Supply-Side Readiness of Primary Health Care in the Philippines SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 1 Acknowledgements This report was prepared as part of the analytical and advisory support provided by the World Bank to the Government of the Philippines. The report has been prepared by a team consisting of members from the World Bank’s Philippines Health, Nutrition, and Population Team (Tomo Morimoto, Roberto Rosadia, Chantelle Boudreaux, and Vida Gomez) and the Korean Development Institute School (Ha Kyeong Lee). The authors would like to thank the following World Bank staff for their contributions to the report: Damien de Walque, Mickey Chopra and Ajay Tandon as peer reviewers; Caryn Bredenkamp, Rouselle Lavado, Robert Oelrichs, Shuo Zhang and Gabriel Demombynes for advice to the team; and Regina Calzado for copy editing. The report was prepared under the overall guidance of Toomas Palu (Practice Manager for Health, Nutrition and Population). In addition, inputs received from Professor Juhwan Oh of the Seoul National University College of Medicine as peer reviewer is gratefully acknowledged. The authors are especially grateful for the advice and comments received from the Department of Health (DOH) and the Philippine Health Insurance Corporation (PhilHealth). In particular, we would like to thank the DOH’s Disease Prevention and Control Bureau, Health Facilities Services and Regulatory Bureau, Knowledge Management and information Technology Service, Health Policy Development and Planning Bureau, and Bureau of International Health Cooperation; and PhilHealth’s Health Finance Policy Sector, Quality Assurance Group, Standards and Monitoring Department, Accreditation Department, MDG Team, and Primary Care Benefit Team. The team acknowledges the generous contribution by the Strategic Impact Evaluation Fund and KDI School of Public Policy and Management to the baseline study on the implementation of PhilHealth’s Primary Care Benefit Package, since this report relies on data originally collected for this purpose. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 2 Table of Contents Acknowledgements ................................................................................................................................ 2 Table of Contents ..................................................................................................................................... 3 Acronyms.................................................................................................................................................... 6 Executive Summary ................................................................................................................................ 9 I. Introduction .................................................................................................................................. 13 II. Analytical Approach................................................................................................................... 21 Data ..................................................................................................................................................................................21  Methods ..........................................................................................................................................................................22 III. Findings .......................................................................................................................................... 25 1. General Service Readiness ..........................................................................................................................25 2. Maternal and Child Health .........................................................................................................................45 Error! Bookmark not defined. Antenatal Care ................................................................................................................................................46 ǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ ƒ‹Ž›Žƒ‹‰ǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤͷʹ —‹œƒ–‹‘ǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤͷ͸ Š‹Ž† ‡ƒŽ–ŠǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͸ʹ 3. Noncommunicable Diseases (NCD) Prevention and Treatment ...............................................68 ‹ƒ„‡–‡•‡ŽŽ‹–—•ǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͸ͻ ƒ”†‹‘˜ƒ•…—Žƒ”‹•‡ƒ•‡ǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͹ʹ Š”‘‹…‡•’‹”ƒ–‘”›‹•‡ƒ•‡ǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͹͹ ‡”˜‹…ƒŽƒ…‡”…”‡‡‹‰ǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤͺͲ 4. Tuberculosis ......................................................................................................................................................83 5. Variations in Service Readiness ...............................................................................................................86 IV. Discussion, Limitations, and Areas for Further Work ................................................... 97 References............................................................................................................................................. 101 Annexes .................................................................................................................................................. 103 Annex V. 1: Standards  Annex for Accreditation 1: Standards of PhilHealth’s for Accreditation of PhilHealth’s PCB Package PCB Package Providers;Providers; Availability.............................................................................................103 Diagnostic and Service Availability ............................................................................................. 103 VI.  Annex Annex 2: Standards 2: Standards for Accreditation for Accreditation of PhilHealth’s of PhilHealth’s PCB Package PCB Package Providers;Providers; Infrastructure and Supplies Requirements .............................................................................. 104 .............................................................................104 VII. Annex............................................................................................................................................................ 3: RHU Personnel .................................................................................................................105 105 VIII. Annex Annex  4: 3: RHU Provinces Personnel and .................................................................................................... Municipalities Included In This Survey ......................................105 106 IX.  Annex Annex 4: Provinces 5: Indicators in WHO andSARA Municipalities Guidelines Included and National In This Survey............................. and Data 107 Guidelines, Availability...........................................................................................................................................107 X. Annex 5: Indicators in WHO SARA Guidelines and National Guidelines, and Data Availability ............................................................................................................................................ 113   6833/<6,'(5($',1(662)35,0$5<+($/7+&$5(,17+(3+,/,33,1(6   Tables Table 1. Top causes of YLL due to premature mortality in the Philippines, 1990 and 2013 ........................................................................................................................................... 14 Table 2. Contents of the PCB Package ............................................................................. 16 Table 3. Details of LGU income classification at the municipality level ......................... 24 Table 4. General service readiness tracer indicators: SARA and from survey ................. 25 Table 5. General service readiness score by LGU income classification ......................... 32 Table 6. General service readiness score by region .......................................................... 33 Table 7. RHU personnel compared with PCB requirements (left) and DOH national requirements (right) .......................................................................................................... 40 Table 8. RHU and DOH-deployed personnel, average by region .................................... 43 Table 9. RHU and DOH-deployed personnel by LGU income class ............................... 43 Table 10. Access to maternal health services, 2014a ........................................................ 46 Table 11. ANC tracer indicators: SARA guidelines and indicators used for assessment. 47 Table 12. ANC service readiness score by LGU income classification ........................... 51 Table 13. ANC service readiness score by region ............................................................ 51 Table 14. Family planning tracer indicators: SARA guidelines and indicators used for assessment ......................................................................................................................... 52 Table 15. Family planning service readiness score by LGU income group ..................... 55 Table 16. Family planning service readiness score by region .......................................... 55 Table 17. Immunization coverage by region, 2014 .......................................................... 56 Table 18. Immunization tracer indicators: WHO SARA guidelines and indicators used for assessment ......................................................................................................................... 57 Table 19. Immunization service readiness score by LGU income group ......................... 61 Table 20. Immunization service readiness score by region .............................................. 61 Table 21. Access to child health and nutrition services by region, 2014.......................... 62 Table 22. Child health: SARA guidelines and indicators used for assessment ................ 63 Table 23. Child health service readiness score by LGU income classification ................ 66 Table 24. Child health service readiness score by region ................................................. 67 Table 25. Top ten causes of mortality in the Philippines, 2009........................................ 68 Table 26. DM tracer indicators: SARA guidelines and indicators used for assessment... 70 Table 27. DM service readiness score by LGU income group ......................................... 72 Table 28. DM service readiness score by region .............................................................. 72 Table 29. CVD tracer indicators: SARA guidelines and indicators used for assessment. 73 Table 30. CVD service readiness score by LGU income classification ........................... 76 Table 31. CVD service readiness score by region ............................................................ 76 Table 32. CRD tracer indicators: SARA guidelines and indicators used for assessment . 77 Table 33. CRD service readiness score by LGU income group ....................................... 79 Table 34. CRD service readiness score by region ............................................................ 79 Table 35. CCS tracer indicators: SARA guidelines and indicators used for assessment . 81 Table 36. CCS service readiness score by LGU income classification ............................ 82 Table 37. CCS service readiness score by region ............................................................. 82 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 4 Figures Figure 1. Breakdown of health care utilization by facility type, Philippines ................... 15 Figure 2. Financing sources and amounts for preventive and outpatient curative care, 2012–2014......................................................................................................................... 19 Figure 3. Supply-Side Readiness Assessment Framework ............................................... 23 Figure 4. Basic infrastructure by region ........................................................................... 28 Figure 5. Power outages - Frequency and duration by region .......................................... 29 Figure 6. General service readiness: Basic equipment ..................................................... 30 Figure 7. General service readiness: Infection prevention................................................ 30 Figure 8. General service readiness: Diagnostic capacity ................................................ 31 Figure 9. General service readiness: Essential medicines ................................................ 32 Figure 10. Regional variation in the availability of basic infrastructure .......................... 34 Figure 11. Regional variation in the availability of basic equipment ............................... 35 Figure 12. Regional variation in infection prevention ...................................................... 36 Figure 13. Regional variation in diagnostic capacity........................................................ 37 Figure 14. Regional variation in essential medicine availability ...................................... 38 Figure 15. LGU health personnel and DOH deployment, by region ................................ 44 Figure 16. LGU health personnel and DOH deployment, by income class ...................... 44 Figure 17. ANC service readiness: Medicines and commodities availability .................. 49 Figure 18. ANC service readiness: Diagnostics availability ............................................ 49 Figure 19. RHU staff who have undergone BEmONC training ....................................... 50 Figure 20. Family planning service readiness: Medicines and commodities availability 54 Figure 21. Immunization service readiness: Equipment availability ................................ 59 Figure 22. Immunization service readiness: Medicines and commodities availability .... 