203.109

666.166 10.67

10.808

10.808

48.832 0.78

1,376.393 1,475.059 1,504.505 6,245.950 100.00

22.04

23.62

24.09

100

66


IX. MONITORING AND EVALUATION SCHEME

Monitoring and evaluation is very crucial in tracking the progress of AIPH for the five-year period. However, there are no monitoring tools developed by the region designed to monitor several health performance indicators like scorecards, benchmarks, etc. There are no tools crafted intended to monitor the proposed health reforms for the next five years in conformity with FOURmula One being pursued by national DOH. The region has insufficient funds for monitoring the Island provinces which necessitates big amount of money considering the distance from the regional health office is very far. Most of the time, the health personnel conducting monitoring have to pass and stay in Zamboanga City before reaching the final destinations. The regional health office has no monitoring vehicles that can be used by the major program clusters to monitor the mainland provinces considering that the there are some areas that have no regular transportations for the commuting public. In fact, there is no single ambulance allocated for the region that would serve as ready vehicle in times of emergency response. At the provincial and city levels, sanitary inspectors lacked monitoring motorcycles in their dayto-day health activities considering that they have limited funds for cash disbursements ceilings. There are no equipments like laptop to collate data while at the fieldworks and no LCD issued for conducting visual presentations among the target clients at the regional and provincial levels. The region has training center and conference room that is fully equipped with audio-visual equipments and gadgets for the regular conferences, executive meetings and trainings. To release the bottle neck of monitoring and evaluation, the region will have to develop monitoring tools tailored to ARMM such as scorecards, benchmarks and performance indicators. The region must organize an AIPH Monitoring and Evaluation Team (AMET) to fast track the smooth implementation of the programs and projects for the five year period and beyond. The team must be supported with technical assistance like PHEMAP (Public Health Emergency Management in Asia Pacific) and the like. It must be supported also with financial allocation to subsidize regular monitoring activities. There must be a provision of monitoring vehicles, ambulances and motorcycles at the regional health office as well as in the field for monitoring the mainland provinces and for emergency response. There must be a provision also of laptop units among AMET and program managers. Training center and conference room that is fully equipped with audio-visual equipments and gadgets will be established in consonance with AIPH.

ARMM-wide Investment Plan for Health

67


REFERENCES ARMM Medium-Term Development Plan, 2005-2010, Manila, Philippines.

ARMM Regional Development Plan 2004-2010. Manila, Philippines.

ARMM Regional Executive Agenda and Development Investment Program 2006-2008. Cotabato City, Philippines.

Department of Health. National Objectives for Health, 2005-2010, Manila, Philippines.

Department of Health. Philippine Health Statistics. Manila, Philippines, 2003.

International Center for Innovation, Transformation and Excellence in Governance (INCITEGov) and Local Governance Support Programme (LGSP) in ARMM , Towards Strengthening the Fiscal Capabilities of ARMM, A Policy Paper. 2007.

Joint Needs Assessment for Reconstruction and Development of Conflicy-Affected Areas in Mindanao, Integrative Report Volume 1,Report produced jointly by the GOP, International Funding Agencies and Mindanao Stakeholders. December 2005.

LEAD Project . Proposed ARMM Cooperation in Health System (ARCHeS) Cooperation Framework for ARMM Strategy for Health Improvement (ASHI) Draft Report.

National Economic and Development Authority, and United Nations Country Team. Second Philippine Progress Report on the Millennium Development Goals, Manila, Philippines, 2005. National Statistics Office. National Demographic and Health Survey. Manila, 2003.

National Statistics Office. Family Planning Survey. Manila, 2006.

Panelo, Carlo Irwin A. Health Sector Reform Frame for Investment Planning in ARMM, A presentation, UP College of Medicine, 2007.

Regional Economic and Development Planning Board, ARMM Medium-Term Regional Development Investment Plan 2005-2010, Cotabato City.

Regional Planning and Development Office. ARMM First Progress Report on the Millennium Development Goals. June 2006. Republic Act 6734 or “An Act Providing For An Organic Act For The Autonomous Region In Muslim Mindanao�, August 1, 1989. The World Bank Human Development Sector Unit East Asia and Pacific Region. Human Development For Peace in the ARMM. November 2003. ARMM-wide Investment Plan for Health

68


ACRONYMS AI

Avian Influenza

HHR

Health Human Resource

AIDS

Acquired Immune Deficiency Syndrome

HIV

Human Immunodeficiency Virus

AIPH

ARMM Investment Plan for Health

HNP

Health and Nutrition Posts

ARG

ARMM Regional Government

HRD

Human Resource Development

ARMM

Autonomous Region in Muslim Mindanao

ICD

International Classification of Disease

ASHI

ARMM Strategy for Health Improvement

IEC

Information, Education, and Communication

BAC

Bids and Awards Committee

IMR

Infant Mortality Rate

BCC

Behavioral Change and Communication

IPHO

Integrated Provincial Health Office

BEmOC

Basic Emergency Obstetric Care

IRA

Internal Revenue Allotment

BFAD

Bureau of Food and Drugs

LCE

Local Chief Executive

BHS

Barangay Health Stations

LGUs

Local Government Units

BHW

Barangay Health Workers

MCP

Maternity Care Package

BnB

Botika ng Barangay

MFHSIS

Modified Field Health Service Information System

BNS

Barangay Nutrition Scholar

MMR

Maternal Mortality Ratio

CEmOC

Comprehensive Emergency Obstetric Care

MOA

Memorandum of Agreement

CHD

Center for Health Development

NEC

National Epidemiology Center

CHO

City Health Office

NGO

Non-Government Organization

CON

Certificate of Need

NTFAI

National Task Force on Avian Influenza

CPR

Contraceptive Prevalence Rate

NTP

National Tuberculosis Control Program

CSR

Commodity Self-Reliance

OPB

Out-patient Benefits

CSW

Commercial Sex Workers

PDAF

Priority Development Assistance Fund

DA

Department of Agriculture

PFM

Public Finance Management

DBM

Department of Budget and Management

PHIC

Philippine Health Insurance Corporation

DepEd

Department of Education

PHO

Provincial Health Officer

DF

Dengue Fever

PIPH

Province-wide Investment Plan for Health

DOH

Department of Health

PRO

PhilHealth Regional Office

DOH-CO

Department of Health-Central Office

PTC

Permit to Construct

DSWD

Department of Social Welfare and Development

RA

Republic Act

EPI

Expanded Program on Immunization

RHU

Rural Health Units

FDRO

Food and Drug Regulatory Officer

RLA

Regional Legislative Assembly

FHSIS

Field Health Service Information System

SDAH

Sectoral Development Approach for Health

FIC

Fully Immunized Children

SS

Sentrong Sigla

FP

Family Planning

STI

Sexually Transmitted Infection

FPS

Family Planning Survey

TB

Tuberculosis

ARMM-wide Investment Plan for Health

69


GFATM

Global Fund for AIDS, TB, Malaria

TB-DOTS

TB-Directly Observed Treatment Short course

HEPO

Health Education and Promotion Officers

TFR

Total Fertility Rate

HF

Health Facility

USAID

United States Agency for International Development

ARMM-wide Investment Plan for Health

70


AIP Health