60 Figure 23. Child health service readiness: Diagnostics availability ................................. 64 Figure 24. Child health service availability: Medicines and commodities availability .... 65 Figure 25. DM service readiness: Diagnostics availability and medicines and commodities availability ................................................................................................... 71 Figure 26. CVD service readiness: Diagnostics availability ............................................ 75 Figure 27. CVD service readiness: Medicines and commodities availability .................. 75 Figure 28. CRD service readiness: Medicines and commodities availability and equipment availability ....................................................................................................... 78 Figure 29. CCS service readiness: Equipment availability and diagnostics availability .. 81 Figure 30. Equipment availability and medicines and commodities availability ............. 85 Figure 31. Regional variation in ANC service readiness.................................................. 88 Figure 32. Regional variation in FP service readiness ...................................................... 89 Figure 33. Regional variation in immunization service readiness .................................... 90 Figure 34. Regional variation in child health service readiness ....................................... 91 Figure 35. Regional variation DM service readiness ........................................................ 92 Figure 36. Regional variation in CVD service readiness.................................................. 93 Figure 37. Regional variation in CRD service readiness .................................................. 94 Figure 38. Regional variation in CSS service readiness ................................................... 95 Figure 39. Regional variation in TB service readiness ..................................................... 96 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 5 Acronyms Acronym Meaning ACE Angiotensin Converting Enzyme AGE Acute Gastroenteritis AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care AO Administrative Order ARI Acute Respiratory Infection ARMM Autonomous Region of Muslim Mindanao BCG Bacillus Calmette-Guérin BEmONC Basic Emergency Obstetric and Neonatal Care BHS Barangay Health Station BHW Barangay Health Worker BNS Barangay Nutrition Scholar BP Blood Pressure CAR Cordillera Administrative Region CBC Complete Blood Count CD Communicable Disease ComPacks Complete Treatment Packs COPD Chronic Obstructive Pulmonary Disease CRD Chronic Respiratory Disease CCS Cervical Cancer Screening CVD Cardiovascular Disease DALY Disability-adjusted Life Year DM Diabetes Mellitus DMPA Depot Medroxyprogesterone Acetate (Injectable Contraceptive) DOH Department of Health DOTS Directly Observed Therapy-Short Course DPT-Hib-HepB Pentavalent Vaccine: Diphtheria, Pertussis, Tetanus, Haemophilus Influenza B and Hepatitis B DTTB Doctors to the Barrios EMR Electronic Medical Record EPI Expanded Program for Immunization FBS Fasting Blood Sugar FHSIS Field Health Service Information System FIC Fully Immunized Child FP Family Planning Hb Hemoglobin HFEP Health Facilities Enhancement Program HIV Human Immunodeficiency Virus HPV Human Papillomavirus HRH Human Resources for Health I3QUIP Philippines Impact of Incentives and Information on Utilization and Quality of Primary Care ICS Inhaled Corticosteroids IHME Institute of Health Metrics and Evaluation IMCI Integrated Management of Childhood Illness IPV Inactivated Polio Vaccine SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 6 IPT Intermittent Preventive Treatment IRA Internal Revenue Allotment ITN Insecticide-treated Net IUCD Intrauterine Contraceptive Device IUD Intrauterine Device LGU Local Government Unit MCH Maternal and Child Health MCP Maternity Care Package MDG Millennium Development Goal MDR Multi-drug Resistant MMR Maternal Mortality Rate MNCHN Maternal, Newborn and Child Health and Nutrition MOP Manual of Operations NCD Noncommunicable Disease NCR National Capital Region NDHS National Demographic and Health Survey NDP Nurse Deployment Program NIP National Immunization Program NNS National Nutrition Survey OPV Oral Polio Vaccine ORS Oral Rehydration Salts PCB Primary Care Benefit PCV Pneumococcal Conjugate Vaccine PhilHealth Philippine Health Insurance Corporation PhilPEN Philippine Package of Essential NCD Interventions RHM Rural Heath Midwife RHMPP Rural Health Midwives Placement Program RHU Rural Health Unit RNHEALS Registered Nurses for Health Enhancement and Local Service Project SARA Service Availability and Readiness Assessment SDG Sustainable Development Goal STI Sexually Transmitted Infection SW Shortwave TB Tuberculosis TsekAp Tamang Serbisyo sa Kalusugan ng Pamilya TT Tetanus Toxoid UHC Universal Health Coverage UTI Urinary Tract Infection URTI Upper Respiratory Tract Infection VIA Visual Inspection with Acetic Acid WHO World Health Organization WHO PEN WHO’s Package of Essential NCD Interventions YLL Years of Life Lost SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 7 6833/<6,'(5($',1(662)35,0$5<+($/7+&$5(,17+(3+,/,33,1(6   Executive Summary Health indicators in the Philippines currently lag well behind what would be expected given the nation’s level of economic development. The country has a substantial and rapidly growing noncommunicable disease (NCD) burden while continuing to struggle with long- standing health challenges, including poor maternal and child health (MCH) outcomes and lagging communicable disease (CD) indicators. Immunization rates are at their lowest point in 10 years, maternal mortality remains very high, and one in three Filipino children suffer from malnutrition. The resulting epidemiologic profile is complex, and an adequate response requires a robust primary health care system. With the introduction and subsequent expansion of national social health insurance, administered by the Philippine Health Insurance Corporation (PhilHealth), the central government has sought to ensure access to high-priority health services, including a number of services delivered through primary care. This policy paper examines the capacity of rural health units (RHUs), the facilities charged with spearheading the country’s public primary health care system, to provide high-quality primary care in the Philippines. Using the World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA) as an organizing framework, we first present an overview of general service readiness, then examine seven high-priority health conditions, which are categorized into MCH conditions (antenatal care [ANC], family planning [FP] care, immunization, and child health); NCD conditions (diabetes mellitus [DM], chronic cardiovascular disease [CVD], chronic respiratory diseases [CRDs], and cervical cancer screening [CCS]); and CDs (tuberculosis [TB]). For each condition, the SARA framework specifies tracer indicators that can be used to assess the readiness to deliver services within critical domains (for example, equipment, diagnostics, or medicines and commodities). Using data collected from 240 RHUs across 14 regions, we present the current capacity of the primary health care system to deliver health services. This analysis identified both strengths and weaknesses in the delivery of primary care in the Philippines. Basic equipment, including adult and child scales, blood pressure (BP) apparatuses, sterile gloves, thermometers, and stethoscopes, were all commonly available. Basic medicines and commodities are also widely available. For example, very few stock- outs were identified for tetanus toxoid (TT), bacillus Calmette-Guérin (BCG), and oral polio vaccine (OPV), oral and injectable contraceptives, mebendazole, oral rehydration salts (ORS), amoxicillin, co-trimoxazole, and paracetamol. Selected therapies for the NCDs were also generally available, including the diabetes drugs metformin and sulfonylureas; angiotensin converting enzyme (ACE) inhibitors, diuretic, beta-blockers, calcium channel blockers, metformin, and angiotensin receptor blockers for CVD; and beta2-agonists and beta-blockers for asthma. The average overall scores for both FP and TB were nearly 100 percent. There were, however, a number of important gaps. The survey identified issues with the basic infrastructure and equipment at the facilities: 49 percent of RHUs had experienced some power outage in the week leading up to the survey, and 20 percent of facilities did not have refrigerators for vaccines. While there were some shortages in the availability of drugs and commodities (for example, the relatively newly introduced pneumococcal and rotavirus vaccines were each available at fewer than half of the facilities, as was inhaled SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 9 corticosteroids [ICS] for asthma), the main gaps were in diagnostic capacity. Hemoglobin (Hb) testing was available at only 30 percent of RHUs and fecalysis was available at 77 percent. Fasting blood glucose testing was available at just 70 percent of RHUs visited overall, and at only 25 percent of RHUs in the Cordillera Administrative Region (CAR) and 38 percent of RHUs in Region 10. Similar gaps were found in the ability to conduct urine analysis: 77 percent of RHUs overall could provide this test and only 31 percent of RHUs in CAR and 56 percent in Region 5 could do so. Only 4 percent of RHUs had a peak expiratory flowmeter in place for asthma diagnosis on the day of the survey and only one- fourth of RHUs had staff trained on CCS at the time of the survey. Overall scores for CRD, CCS, and immunization are low, at 70 percent, 61 percent, and 79 percent, respectively. There was also substantial regional variation in readiness to provide some services, with some regions consistently under- or over-performing compared to their neighbors. CAR performed at or below the sample mean in all but three domains, as did Region 2. Meanwhile, Region 10 and CARAGA performed better than others on almost all the domains. This has important implications for equity in the distribution of and access to national resources. Although immunization and diabetes services are intended to be universally available, regional immunization scores varied from 70 percent to 85 percent, and diabetes scores ranged from a low of just 67 percent in CAR to a high of 98 percent in Region 3. Across the regions, facilities in relatively more prosperous local government units (LGUs) outperformed those in relatively less prosperous LGUs. RHUs located in first or second income class municipalities tended to have better basic infrastructure, more basic equipment, and higher diagnostic capacity than RHUs in fifth and sixth income class municipalities. RHUs located in first class LGUs perform well above the sample means for all categories except FP (which has a very high overall average score of 97 percent) and have the top performance for several categories, while RHUs located in the sixth class LGUs have the lowest performance in five of the nine health service categories (ANC, FP, immunization, diabetes, and TB), and are above the sample mean for only one category— CRD. The findings presented in this analysis suggest that much remains to be done to ensure that entitlements for primary care are met. The Philippines has made remarkable strides in ensuring PhilHealth coverage. Efforts are needed to ensure that the public sector is able to deliver on the entitlements promised by the insurer. The country currently subsidizes coverage for 45 million poor people, and has repeatedly enacted plans to expand the benefit package over the past decade. While national guidelines for the provision of care are generally well aligned with—or more comprehensive than—international norms, there are systematic gaps in the availability of key inputs, particularly those related to diagnostic testing. And, despite national efforts to make RHUs the main point of care for the health conditions considered here, these service delivery gaps fundamentally limit the public primary care system’s ability to deliver services. While this is an important finding, we note that this report does not present a comprehensive picture of the health system, but must rather be placed in the broader health context. Private providers are responsible for more than 50 percent of health service delivery in the Philippines. If new investments are to maximize efficiency gains, efforts to SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 10 understand and expand the public system must leverage these existing resources. By highlighting the existence and location of supply-side deficiencies, this work can help target future efforts to understand why these deficiencies exist. The current analysis can also be complemented with utilization data to better understand gaps in utilization of health services, and the extent to which a failure to use services represents access barriers that can and should be resolved by the public sector. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 11                                              6833/<6,'(5($',1(662)35,0$5<+($/7+&$5(,17+(3+,/,33,1(6   I. Introduction Health indicators in the Philippines currently lag well behind what would be expected given the country’s level of economic development. Immunization rates are at their lowest point in 10 years, maternal mortality remains very high, one in three Filipino children suffer from malnutrition, and the noncommunicable disease (NCD) burden is growing (Food and Nutrition Research Institute 2008, 2013; Philippine Statistics Authority 2013). The resulting epidemiologic profile is complex, and an adequate response requires a robust primary health care system. With the introduction and subsequent expansion of the social health insurer, administered by the Philippine Health Insurance Corporation (PhilHealth), the central government has sought to ensure access to a number of high-priority health services, including at the primary level. However, much of the responsibility for implementing the publicly funded health system is at the local level, where capacity and resources differ. This paper seeks to understand the extent to which basic service delivery units (specifically rural health units [RHUs]) have the capacity to deliver the primary health care services mandated by the government. Philippines Health Sector: Health Status, Financing, and Service Delivery Arrangements The Philippines’ health challenges are substantial. With an estimated maternal mortality rate (MMR) of 114 deaths per 100,000 live births, the 2015 MMR was more than double the Millennium Development Goal (MDG) 5 target (World Bank 2016). One-third of children under the age of five are stunted in the country and, given the high prevalence and large population, the Philippines is in the global top 10 countries in terms of the burden of stunting (Food and Nutrition Research Institute 2013). In the 2013 National Demographic and Health Survey (NDHS), vaccination rates were at their lowest point in 10 years, and national programs for vaccination have not met their coverage targets since 2000 (Philippine Statistics Authority 2013). Communicable diseases (CDs), such as tuberculosis (TB), account for a considerable proportion of disability-adjusted life years (DALYs), even while the country must also address the rapid emergence of NCDs—now the dominant cause of death in the Philippines. In 2013, the leading cause of years of life lost (YLL) in the Philippines was ischemic heart disease, and diabetes ranked seventh (IHME 2013). Tellingly, NCDs account for the fastest-growing share of the health burden. YLL due to ischemic heart disease increased by 43 percent between 1990 and 2013, while diabetes increased by an alarming 266 percent (IHME 2013). By contrast, YLL from the most important communicable and maternal health issues all decreased over this time (Table 1). Given this backdrop, attainment of the health-related targets of the Sustainable Development Goals (SDGs), which include a global MMR target of 70 deaths per 100,000 live births and reducing by one-third premature mortality due to NCDs, is likely to require intensified efforts. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 13 Table 1. Top causes of YLL due to premature mortality in the Philippines, 1990 and 2013 1990 2013 % Change (1990– Ranking Ranking 2013) 1. Lower respiratory infection 1. Ischemic heart disease (NCD) 43 (CD) 2. Neonatal pre-term birth (CD) 2. Lower respiratory infection (CD) −68 3. Ischemic heart disease (NCD) 3. Cerebrovascular disease (NCD) 48 4. TB (CD) 4. TB (CD) −36 5. Measles (CD) 5. Neonatal preterm birth (CD) −55 6. Diarrheal disease (CD) 6. Congenital anomalies (NCD) −2 7. Other neonatal issues (CD) 7. Diabetes (NCD) 266 8. Cerebrovascular disease (NCD) 8. Interpersonal violence (I) −2 9. Intestinal infectious diseases 9. Road traffic accidents (I) 39 (CD) 10. Congenital anomalies (NCD) 10. Neonatal encephalopathy (CD) 0 13. Interpersonal violence (I) 11. Intestinal infectious diseases (CD) −55 17. Neonatal encephalopathy (CD) 12. Diarrheal diseases (CD) −71 21. Road traffic accidents (I) 20. Other neonatal (CD) −76 31. Diabetes (NCD) 21. Measles (CD) −80 Source: Adapted from the Institute of Health Metrics and Evaluation (IHME). Note: CD: Communicable, maternal, neonatal, and nutritional diseases; NCD: Noncommunicable diseases; I: Injuries. The ongoing and emerging health challenges place a strong pressure upon primary health services in the Philippines. Primary health care is well placed to cost-effectively identify, manage, refer, and/or cure these issues, and should be geographically accessible to the majority of the population. A consensus was reached among high-level health sector stakeholders in the Universal Health Coverage (UHC) Stocktaking event held in Manila from October 7 to 11, 2013, that access of every Filipino to primary health care was one of the most immediate needs if the country is to achieve UHC and, ultimately, its health outcome goals. The country has mixed public-private provision of primary health care. While the majority of care is delivered by the public sector, private providers are also an important source of care. One out of nine (11 percent) Filipinos visited a health care provider in the 30 days prior to the 2013 NDHS (Philippine Statistics Authority 2013). Approximately two-thirds of these visits took place in the public sector (7 percent) with the remaining one-third (4 percent) visiting private providers. However, the importance of the private sector varies by service type: while contraceptives were equally likely to come from either the public or the private sector and approximately 45 percent of hospital stays were in the private sector, women were more than twice as likely to deliver in the public sector (43 percent of births) as in the private sector (19 percent).1 Use of the private sector is more common in urban areas and among individuals from higher socioeconomic strata (Philippine Statistics Authority 2013). Overall, RHUs and barangay health stations (BHSs) are the most utilized (49 percent) (Figure 1). 1 Nearly 40 percent of women deliver outside of a facility. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 14 Figure 1. Breakdown of health care utilization by facility type, Philippines Souce of Care Others 2% Regional hospital/ medical center 5% Private hospital, clinic, or other 33% Provincial, District, and Municipal RHU/Urban health Hospitals 11% center and BHS, and other public 49% Source: National Demographic Health Survey, 2013 With the decentralization of the health sector more than two decades ago, public sector delivery of care in the Philippines has been primarily the responsibility of local government units (LGUs), that is, municipalities, cities, and provinces, who have a substantial degree of autonomy. Provinces are responsible for managing the local hospital systems, while cities and municipalities are responsible for managing RHUs or city health centers (both often referred to as RHUs or health centers) and Barangay Health Stations (BHSs) (also referred to as health centers). While the primary role of the Department of Health (DOH) should be regulatory and advocacy, it has continued to operate 70 secondary and tertiary hospitals, which serve as referral hospitals in the local hospital systems. With this fragmented scope of responsibilities, integration of health services through referral systems among the different levels of facilities necessitates agreements between the different local government levels, as well as with private facilities. The DOH has been promoting such linkages and rationalization of health delivery, but in practice there is no adequate referral and gatekeeping system in place. Bypassing of primary care facilities is common, with patients citing dissatisfaction with the quality of care or lack of supplies at public facilities as important motivating factors in their decision to attend higher-level facilities for primary health concerns (Romualdez et al. 2011). Despite the frequent bypassing of primary care facilities, RHUs and BHSs remain the most heavily utilized facilities, and generally serve as patients’ first point of contact with health services. BHSs are staffed by volunteer community or barangay health workers (BHWs), and midwives, while the RHUs are staffed by doctors, nurses, midwives, medical technologists, sanitary inspectors, nutritionists, and volunteer health workers (Romualdez et al. 2011). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 15 Although referral arrangements are encouraged by the DOH, there are no formal standards to help structure these arrangements, nor are there licensing requirements for public or private primary care facilities. However, some specific health programs espoused by the DOH outline specific capacity requirements with regard to staff, equipment, and supplies. For example, operational manuals on immunization, family planning (FP), and maternal and child health (MCH) detail the basic facility requirements needed to deliver these services. Standards are likewise defined in accreditation requirements and clinical guidelines for PhilHealth’s specific benefit packages. One important example of the latter is PhilHealth’s Primary Care Benefit (PCB) Package, which targets PhilHealth’s indigent members and is delivered through RHUs and BHSs. The PCB is a special benefit package that has been established to increase access to primary care services among this population. In exchange for a fixed payment per enrolled family, PCB providers are expected to deliver a set of services, including basic primary care consultations, specified diagnostic examinations, and priority essential medicines (see Table 2). Table 2. Contents of the PCB Package PCB Package; Launched 2012 Primary preventive services Diagnostic examinations Drugs and medicines  Consultation  Complete blood count  Asthma, including  Cervical cancer screening (CBC) nebulization services (CCS): Visual inspection  Urinalysis  Acute gastroenteritis with acetic acid (VIA)  Fecalysis (AGE), with no or mild  Regular blood pressure (BP)  Sputum microscopy dehydration measurements  Fasting blood sugar (FBS)  Upper respiratory tract  Breastfeeding program and  Lipid profile infection (URTI) and education  Chest X-ray pneumonia  Periodic clinical breast  Urinary tract infection examinations (UTI)  Counseling for lifestyle modification  Counseling for smoking cessation  Body measurements  Digital rectal examination Source: PhilHealth 2012. While the PCB Package targets indigent members, a number of primary care services are available to the broader PhilHealth beneficiary base through the MDG-related benefit packages for maternity care, malaria, TB, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), voluntary surgical contraception, and animal bite treatments. Each of these packages requires different accreditation procedures. Thus, a facility might be accredited to deliver the Maternity Care Package (MCP) care but not the TB Directly Observed Therapy-Short Course (DOTS) package, depending on the available personnel, infrastructure, and supplies. For these packages, both public and private facilities and different levels of facilities may apply for accreditation. PhilHealth, however, actively pursues that each LGU has at least one public health facility accredited SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 16 for PCB, MCP, and TB DOTS. As of 2015, 96 percent of LGUs have at least one PCB- accredited RHU, 79 percent LGUs have at least one MCP-accredited facility, and 78 percent LGUs have at least one TB DOTS-accredited facility (PhilHealth 2015). Whether or not accredited by PhilHealth for any benefit package, the RHU is the facility through which Municipal or City Health Offices deliver the primary and public health services for which they are tasked by the national devolution of health service delivery. The discussion of service readiness for different types of health services in the latter sections outlines the standards and guidelines, if any, of the DOH and PhilHealth for such services. A Municipal or City Health Office may have more than one RHU, especially in geographically large LGUs or LGUs with extremely remote barangays, but there is typically a facility, designated the main RHU, that is located within the town proper. The Municipal Health Officer is generally also the RHU physician. Service availability may differ between RHUs. For example, different RHUs also offer different health services and PhilHealth benefit packages and, while many RHUs operate just like other government offices—eight hours per day, Monday through Friday—some RHUs operate 24 hours per day, seven days per week. Financing RHU Services Direct spending for health by an LGU from its General Fund is subject to the overall budgetary constraints within each LGU and must compete locally with other sectors for funds, thereby resulting in variations in health spending from one LGU to the next. From 2011 to 2014, the health sector comprised, on average, 9 percent of expenditure of cities and municipalities (Department of Finance: Bureau of Local Government Finance, n.d.). Except for a few municipalities or cities that are operating hospitals, almost all health spending goes to the operation of RHUs for delivery of primary and public health care services. A case study of LGUs showed that such health spending for primary and public health care services were in the range of PHP 2 million to PHP 5 million in municipalities and approximately PHP 19 million in cities (Lavado 2016). As with the other LGU offices, hiring of Municipal Health Office and RHU personnel is managed by the LGU. Spending for equipment, supplies, and operating expenses in the RHU also go through the spending procedures of the LGU, which usually consists of preparing an Annual Procurement Plan and requesting for the execution of any purchase, including emergency purchases not contained in the procurement plan. All procurement must go through the General Service Office of the LGU through a bids and awards committee and must follow national rules and regulations on procurement. In RHUs that collect user fees, any revenues revert to the General Fund. Approximately 60 percent of LGU health spending for RHUs are on salaries and benefits of health personnel. Except in years with expenses on major equipment and infrastructure, the rest of the health budget is spent for the operating expenses of the RHU such as for utilities, supplies, and medicines. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 17 The DOH and PhilHealth also provide critical financial, in-kind, and human resource support to RHUs. For example, the DOH has staff deployment programs to augment the existing health workforce in RHUs. Although intended as stopgap measures to fill critical needs, these programs have been ongoing for a number of years. Public health goods such as vaccines are provided by the national government, procured centrally by the DOH, and distributed in-kind to the various RHUs and BHSs through the DOH regional offices. Similarly, the DOH distributes medicines under a variety of programs for medicine access, such as the Complete Treatment Packs (ComPacks), which contain complete treatment regimens for common diseases, including hypertension and diabetes. ComPacks are intended to ensure access to high-priority medicines by the poor, although the system has struggled with both leakage of the program benefits to the non-poor and stock-outs of the priority drugs. The DOH has also poured significant resources on equipment and infrastructure for public health care facilities, including RHUs. Over the past five years, the DOH has used its Health Facilities Enhancement Program (HFEP) to accelerate the supply-side readiness to provide health services. While the HFEP shows promise in improving health facilities resourcing, the program has been struggling with issues related to the transparency of allocation processes and decisions (that is, which facilities get which infrastructure and equipment) and with implementation challenges related to monitoring, delivery of equipment, and construction projects, among others. Revenues from PhilHealth for accredited benefit packages are put in an LGU-specific PhilHealth Trust Fund. Twenty percent of this fund is earmarked for the service providers (RHU physician and other health personnel). These funds may have been substantially augmenting the salaries that these staff receive from the LGU, although there is no known documentation on the distribution of these funds. The remaining funds in the trust fund are earmarked for the facility’s operating expenses. Half of the PCB payments (net of professional fee) are earmarked for medicines. However, with issues in reporting and payment delays—especially for the PCB Package—funds from PhilHealth have not been a consistent source of funding for the RHUs. Overall Financing for Primary Health Care While there are no specific data on expenditure for primary health care, overall health expenditure data (for all types of health care at all types of providers, including pharmacies and private and public facilities) strongly suggest that out-of-pocket spending is substantial, even for primary health care, and that medical expenditures are particularly high. Current data do not permit us to perfectly track financing for primary health care to the major funding sources. Primary health care falls into two distinct health care function categories of the Philippine National Health Accounts: preventive care and outpatient curative care, 2 and both of these care categories might also include higher-level care delivered in an outpatient setting. Nevertheless, these two categories serve as a useful proxy to examine expenditure for primary health care. Together, they comprised 18 percent to 19 2 PhilHealth capitation payments for the PCB rendered in RHUs, for example, are categorized as Outpatient Curative Care, while LGU expenditure for RHUs are classified under Preventive Care. Other health care function categories include Inpatient Curative Care, Rehabilitative Care, Ancillary Services, Medical Goods, Governance and Health System, and Financing Administration. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 18 percent of all health expenditure in 2012–2014. Figure 2 links the expenditure on these categories to their funding source for the period 2012–2014. Household out-of-pocket payments accounted for more than half of all spending on primary care, local governments spent for almost 20 percent, health maintenance organizations and private corporations cover 4 percent, and national government and PhilHealth accounted for between 23 percent and 28 percent. It can be noted that considering that PhilHealth has almost the same share as LGUs, it becomes even more imperative that issues with the capitation payments be addressed such that this substantial funding from PhilHealth can become an integral part of LGU finances in ensuring the readiness of supply side for primary care delivery. Figure 2. Financing sources and amounts for preventive and outpatient curative care, 2012–2014 Financing Agents for Preventive Care and Outpatient Curative Care 120 100 Household Out-of- Pocket 80 in billion Pesos Health Maintenance 60 Organizations (HMOs) Local Government 40 Central Govt and 20 PhilHealth - 2012 2013 2014 Source: Racelis 2016. Some medicines for primary health care may also form part of the health care function classified as medical goods, which comprised 35–37 percent of all health expenditure. The proportion of these medical goods that contributes to primary health care cannot be estimated. It is notable, however, that 99 percent of medical goods were paid for by household out of pocket, further emphasizing the burden of out-of-pocket expenses in health care financing. The government aims to reduce fragmentation in the financing of primary and preventive health services by expanding the share of primary health care financed by PhilHealth, with the long-term vision (per the Health Financing Strategy 2010–2020) that PhilHealth would pay for personal primary care services, while LGUs maintain responsibility for community-level public health. Expanding the scope of PhilHealth’s PCB and modifying the provider payment method for the package is a step in that direction. An upgraded version of the PCB, known as Tsekap, expands the package to cover more conditions, more diagnostic tests, and more medicines.3 Also, building upon the PCB Package, the Tsekap is a blended payment system that combines ‘capitation’ (per family) payment with 3 PhilHealth Circular No. 002-2015: Governing Policies on the Expanded Coverage of the PCB Package: Tamang Serbisyo sa Kalusugan ng Pamilya (Tsekap) was issued in February 2015 but has not been implemented to date; a formal advisory deferring Tsekap was issued in November 2015. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 19 performance incentives to deliver certain obligated services, namely monitoring the BP of hypertensive patients, monitoring the blood sugar level of diabetes patients, cervical cancer screening (CCS), and breast examination. These revised incentives aimed to ensure that the RHUs obtain and monitor the health profiles of target beneficiaries, and follow up with patients with chronic conditions. There are plans to integrate still other primary and preventive services into the PhilHealth benefit package; for example, the Immunization Act in 2011 already foresees that immunization should eventually be financed by PhilHealth. Moreover, the package is intended to be made available to all PhilHealth members, and to expand the network of providers to include both public and private primary care providers. The government is also working to improve the efficiency of services paid for by PhilHealth. The government is currently rolling out the mandatory use of electronic medical records (EMRs) at the primary care level. Once fully implemented, EMRs will allow PhilHealth to obtain health profiles and monitor services rendered by the primary care providers. Although there are a number of resources available to the health sector at the local level— including its own budget, in-kind contribution, budget transfers from the DOH, PhilHealth, and collection of user fees—health sector spending is saddled with inefficiencies stemming from overlapping allocations. Meanwhile, the political priority placed on health varies between regions. This affects budgetary allocations which can be difficult to predict from the central level. While there are national guidelines and standards in place, and technical assistance is available from the DOH, implementation capacity varies from region to region. This has resulted in substantial, but not well-documented, variability in the availability of health care services and resources. Objective and Structure of the Paper This study assesses the ability of the Philippines’ public primary health care facilities to provide preventive, diagnostic, and curative care for selected tracer conditions, with a focus on priority programs delivered at RHUs. We first provide an overview of general readiness to deliver health care services, and then consider a number of specific services divided into MCH services, NCD services, and TB. On the MCH side, these include antenatal care (ANC), FP services, the Expanded Program for Immunization (EPI), and child health.4 Among NCDs, we examine the availability of services for diabetes mellitus (DM), cardiovascular disease (CVD), chronic respiratory disease (CRD), and CCS across the country. Finally, we also examine the ability to provide TB detection and treatment services. This paper relies on the World Health Organization’s (WHO) recommendations for Service Availability and Readiness Assessment (SARA) to establish a list of supply- side requirements for each of these conditions. 4 Basic Emergency Obstetric and Neonatal Care (BEmONC) services is another component of MCH that would have been important to include in this analysis. However, the survey on which the data was based did not include some of the key indicators that are required to measure the supply-side readiness of BEmONC, and therefore this component was dropped from the study as it only provided an incomplete picture. The discussion on general service readiness nevertheless captures some BEmONC indicators such as availability of emergency transport and emergency medicines. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 20 The remainder of the study is structured as follows: Section II explains the analytical approach and describes the data used for this study. Sections III.1 and III.4 present findings related to tracer general service readiness, MCH indicators, NCD, and TB indicators, respectively. Each section includes a brief background on the relevant demographic and epidemiologic context, describes government programs and guidelines related to the key tracer conditions, compares the available data to the WHO’s SARA-recommended indicators, and presents an overview of the overall availability and readiness to provide services in the study sample of LGUs. Section III.5 aggregates the results of the previous sections into composite measures of supply-side readiness. Section IV concludes with a summary and some policy implications. II. Analytical Approach Data This report relies on data originally collected to serve as a baseline for a study on the implementation of PhilHealth’s PCB Package, conducted by Onishi et al. (2016), and includes facility survey and health worker interviews at each RHU. Data were collected at one RHU in each of the 240 LGUs across 14 regions in 2014.5 Random selection into the survey occurred at the municipality level, stratified by region and province. To be eligible for inclusion in the survey, municipalities must have had at least one PCB-accredited RHU at the time of the survey. Three regions were excluded from the baseline, namely the National Capital Region (NCR) which constitutes Metro Manila, the Autonomous Region of Muslim Mindanao (ARMM) because its health system is organized differently,6 and Region 8 because it had been severely affected by Typhoon Haiyan in late 2013, shortly before data collection. The sample comprised a total of 1,120 eligible LGUs across 30 provinces; eight LGUs were randomly selected in each province. Within each selected LGU, the main RHU was visited. In provinces with less than eight eligible LGUs, the balance was randomly drawn from a nearby province within the same region. Informed consent was obtained from all participating LGUs. While a number of LGUs refused to participate, these were not significantly different from the participating LGUs across a number of characteristics considered.7 The final sample included 16 LGUs for all regions other than Regions 6 and 7 where a total of 24 LGUs were selected for each region. A full list of LGUs visited is provided in Annex 4 of this report. 5 Data analysis was designed to be representative at the national and regional levels. Approximately half of provinces are represented. 6 The ARMM does not have health services decentralized at the municipality level and therefore the interventions are not relevant. The NCR was taken out as each municipality and city was considered too large (with too many RHUs) and therefore was deemed inefficient to include in the study. 7 Philippines Impact of Incentives and Information on Utilization and Quality of Care (I3QUiP): Baseline Survey Report, 2016. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 21 The survey asked for availability and details of priority primary care services, both those that are delivered as part of the PCB, as well as those that are covered outside of the PCB such as maternal care and TB detection and treatment. Most RHUs reported offering maternal health services: 88 percent offered normal delivery care, 99 percent offered ANC, and 93 percent provided FP services; 98 percent of the RHUs provided TB diagnostics services.8 Methods The study uses the WHO’s Service Availability and Readiness Assessment (SARA) as an organizing framework and guide to the inputs needed to deliver health services. SARA is a framework for monitoring and assessing key aspects of service delivery in a health system along three dimensions: (a) service availability; (b) service readiness; and (c) service utilization (WHO 2014). Availability focuses on physical access to and distribution of health facilities. Readiness considers distribution of different types of inputs needed to deliver high-quality services. These inputs are categorized into a number of domains, including infrastructure, equipment, and diagnostics and medicines. Utilization considers the uptake of services through inpatient and outpatient visits at public and private facilities. Due to data availability, this report primarily focuses on the second dimension, service readiness, that is, whether or not RHUs have the basic infrastructure, equipment, diagnostic capacity, medicines, and commodities to provide services in general and for specified conditions. SARA includes checklists to evaluate the readiness and availability of general services as well as the specific infrastructure and supply needs for a number of specific services, including the maternal, child, NCD, and communicable health issues considered here. The checklists are not intended to reflect an exhaustive list of inputs needed to deliver services, but offer a succinct list of items that can be realistically captured during survey visits while also reflecting the broader system. While the bulk of this report focuses on service readiness, we also provide an overview of RHU staffing levels, an important component of service availability. SARA functions as an organizing framework for the study in the sense that it provides ways to classify health services into different categories which form the main sections of this study, namely (a) general service readiness, (b) MCH, (c) NCDs, and (d) TB. Within MCH are four subcategories: ANC, FP, immunization, and child health. The section on NCDs also includes four subcategories: DM, CVD, CRD, and CCS. More importantly, though, SARA provides a guide to use available data to learn about the readiness of the RHUs to deliver primary health care services. Operationally, domain-specific SARA indicators were reviewed and compared against available data. Because this analysis was not an ex ante objective of the survey data which underlies this report, not all SARA indicators were included. However, we believe there is sufficient overlap between the SARA guidelines and the available data to yield important information about supply-side 8 Only 65 percent of the RHUs reported being accredited for MCP and TB DOTS. Higher percentages reported providing the different MCH and TB services, indicating some RHUs offer the services even if not accredited for these benefit packages. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 22 readiness, and can reasonably serve as tracer indicators for supply-side readiness for the respective health service categories. For general service readiness, information is divided into five domains: basic infrastructure, basic equipment, infection prevention, diagnostic capacity, and essential medicines. For the specific health service categories, we present varying combinations of three domains: equipment, diagnostics, and medicines and commodities. Where available, information on staffing and training is also included. For each domain, we report the aggregate results for the entire study sample. Figure 3. Supply-Side Readiness Assessment Framework Note: General services considered along five domains (basic infrastructure, basic equipment, infection prevention, diagnostic capacity, and essential medicines). Specific services considered along up to four domains (staffing and training, equipment, diagnostics, and medicines and commodities). Tracer indicators assessed for each. Individual indicators were then aggregated to calculate domain scores. Average domain scores are presented by region and income class. Domains are then aggregated to present overall general and specific service readiness scores. Overall scores are presented here by region and income class. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 23 In Section III.5, we compare the aggregate scores of the different health service categories/subcategories by region and by LGU income class. The Philippines government classifies LGUs into six groups according to their average total annual income 9 over the four years immediately preceding the classification (Department of Finance 2008), with first group (termed ‘first class’) having the largest overall income (that is, the richest) and the sixth group (termed ‘sixth class’) having the smallest (that is, the poorest). The six groups are summarized in Table 3. Note that income refers to the LGU’s income and not to the income of the population of that LGU. Wealthier LGUs tend to have more concentrated populations, and thus a larger base from which to collect resources. The main purpose of income classification of LGUs is to determine their financial capability to provide in full or in part the funding requirements of priority needs in their locality. The income class of LGUs is therefore used as a factor in the allocation of national or other financial grants, as well as determining the maximum amount expendable for salaries and wages and in implementing personnel policies. Table 3. Details of LGU income classification at the municipality level Proportion Number of Number of Income of LGUs Average Annual Income (PHP) LGUs LGUs Class Surveyed Nationwide in Survey (%) First 55 million or more 350 52 15 Second 45 million or more but less than 55 million 188 29 15 Third 35 million or more but less than 45 million 264 54 20 Fourth 25 million or more but less than 35 million 394 59 15 Fifth 15 million or more but less than 25 million 272 39 14 Sixth Below 15 million 22 7 32 To aid in the interpretation of the findings, it is important at the outset to summarize some of the limitations of the analytical approach and underlying data, even though they have already been referred to in the preceding discussion. These limitations all stem from the fact that the facility survey data used for the analysis were not collected for the purpose of doing a supply-side readiness; rather, this study opportunistically uses the availability of an existing health facility survey collected to assess the implementation of the PhilHealth PCB Package. Consequently, one limitation is that the dataset does not contain all the indicators that are usually used to measure supply-side readiness using the SARA framework. It is, however, at least as comprehensive as most health facility surveys collected in developing countries where, for reasons of cost, a relatively small number of indicators (of infrastructure, equipment, supplies and medicines) are collected with the intention of providing an indication of the facility’s ability to deliver the health service in question.10 Second, while some aspects of quality were captured in the facility survey data, they did not provide sufficient information to conduct a comprehensive analysis of quality 9 Annual income refers to revenues and receipts realized by LGUs from regular sources of Local General Fund, inclusive of internal revenue allotment (IRA). It excludes non-recurring receipts such as national aids, grants, financial assistance, loan proceeds, among others. 10 Indeed, as described in the baseline report of the I3QUiP study, the instruments of a number of different health facility surveys, including the SARA, were reviewed (and also discussed with the Philippines government) before the indicators included in this survey were selected. Further, the indicators were discussed with the Philippines government (both the DOH and PhilHealth) and deemed good indicators of the services whose availability they were intended to capture. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 24 of services provided and therefore this study is limited to availability of supply-side inputs. Finally, because the survey was designed to measure implementation of the PCB Package, the sample is restricted to those facilities who were already accredited to deliver the PCB Package. As such, supply-side readiness in the RHUs included in the sample is expected to be much better than in the RHUs that are not PCB-accredited. It is also important to note that the study excludes the NCR, ARMM, and typhoon-affected Region 8 where administrative records suggest that health outcomes and service delivery indicators are generally worse. III. Findings 1. General Service Readiness We first provided an overview of ‘general service readiness’, a broad category covering general inputs needed to provide basic medical service, divided into five domains: basic infrastructure, basic equipment, infection prevention, diagnostic capacity, and essential medicines (Table 4). Tracer indicators from each domain are aggregated to create a domain-specific score for each RHU. These scores are then further aggregated at either the regional level or over LGU income levels. Table 4. General service readiness tracer indicators: SARA and from survey Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Basic  Power  Is the electricity always available or is it Infrastructure sometimes interrupted?  Improved water source inside  Does the laboratory have running water? OR within the ground of the Or does the delivery room have running RHU water?  Room with auditory and visual  There is visual privacy AND auditory privacy for patient consultations privacy in the doctor's consultation room.  Access to adequate sanitation in  Is there a toilet in the RHU that is RHUs for clients available for general client use?  Communication equipment  Indicator Dropped - Data not available. (phone or shortwave [SW] radio)  RHU has access to computer  Does this RHU have a functioning with email/Internet access computer? AND is Internet connection available in the RHU?  Emergency transportation  Does this RHU have a functional ambulance or other vehicle for emergency transportation for clients? Basic  Adult scale  Weighing scale (Adult) Equipment  Child scale  Weighing scale (infant)  Thermometer  Non-mercurial thermometer  Stethoscope  Stethoscope  BP apparatus  Non-mercurial BP apparatus  Light source (spotlight source  Indicator Dropped - Data not available for consultations) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 25 Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Infection  Safe final sharps disposal  Safe disposal of sharps: Puncture-proof Prevention receptacles for disposal of pointed/sharp objects  Safe final disposal of infectious  Safety vault for disposing contaminated waste waste  Sharps container/storage  Safe disposal of sharps: Puncture-proof receptacles for disposal of pointed/sharp objects  Infectious waste storage  Indicator Dropped - Data not available  Single-use syringes  Disposable needles and syringes  Soap and running water, or  70% isopropyl alcohol alcohol rub  Latex gloves  Latex gloves  Guidelines for standard  Indicator Dropped - Data not available precautions Diagnostic  Hemoglobin (Hb)  Hemoglobinometer kit/acid hematin (for Capacity RHUs with laboratory)  Blood glucose  Offering fasting blood glucose  Malaria diagnostic  Offering diagnosis or treatment of malaria  Urine dipstick-protein  Indicators merged: Dipstick for qualitative  Urine dipstick-glucose urine analysis  HIV diagnostic capacity  Offering HIV counseling and testing services  Syphilis rapid test  Offering diagnosis or treatment of sexually transmitted infections (STIs) (excluding HIV)  Urine test for pregnancy  Indicator Dropped – data not available Essential  Amlodipine/calcium channel  Calcium channel blocker, for example, Medicines blocker amlodipine, nifedipine  Amoxicillin syrup, suspension or  Indicator Dropped - Data not available dispersible tablet  Amoxicillin tablet  Amoxicillin (stock availability)  Ampicillin powder for injection  Indicator Dropped - Data not available  Aspirin capsule/tablet  Indicator Dropped - Data not available  Beclomethasone inhaler  ICS, for example, beclomethasone or budesonide or fluticasone (stock availability [asthma])  Beta-blocker  Beta-blocker (stock availability [hypertension])  Carbamazepine tablet  Indicator Dropped - Data not available  Ceftriaxone injection  Indicator Dropped - Data not available  Diazepam injection  Injectable diazepam (stock availability [BEmONC])  Enalapril tablet/ angiotensin converting enzyme (ACE)  ACE inhibitor (stock availability inhibitor [hypertension])  Fluoxetine tablet  Indicator Dropped - Data not available SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 26 Domain WHO SARA Tracer Indicators Tracer Indicators from Survey  Gentamicin injection  Indicator Dropped - Data not available  Glibenclamide tablet  Sulfonylureas, for example, glibenclamide, gliclazide (observed available preparation [hypertension])  Haloperidol tablet  Indicator Dropped - Data not available  Insulin regular injection  Indicator Dropped - Data not available  Magnesium sulfate injectable  Magnesium sulfate (stock availability [BEmONC])  Metformin tablet  Metformin (stock availability [diabetes])  Ome/panto/rabeprazole tablet  Indicator Dropped - Data not available  Oral rehydration salts (ORS)  ORS (stock availability [gastroenteritis])  Oxytocin injection  Oxytocin (stock availability [BEmONC])  Salbutamol inhaler  Beta2-agonist, for example, salbutamol (stock availability [asthma])  Simvastatin tablet or other statin  Indicator Dropped - Data not available  Thiazide  Diuretic, for example, hydrochlorothiazide  Zinc sulfate tablets, dispersible  Zinc supplements (stock availability tablets or syrup [gastroenteritis]) Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. Basic infrastructure indicators include availability of electricity, water and sanitation facilities, privacy for consultations, computer with Internet access, and emergency transportation. Many of the basic amenities are in place across the Philippines. Access to water and sanitation is nearly universal, and room privacy is also generally available. However, the survey identified a number gaps in electricity, Internet access, and emergency transport. While nearly all RHUs had a functional computer, one in three did not have Internet access on the day of the survey. Internet access, which is an important factor for the planned introduction of EMRs, was particularly limited in the Cordillera Administrative Region (CAR) and Regions 2, 3, and 9. Gaps in emergency transportation were concentrated in specific regions. While nearly 90 percent of RHUs have access to a vehicle for emergency referral, RHUs in Region 3—where nearly one-third of facilities visited were without emergency transport—were least likely to have access to a vehicle. The same was true for one-quarter of RHUs in Region 9, and nearly one-fifth of RHUs in CAR and Region 5. In comparison, all RHUs in Region 1 reported having access to an emergency vehicle (see Figure 4). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 27 Figure 4. Basic infrastructure by region Basic infrastructure 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Overall Power Improved Water Room Privacy Adequate Sanitation Computer with internet Emergency Transport Note: This figure indicates the regional availability of the tracer indicators included in the Basic Infrastructure domain. Blue bars indicate aggregate performance by region. The survey results highlight gaps in access to power. Only 51 percent of the RHUs had uninterrupted power in the seven days prior to the survey team’s visits, while the remaining 49 percent had power interruptions of at least two hours for an average of 2.7 days in the seven days prior to the visits. As shown in Figure 5, power access was particularly problematic in Region 3, where power interruptions (for at least two hours) in the RHUs occurred every day during the entire week preceding the survey. These power outages were found despite the fact that power access is a standard requirement for all RHUs eligible for PCB accreditation with PhilHealth and, thus, for participation in this survey. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 28 Figure 5. Power outages - Frequency and duration by region Power 100% 7 Percent Interrupted 6 80% 5 60% 4 Days 40% 3 2 20% 1 0% 0 Sometimes Interrupted Always Available Days electricity was interrupted in the past week Basic equipment includes a BP apparatus, stethoscope, thermometer, a child scale, and an adult scale. All of these items were widely available. Stethoscopes and scales were available at all facilities visited, while BP apparatuses and thermometers were available at 96 percent of facilities. There was also little variance in aggregate regional scores. CAR (96.3 percent) and Region 1 (92.5 percent) had the lowest regional performance. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 29 Figure 6. General service readiness: Basic equipment Domain Score: Basic Equipment Equipment Score by Region BP Apparatus 96 100% Stethoscope 100 80% 60% Thermometer 96 40% Child Scale 100 20% Adult Scale 100 0% 0 20 40 60 80 100 Percent of Facilities (%) Note: The left panel indicates the availability of tracer indicators at RHUs nationwide. The right panel indicates aggregate scores at the regional level. Figure 7 provides an overview of infection prevention efforts in RHUs. While almost all RHUs have disposable gloves and syringes, disinfectant is missing from 15 percent of RHUs and nearly 8 percent of RHUs had neither running water nor alcohol solution for hand hygiene. There are also still serious gaps in waste management. A quarter of RHUs did not have the infrastructure in place for storage and safe disposal of sharps, and 35 percent of RHUs were unable to safely dispose of infectious materials. Figure 7. General service readiness: Infection prevention Domain Score: Infection Infection Prevention by Region Prevention Latex gloves 100 Soap and running water or 100% 92 alcohol based hand rub Single use-standard disposable 80% 100 or auto-disable syringes Disinfectant 85 60% Appropriate storage of sharps 75 waste 40% Safe final disposal of 65 infectious wastes Safe final disposal of sharps 75 20% 0 20 40 60 80 100 0% Percent of Facilities (%) Note: The left panel indicates the availability of tracer indicators at RHUs nation-wide. The right panel indicates aggregate scores at the regional level. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 30 The domain on diagnostic capacity checks whether some common diagnostics tests (syphilis rapid test, HIV testing, urine dipstick, malaria diagnosis, blood glucose, Hb) can be conducted on-site in the facility and functional equipment and reagents needed to conduct the tests are observed in the facility. Survey results show that there is substantial scope for an improvement in diagnostic capacity across the country. The average domain score within our sample was just 67 percent, and it ranged from a high of 82 percent in Region 12 to a low of just 50 percent in Region 4B (Figure 8). The specific components of the diagnostic capacity score are discussed in more detail in the sections of the report dealing with the domains to which they apply. Figure 8. General service readiness: Diagnostic capacity Domain Score: Diagnostic Capacity Diagnostic Capacity by Region Syphilis rapid test 75 100% HIV testing 48 80% Urine dipstick 81 60% Malaria diagnosis 50 40% Blood glucose 79 20% Haemoglobin 65 0% 0 20 40 60 80 100 Percent of Facilities (%) Note: The left panel indicates the availability of tracer indicators at RHUs nationwide. The right panel indicates aggregate scores at the regional level. Availability of essential medicines is presented in Figure 9. I3QUiP data collection focused on supplies and commodities required for the PCB-covered conditions (for example, hypertension, TB, AGE, asthma) and the most basic commodity requirements in a primary care facility for other priority programs (for example, TB, maternal and newborn care, and FP). Generally, medicines are more widely available than are diagnostics. The national average score was 87 percent, indicating that most medicines were available at most RHUs visited. There was also less variability in the availability of medicines, with scores ranging from a low of 83 percent in Region 5 and CARAGA to a high of 89 percent in Region 11. While the survey did not ask for the source of these medicines, it can be noted that the most widely available are the medicines that are distributed by the DOH, either through medicines access programs such as ComPacks or through disease-specific programs. More details are provided on the specific components of the domain in service-specific sections of this report. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 31 Figure 9. General service readiness: Essential medicines Domain Score: Essential Medicines Essential Medicines by Region Zinc suphate tablets,… 81 Thiazide 99 100% Sablutamol inhaler 98 Oxytocin injection 89 Oral rehydration solution 96 80% Metformin tablet 97 Magnesium sulphate… 55 60% Glibenclamide tablet 98 Enalapril tablet (or ACE… 99 Diazepam injection 40 40% Beta blocker 99 Beclometasone inhaler 50 20% Amoxicillin tablet 97 Amoxicillin… 88 Amlodipine tablet (or Ca… 97 0% 0 20 40 60 80 100 Percent of Facilities (%) Note: The left panel indicates the availability of tracer indicators at RHUs nationwide. The right panel indicates aggregate scores at the regional level. Looking at details on aggregate general service readiness scores, LGUs in the upper income class levels performed better in several of the domains, including basic amenities, basic equipment, and diagnostic capacity. However, the sixth class LGUs performed slightly better than their wealthier counterparts on infection prevention and availability of essential medicines (Table 5). Table 5. General service readiness score by LGU income classification Basic Basic Infection Diagnostic Essential Income Class Infrastructure Equipment (%) Prevention (%) Capacity (%) Medicines (%) (%) 1 79 85 89 77 88 2 80 83 88 65 85 3 82 88 88 71 87 4 79 81 86 63 87 5 70 68 87 56 85 6 74 79 90 67 90 Total 78 81 87 67 87 Note: Basic infrastructure includes power, water access, auditory and visual privacy for consultations, access to sanitation, access to a computer with Internet, and emergency transportation. Basic equipment includes child scale, adult scale, thermometer, stethoscope, and BP apparatus. Infection prevention includes infectious waste disposal, sharps containers, single-use syringes, alcohol rub, and latex gloves. Diagnostic capacity includes tests for Hb, blood glucose, urine, HIV, and syphilis. Essential medicines include calcium channel blockers, amoxicillin, ICS, beta-blockers, injectable diazepam, ACE inhibitors, sulfonylureas, magnesium sulfate, metformin, ORS, oxytocin, beta2-agonist, diuretic, and zinc supplements. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 32 Regionally, there was little variation in the availability of essential medicines, but CAR was below average in all domains, with Region 4A below average in four out of five domains (Table 6). Table 6. General service readiness score by region Basic Basic Infection Diagnostic Essential Region (%) Infrastructure Equipment Prevention Capacity Medicines (%) (%) (%) (%) (%) CAR 67 96 83 57 86 Region 1 89 93 81 69 88 Region 2 77 98 83 76 88 Region 3 76 100 81 69 87 Region 4A 78 100 74 66 85 Region 4B 77 100 92 50 85 Region 5 70 100 81 79 83 Region 6 83 99 87 57 88 Region 7 83 98 94 62 85 Region 9 71 99 95 56 89 Region 10 86 97 85 81 88 Region 11 78 100 98 77 89 Region 12 81 98 86 82 86 CARAGA 75 100 98 70 84 Total 78 98 87 67 87 Note: Basic infrastructure includes power, water access, auditory and visual privacy for consultations, access to sanitation, access to a computer with Internet, and emergency transportation. Basic equipment includes child scale, adult scale, thermometer, stethoscope, and BP apparatus. Infection prevention includes infectious waste disposal, sharps containers, single-use syringes, alcohol rub, and latex gloves. Diagnostic capacity includes tests for Hb, blood glucose, urine, HIV, and syphilis. Essential medicines include calcium channel blockers, amoxicillin, ICS, beta-blockers, injectable diazepam, ACE inhibitors, sulfonylureas, magnesium sulfate, metformin, ORS, oxytocin, beta2- agonist, diuretic, and zinc supplements. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 33 Figure 10. Regional variation in the availability of basic infrastructure Note: Infrastructure includes power, water access, auditory and visual privacy for consultations, access to sanitation, access to a computer with Internet, and emergency transportation. Low score is 67 percent, high score is 89 percent. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 34 Figure 11. Regional variation in the availability of basic equipment Note: Basic equipment includes child scale, adult scale, thermometer, stethoscope, and BP apparatus. Low score is 93 percent, high score is 100 percent. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 35 Figure 12. Regional variation in infection prevention Note: Infection prevention includes infectious waste disposal, sharps containers, single-use syringes, alcohol rub, and latex gloves. Low score is 74 percent, high score in 98 percent. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 36 Figure 13. Regional variation in diagnostic capacity Note: Diagnostic capacity includes tests for Hb, blood glucose, urine, HIV, and syphilis. Low score is 50 percent, high score is 82 percent. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 37 Figure 14. Regional variation in essential medicine availability Note: Essential medicines include calcium channel blockers, amoxicillin, ICS, beta-blockers, injectable diazepam, ACE inhibitors, sulfonylureas, magnesium sulfate, metformin, ORS, oxytocin, beta2-agonist, diuretic, and zinc supplements. Low score is 83 percent, high score is 89 percent SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 38 6833/<6,'(5($',1(662)35,0$5<+($/7+&$5(,17+(3+,/,33,1(6   RHU Personnel Within the SARA framework, human resources for health (HRH) fall under the scope of service availability and are considered at the macro level, as ratio of health worker to total population. Although an explicit analysis of health workforce level and distribution is not part of the supply-side readiness framework, HRH are critical for the delivery of clinical services. In this section, we provide an overview of staffing levels to help inform the discussion. To become PCB-accredited, an RHU is required (a) to have on staff one each of a licensed doctor, licensed nurse, and licensed midwife; (b) to have a licensed medical technologist for those that provide laboratory services; and (c) to have a licensed radiologist for those that provide X-ray services.11 Aside from these personnel, RHUs typically employ one or more dentist(s), dental aide(s), rural sanitary inspector(s), administrative personnel, and driver(s). The RHU personnel work closely with BHWs, volunteers who render primary health care services in the community after undergoing training and accreditation. Error! Reference source not found. shows that RHUs meeting the above requirement varied between regions, especially on having at least one full-time physician—only 62 percent for Region 2 to 100 percent for Regions 4A and 4B. Only Region 4A had met full requirement with at least one full-time physician, nurse, and midwife. The DOH standard requirement of health worker to catchment population ratio is 1:20,000 for physicians, 1:10,000 for nurses, and 1: 5,000 for midwives. Table 7 shows that the actual ratios for public health workers in the RHUs are much lower than these requirements. There may possibly be private sector facilities serving the same populations, so these ratios could be underestimated. Table 7. RHU personnel compared with PCB requirementsand DOH requirements (right) Region PCB Requirements DOH Requirements At least one At least one At least one Physician Nurse Midwife full-time full-time full-time (1:10,000) (1:20,000) (1:5,000) physician nurse midwife CAR 93.75 93.75 100.00 6.32 6.32 25.06 Region1 87.50 87.50 100.00 38.78 21.68 21.68 Region 2 62.50 93.75 100.00 25.45 31.81 38.18 Region 3 93.75 100.00 100.00 78.68 50.25 63.96 Region 4A 100.00 100.00 100.00 70.78 64.93 70.78 Region 4B 100.00 93.75 100.00 49.23 49.23 55.86 Region 5 87.50 100.00 100.00 55.28 34.80 41.63 Region 6 95.83 87.50 95.83 55.55 49.78 11.53 Region 7 91.67 95.83 100.00 56.52 56.67 43.15 Region 9 81.25 87.50 81.25 44.89 25.00 37.5 Region 10 87.50 87.50 93.75 62.5 51.69 34.13 Region 11 93.33 93.33 93.33 73.64 63.56 73.64 11 RHUs with no laboratory or X-ray services may still get accredited provided they have a Memorandum of Understanding with a licensed laboratory and X-ray provider/s. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 40 Region PCB Requirements DOH Requirements At least one At least one At least one Physician Nurse Midwife full-time full-time full-time (1:10,000) (1:20,000) (1:5,000) physician nurse midwife Region 12 93.75 93.75 93.75 84.82 70.09 32.59 CARAGA 94.12 100.00 100.00 45.13 38.63 6.50 Total 90.42 93.75 97.08 53.46 43.21 39.38 Note: PCB guidelines require that all facilities have at least one full-time physician, nurse, and midwife. National guidelines indicate a minimum of 1 physician for every 10,000 people, 1 nurse for every 20,000 people, and 1 midwife for every 5,000 people. In addition to the core staff hired locally, the DOH has deployment programs to augment the existing health workforce in RHUs. Although intended as stopgap measures, these programs have been ongoing for a number of years. The Doctors to the Barrios (DTTB) program started in the early 1990s in response to shortage of doctors in remote areas. More recently in 2011, the Nurse Deployment Program (NDP, formerly known as Registered Nurses for Health Enhancement and Local Service Project or RNHEALS) was launched, while the Rural Health Midwives Placement Program (RHMPP) started deploying midwives to areas underperforming in the coverage of institutional delivery care, immunization, and contraceptive prevalence rates. The DOH-National Nutrition Council also sponsors barangay nutrition scholars (BNSs), who are volunteer community workers trained specifically to assist in implementing nutrition programs in the locality. Table 8 shows that among full-time staff, RHUs had an average of 1.2 physicians, 1.9 nurses, and 7.3 midwives for every facility. However, RHUs were more likely to have part- time or volunteer nurses among their staff. The highest density of physicians was in CARAGA (2.3 physicians per RHU) and Region 12 (1.5 physicians per RHU), while CAR and Regions 2 and 5 all had less than one full-time physician per RHU. Region 2, which has the fewest doctors per RHU in the sample, also has the fewest full-time nurses at 1.1 nurses per RHU, and disproportionately relies on part-time and volunteer nurses. Full-time rural health midwives (RHMs) followed a similar pattern and were, again, most common in Region 12 (13.2) and CARAGA (8.5 per RHU), while CAR (3.4) and Region 2 (4.9) had low density, as did Region 4B (4.8). RHUs in Regions 3, 10, 11, 12 and CARAGA all had at least one medical technologist on staff, compared to one medical technologist for every three RHUs in CAR, Region 1, and Region 4B. There were also variations in staffing by LGU income level. In general, RHUs in the first to third class LGUs had more physicians, nurses, midwives, and medical technologists than the RHUs in the poorer fourth to sixth class LGUs, whether full time or part time. All RHUs in the first group have at least one physician, nurse, or midwife, compared to 86 percent in the sixth income group. Table 9 shows that the RHUs in first to fifth class LGUs had on average one or more than one full-time physician, while RHUs in sixth class LGUs only had 0.4 physician. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 41 Deployment by the DOH of health personnel does not appear to correspond to the regions with personnel gaps (Figure 15). In terms of LGU income class, however, it is notable that DTTB and RHMPPs mostly complemented the physician and midwife gaps in the poorest set of LGUs, but the same cannot be said of the nurse deployments (Figure 16). Details on other RHU staff, including sanitary inspectors, dentists, dental aides, and administrative staff, and BHWs and nutrition scholars can be found in Annex 3. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 42 Table 8. RHU and DOH-deployed personnel, average by region Region Health RHU Personnel and DOH-deployed Personnel Physician Nurse (excluding Rural Health Midwives Medical Technologists RNHEALS) (RHMs) Full Part Volunteer DTTB Full Part Volunteer NDP/ Full Part Volunteer RHMPP Full Part Volunteer Time Time Time Time RNHEA Time Time Time Time LS CAR 0.9 0.0 0.1 0.2 1.5 0.1 0.3 4.3 3.4 0.1 0.1 1.6 0.3 0.0 0.0 Region 1 1.4 0.2 0.3 0.1 2 0.8 1.7 4.5 6.9 1.2 0.0 1.8 0.4 0.1 0.0 Region 2 0.6 0.2 0.0 0.3 1.1 2.6 3.6 4.5 4.9 2.3 1.0 1.6 0.4 0.1 0.1 Region 3 1.3 0.0 0.1 0.1 2.8 2.4 5.5 5.9 7.1 1.1 1.0 0.9 1.1 0.2 0.0 Region 4A 1.1 0.2 0.0 0.2 2.1 0.9 0.0 5.4 7.0 3.0 0.5 4.2 0.4 0.3 0.0 Region 4B 1.2 0.1 0.0 0.2 1.5 0.4 0.0 4.9 4.8 1.2 0.0 1.3 0.3 0.2 0.0 Region 5 0.9 0.1 0.0 0.1 1.6 0.3 0.3 6.2 5.5 1.3 0.1 2.3 1.0 0.1 0.0 Region 6 1.0 0.1 0.0 0.4 1.1 1.1 0.0 6.3 8.9 1.9 0.0 2.4 0.7 0.4 0.0 Region 7 1.0 0.0 0.0 0.1 1.3 1.0 0.1 6.1 6.5 2.2 0.3 2.5 0.9 0.0 0.0 Region 9 1.0 0.0 0.0 0.3 2.1 0.9 0.1 6.3 6.5 0.3 0.0 1.6 0.9 0.1 0.0 Region 10 1.1 0.1 0.0 0.3 2.3 2.5 0.0 8.6 10.7 2.5 0.1 2.8 1.1 0.1 0.0 Region 11 1.2 0.1 0.0 0.4 2.3 1.2 0.0 7.1 7.6 4.1 1.1 1.5 1.1 0.1 0.0 Region 12 1.5 0.2 0.0 0.1 3.1 1.3 0.5 7.1 13.2 7.1 0.0 2.2 1.3 0.1 0.1 CARAGA 2.3 0.0 0.0 0.1 1.8 0.8 0.1 6.1 8.5 1.5 0.0 1.9 1.1 0.0 0.0 Total 1.2 0.1 0.0 0.2 1.9 1.2 0.8 6.0 7.3 2.1 0.3 2.1 0.8 0.1 0.0 Table 9. RHU and DOH-deployed personnel by LGU income class Region Health RHU Personnel and DOH-deployed Personnel Physician Nurse (excluding Rural Health Midwives Medical Technicians RNHEALS) (RHMs) Full Part Volunteer DTTB Full Part Volunteer NDP/ Full Part Volunteer RHMPP Full Time Part Volunteer Time Time Time Time RNHEALS Time Time Time 1 1.2 0.2 0.0 0.4 2.2 2.2 1.0 7.3 9.8 3.7 0.3 1.6 1.0 0.1 0.0 2 1.7 0.0 0.0 0.1 1.4 1.1 1.3 6.3 7.3 2.1 0.6 2.3 0.8 0.1 0.0 3 1.3 0.1 0.1 0.2 2.3 1.0 1.2 6.6 9.6 2.4 0.5 2.1 1.0 0.1 0.0 4 1.0 0.1 0.0 0.1 1.7 0.9 0.4 5.6 5.6 1.3 0.1 2.2 0.7 0.2 0.0 5 1.0 0.0 0.0 0.1 1.4 0.2 0.3 4.1 4.1 0.5 0.0 1.6 0.4 0.1 0.0 6 0.4 0.4 0.0 0.6 1.6 1.1 0.0 3.4 2.6 3.6 0.0 6.0 0.3 0.1 0.0 Total 1.2 0.1 0.0 0.2 1.9 1.2 0.8 6.0 7.3 2.1 0.3 2.1 0.8 0.1 0.0 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 43 Figure 15. LGU health personnel and DOH deployment, by region 3.0 18.0 25.0 16.0 2.5 20.0 14.0 2.0 12.0 10.0 15.0 1.5 8.0 10.0 1.0 6.0 4.0 5.0 0.5 2.0 - - - CAR CAR CAR Total Total Total Region 9 Region 9 Region 9 Region 5 Region 6 Region 7 Region 6 Region 7 Region 6 Region 7 Region 1 Region 2 Region 3 Region 2 Region 3 Region 5 Region 5 Region 1 Region 1 Region 2 Region 3 Region 10 Region 11 Region 12 Region 12 Region 10 Region 11 Region 12 Region 10 Region 11 CARAGA CARAGA CARAGA Region 4B Region 4B Region 4B Region 4A Region 4A Region 4A LGU Physician DTTB LGU Rural Health Nurse NDP/RNHeals LGU Rural Health Midwife RHMPP Figure 16. LGU health personnel and DOH deployment, by income class 2 14 18 1.8 16 12 1.6 14 1.4 10 12 1.2 8 10 1 6 8 0.8 0.6 6 4 0.4 4 2 2 0.2 0 0 0 1st 2nd 3rd 4th 5th 6th Total 1st 2nd 3rd 4th 5th 6th Total 1st 2nd 3rd 4th 5th 6th Total Class Class Class Class Class Class Class Class Class Class Class Class Class Class Class Class Class Class LGU Physician DTTB LGU Rural Health Nurse NDP/RNHeals LGU Rural Health Midwife RHMPP SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 44 2. Maternal and Child Health This section focuses on priority MCH services in the Philippines, with a focus on those services that are delivered through the primary care system. For maternal health, we follow two of the four target actions outlined in the national Maternal, Newborn and Child Health and Nutrition (MNCHN) strategy to reduce deaths, namely: (1) avoiding mistimed, unplanned, unwanted, and unsupported pregnancies and (2) ensuring adequate care during the course of pregnancy (DOH 2011).12 For child health services, we include an analysis of the availability of immunization services, which have been a national priority since the 1970s, and general child health services (such as consultations). Use of ANC is now close to universal: according to the 2013 NDHS, 95.4 percent of pregnant women received at least one ANC visit with a skilled health provider and 84 percent had four or more ANC visits (Philippine Statistics Authority 2013). Despite high service utilization, the survey data suggest uneven distribution of the core components of quality ANC. According to the 2013 NDHS, among women who gave birth in the last five years, 92 percent took iron supplements, 46 percent had folic acid supplements, and 82 percent were protected against tetanus. Among those who had received ANC, 98 percent had their BP measured, but only 65 percent had a urine sample taken and just 59 percent had a blood sample taken (Philippine Statistics Authority 2013). The percentage of facility- based delivery has also increased in recent years, from 44 percent in 2008 to 61 percent in 2013. Yet, bypassing of formal care is common. Almost four out of every ten women deliver at home, and in rural areas this number increases to five out of ten women. Home births can result in delays in identifying, referring, and managing complications.13 Ensuring access to vaccination is among the highest priorities for child health. Although approximately 90 percent of children are fully immunized by age one,14 the Philippines has among the highest burdens of unvaccinated children in the world. Despite concentrated efforts since the 1970s, the Philippines has struggled to maintain consistent results and national targets for immunization have not been met in nearly two decades. The Philippine NDHS shows that Fully Immunized Child (FIC) coverage is at its lowest point in 10 years. In 2013, FIC was only 61.8 percent, down from 79.5 percent coverage in 2008. The trend of decline from 2008 to 2013 shown by the NDHS is similar to the decrease observed when using DOH data for the last four years prior to 2013. The DOH reports, further, that target coverage of 95 percent for all vaccines has not been achieved since 2000. There are also large inequalities in vaccination coverage by region. According to the DOH’s 2013 EPI report, only 5 of the 17 regions reached the service coverage target of 95 percent. This has 12 The strategy also targets (3) delivering with skilled medical assistance and (4) securing appropriate postpartum and newborn care for the mother and newborn, but these targets are not a focus of this paper because the relevant data were not collected in the survey. 13 As noted earlier in the Introduction, this analysis is not able to include BEmONC services because the relevant indicators were not sufficiently captured in the survey. However, some indicators in the general service readiness analysis are relevant to BEmONC services. These include the availability of emergency transport and emergency medicines. 14 FIC coverage measures the proportion of children ages 12 to 24 months who have received bacillus Calmette-Guérin (BCG), measles, and three doses each of DPT and polio and Hepatitis B vaccine (either Hepatitis B0, B1 and B2 or Hepatitis B1, B2 and B3) at any time before the survey. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 45 resulted in an increase in the number of children susceptible to vaccine-preventable diseases and deaths. Much like vaccination, child health care benefits from long-standing political support in the Philippines. Treatment for childhood health issues, including acute respiratory infection (ARI), fever, diarrhea, and malnutrition, was a central component of the country’s successful efforts to achieve the child health MDGs, and remains an important element of the SDG target to end preventable child death. Nonetheless, there are important gaps in child health. Malnutrition, in particular, remains very high in the country and has not declined despite economic growth. The national prevalence of stunting has not declined at all for more than a decade and, with an estimated 4.2 million children under the age of 5 stunted, the Philippines is among the global top 10 in the burden of stunting (Food and Nutrition Research Institute 2013). The Philippines is also among the worst three countries in the East Asia and Pacific region in terms of wasting, low birth weight, and suboptimal infant and young child feeding practices. Recent data suggest that there is still much to do to appropriately respond to child illness. In the 2013 NDHS, 6 percent of children younger than five years had an ARI, 28 percent had fever, and 8 percent had diarrhea in the two weeks prior to the survey (Philippine Statistics Authority 2013) . However, many of these children were not brought for medical care: of children with symptoms of ARI, with fever, and with diarrhea, only 64 percent, 50 percent, and 42 percent, respectively, were taken to a health facility or health provider to seek advice or treatment (Philippine Statistics Authority 2013). Antenatal Care Efforts to increase access to and utilization of ANC have been successful in the Philippines, and the government is now working to ensure that the services are of consistently high quality. To this end, the national guidelines, detailed in the MNCHN Manual of Operations (MOP) and funded by PhilHealth under the MCP, are well aligned with global guidelines on ANC. Women are entitled to at least four prenatal visits during the course of the pregnancy, with the first visit to occur within the first trimester. During these visits, health workers are expected to detect and manage danger signs and potential complications of pregnancy; provide iron folate supplementation (daily for three months) and iodine supplementation; ensure complete TT immunization; and counsel on healthy lifestyle, breastfeeding, prevention and management of infection, and oral health services (Department of Health 2011). Table 10. Access to maternal health services, 2014a Region 4+ ANC Visits 2 doses TT >2 doses TT Complete (%) (%) (%) Iron + Folic Acid (%) CAR 62.13 29.15 51.23 49.62 Region 1 61.89 30.62 61.04 58.90 Region 2 58.78 31.50 59.91 57.41 Region 3 60.61 30.37 51.03 54.47 Region 4A 42.46 23.84 39.20 40.19 Region 4B 60.51 36.06 59.79 53.64 Region 5 65.22 32.90 57.97 64.48 Region 6 54.38 26.67 56.60 50.92 Region 7 63.45 30.68 72.22 55.76 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 46 Region 4+ ANC Visits 2 doses TT >2 doses TT Complete (%) (%) (%) Iron + Folic Acid (%) Region 9 51.62 27.80 44.32 50.02 Region 10 75.39 33.13 61.72 69.04 Region 11 37.39 26.19 71.87 35.40 Region 12 62.29 36.73 64.95 58.97 CARAGA 58.26 33.09 50.26 50.56 Philippines 58.99 30.84 58.29 52.04 Source: Field Health Service Information System (FHSIS) 2014. Note: a Prevalence of pregnant women with access to: 4+ ANC visits, 2 doses of TT, >2 doses of TT, and a complete dose of iron and folic acid. The WHO SARA tracer indicators for ANC call for (a) the availability of ANC guidelines and checklists, and staff trained in ANC; (b) BP apparatus; (c) Hb and urine dipstick- protein testing capacity; and (d) iron folate, TT, intermittent preventive treatment (IPT) drug (for malaria), and insecticide-treated nets (ITNs). As shown in Annex 5, most of these components listed in the WHO SARA guidelines are explicitly referenced in national strategies. As shown in Table 11, Column 3, data are available for all the equipment and diagnostics considered by SARA, as well as for a number of key medicines and commodities, including TT and iron folate. Table 11. ANC tracer indicators: SARA guidelines and indicators used for assessment Tracer WHO SARA Guidelines Indicators Used for Assessment Indicator Staffing and  ANC guidelines  Indicator Dropped - Data not available Training  ANC checklists and/or job aids  Indicator Dropped - Data not available  Staff trained in ANC  Physician, nurse, midwife trained in BEmONC Equipment  BP apparatus  Non-mercurial BP apparatus Diagnostics  Hb  Hemoglobinometer kit/acid hematin (stock availability for today, for RHUs with laboratory)  Urine dipstick-protein  Dipstick for qualitative urine analysis (stock availability for today, for RHUs with laboratory) Medicines and  TT vaccine  TT vaccine (stock availability for Commodities today?)  Iron tablets (or iron folate)  Iron and folic acid combination tablets  Folic acid tablets (or iron folate) OR (iron tablets AND folic acid tablets) (stock availability for today)  IPT drug  Indicator Dropped - Data not available  ITNs  Indicator Dropped - Data not available Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. ANC services are available at all the RHUs visited and survey results show that basic commodities were well distributed. Almost all (95 percent) RHUs had TT in stock during the visit and, with the exceptions of Regions 4B and 5, nearly all RHUs also had iron and folate—either separately or in combination (Figure 17). However, we identify significant SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 47 gaps in diagnostic capacity: only 65 percent of RHUs had Hb testing available on the day of the survey; this varied from 100 percent of RHUs in Region 5 to just 31 percent of RHUs in Region 4B (Figure 18). Although urine dipsticks were more widely available, there were still gaps: 81 percent of RHUs overall had them in stock on the day of the survey, and this ranged from 100 percent (Region 5) to 44 percent (Region 9) (Figure 18). While most facilities had relevant tests in stock, we identified lengthy shortages of Hb tests in Regions 11 and 12 and lengthy urine dipstick shortages in Regions 4B and 7. In all cases, those facilities that reported being “currently out of stock” of the diagnostic test had been out of stock for the entirety of the three months preceding the survey. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 48 Figure 17. ANC service readiness: Medicines and commodities availability Tetanus Toxoid Vaccine Iron and Folic Acid Combination Tablets 100% 12 100% 12 90% 90% 80% 10 80% 10 70% 8 70% 8 60% 60% 50% 6 50% 6 40% 40% 30% 4 30% 4 20% 2 20% Percent Facility 2 Percent Facility for the Past 3 Months for the Past 3 Months Supply Shortage Count Supply Shortage Count 10% 10% 0% 0 0% 0 with Medicines Available (%) with Medicines Available (%) Available Today Currently Out of Stock Never Had It Supply Shortage Available Today Currently Out of Stock Never Had It Supply Shortage Figure 18. ANC service readiness: Diagnostics availability Haemoglobin Dipstick for Qualitative Urine Analysis 100% 12 100% 12 10 80% 10 80% 8 60% 8 60% 6 6 (in weeks) 40% 40% (in weeks) 4 4 for the Past 3 Months 20% 20% Supply Shortage Counting for the Past 3 Months 2 2 Supply Shortage Counting Equipment Availability (%) 0% 0 0% 0 Equipment Availability (%) Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 49 ANC training is provided through the national training on BEmONC. BEmONC training was attended by at least one staff from most (97 percent) RHUs. CARAGA (88 percent) was most likely to report that no staff had attended a BEmONC training, while all RHUs in Regions 1, 2, 3, 5, 9, 10, and 11 had at least one member attend. In all regions, midwives were most likely to have attended the training and, with the exception of CARAGA, physicians15 were least likely to have attended the training (Figure 19). Figure 19. RHU staff who have undergone BEmONC training BEmONC Training 100 with Trained Medical Personnel (%) 80 60 Percent Facility 40 20 0 Physician Nurse Midwife Note: Data are available for any nurse and any midwife at facilities, but only one physician responded to the survey at each facility. Few facilities had more than one physician on staff. Table 12 shows substantially higher overall ANC service readiness of facilities in wealthier LGUs, with sixth class LGUs performing worst in three of the four domains. Disparities were especially notable for scores on diagnostic capacity, with sixth class LGUs receiving an aggregate score of just 38 percent, compared to an aggregate score of 87 percent among first class LGUs. 15 Training is asked differently for nurses/midwives and physicians. For nurses and midwives, the survey asks whether any nurse or midwife at the facility had received training. For physicians, information was collected only for the physician respondent, and not for any physician at the facility. Seventy-three percent of facilities have one physician on staff, 13 percent have two physicians on staff, and 3 percent have more than two physicians on staff. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 50 Table 12. ANC service readiness score by LGU income classification Staff & Basic Medicines & Income Diagnostics Guidelines Equipment Commodities Overall (%) Class (%) (%) (%) (%) 1 100 94 87 97 94 2 90 93 70 98 88 3 98 98 76 95 91 4 96 98 70 94 88 5 97 97 49 98 84 6 86 86 38 100 78 Total 97 96 71 96 89 Note: Staff and Guidelines refers to facilities in which a physician, nurse, or midwife has been trained in BEmONC. Basic Equipment refers to the availability of a BP apparatus. Diagnostics refers to the availability of a hemoglobinometer. Medicines and Commodities refers to the availability of TT vaccine and iron and folic acid. -coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. We also find regional variations in the readiness to provide ANC. RHUs in CAR and Regions 4B and 9 scored well below the survey average. This was driven largely by poor performance in the availability of diagnostics testing (Table 13). Table 13. ANC service readiness score by region Staff & Basic Medicines & Diagnostics Region Guidelines Equipment Commodities Overall (%) (%) (%) (%) (%) CAR 100 100 41 94 80 Region 1 100 75 74 100 89 Region 2 100 94 59 100 88 Region 3 100 100 84 98 95 Region 4A 94 100 80 80 85 Region 4B 94 100 41 100 82 Region 5 100 100 100 84 93 Region 6 96 96 57 100 86 Region 7 92 96 68 96 87 Region 9 100 100 45 92 81 Region 10 100 94 94 100 97 Region 11 100 100 83 100 95 Region 12 94 94 94 100 96 CARAGA 88 100 76 100 92 Total 97 96 71 96 89 Note: Staff and Guidelines refers to facilities in which a physician, nurse, or midwife has been trained in BEmONC. Basic Equipment refers to the availability of a BP apparatus. Diagnostics refers to the availability of a hemoglobinometer. Medicines and Commodities refers to the availability of TT vaccine and iron and folic acid. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 51 Family Planning Avoiding mistimed, unplanned, unwanted, and unsupported pregnancies is a key component of the national strategy to reduce maternal mortality, and the Reproductive Health Law of 201216 guarantees universal access to contraception, sexual education, and maternal care. While injectable contraceptives (depot medroxyprogesterone acetate [DMPA]) and condoms are not included in any of the PhilHealth benefit packages, there are packages for intrauterine devices (IUDs) and implants and LGUs are responsible for procuring a range of FP commodities, including oral contraceptives, DMPA, and condoms. High total fertility, insufficient birth spacing, and young age of mothers are all associated with increased maternal mortality, and are documented challenges in the Philippines. The total fertility rate, at 2.6, is among the highest in the East Asia and Pacific region and 10 percent of Filipino women have already begun childbearing by age 19 (Philippine Statistics Authority 2013). Despite widespread knowledge and increasing access to FP services, the 2013 NDHS found high unmet need for FP, with 18 percent of married women reporting unmet need at the time of the survey (Philippine Statistics Authority 2013). The WHO SARA tracer indicators consist of (a) the availability of guidelines and checklists for FP and staff trained in FP; (b) a BP apparatus; (c) oral contraceptives, injectable contraceptives, and male and female condoms, implants, IUDs, and emergency contraceptives. The third column of Table 14 shows the list of tracer indicators from the survey used in this assessment. This assessment focuses on the availability of oral contraceptives, DMPA, and IUD. Implants are not currently recommended for use in the Philippines17 and are therefore not included in this assessment. Table 14. Family planning tracer indicators: SARA guidelines and indicators used for assessment Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Staff and  Guidelines on FP  Indicator Dropped - Data not available Guidelines  FP checklists and/or job aids  Indicator Dropped - Data not available  Staff trained in FP  Indicator Dropped - Data not available Equipment  BP apparatus  Non-mercurial BP apparatus (number of available instruments/equipment) Medicines and  Combined estrogen progesterone  Oral contraceptives (stock availability [FP]) Commodities oral contraceptive pills  Progestin-only contraceptive pills  Indicator Dropped - Data not available  Injectable contraceptives: Either  DMPA (stock availability [FP]) combined estrogen progesterone injectable contraceptives or progestin-only injectable contraceptives 16 The Supreme Court delayed the implementation of the Reproductive Health Law in 2013, and then ruled the law “not unconstitutional” after striking out some provisions in 2014. 17 There is currently a temporary court-issued restraining order preventing the Philippines government from promoting the use of implants. However, implants are included in the PhilHealth benefit package and are specifically detailed in PhilHealth Circular No. 038-2015, PhilHealth Subdermal Contraceptive Implant Package. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 52 Domain WHO SARA Tracer Indicators Tracer Indicators from Survey  Condoms  Indicator Dropped - Data not available Auxiliary  Combined estrogen progesterone  DMPA (stock availability [FP]) Commodities injectable contraceptives  Progestin-only injectable  Indicator Dropped - Data not available contraceptives  Female condoms  Indicator Dropped - Data not available  Implants: For example,  Indicator Dropped Data not available levonorgestrel or etonogestrel implant  Emergency contraceptive: For  Indicator Dropped - Data not available example, levonorgestrel tablet or ulipristal acetate tablet or mifepristone tablet 10–25 mg  IUD  IUD (stock availability [FP]) Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. FP services were generally available at the RHUs visited in the survey. As discussed in the section on general service readiness, BP apparatuses are widely available at RHUs. Of the commodities investigated, oral contraceptives and DMPA are close to universally available and IUD services were also common. Approximately 87 percent of RHUs had IUD device/commodity on the day of the survey, although this number falls to less than 70 percent in CAR, Region 2, and Region 6; 8 percent of facilities never had it in stock. Stock- outs of FP commodities are relatively uncommon in our sample, although the few that had stock-outs were long lasting. They were missing for 10 to 12 weeks prior to the survey for IUDs in Regions 2, 3, and 7, and for 8 weeks for injectable contraceptives in Region 7 (Figure 20). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 53 Figure 20. Family planning service readiness: Medicines and commodities availability Oral Contraceptive Injectable Contraceptive 100% 12 100% 12 with Commodities Available (%) with Commodities Available (%) Supply Shortage Count 10 90% for the Past 3 Months 80% 10 Supply Shortage Count 80% for the Past 3 Months 8 Percent Facility (in weeks) 60% 70% 8 Percent Facility (in weeks) 6 60% 40% 50% 6 4 40% 20% 30% 4 2 20% 2 0% 0 10% 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage IUD 100% 12 with Commodities Available (%) 90% Supply Shortage Count 10 for the Past 3 Months 80% 70% 8 (in weeks) Percent Facility 60% 50% 6 40% 30% 4 20% 2 10% 0% 0 Available Today Currently Out of Stock Never Had It Supply Shortage In terms of overall readiness to provide FP services at the RHUs, there was a 5-percentage point difference between the sixth class LGUs (91 percent) and the first class LGUs (96 percent) (Table 15). CAR and Regions 1, 2, 6, and 7 underperformed compared to their neighbors, largely due to variability in the available drugs and commodities (Table 16). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 54 Table 15. Family planning service readiness score by LGU income group Basic Medicines & Income Equipment Commodities Overall (%) Level (%) (%) 1 94 97 96 2 93 94 94 3 98 97 97 4 98 95 96 5 97 94 95 6 86 93 91 Total 96 96 96 Note: Relevant FP staffing indicators were not collected and are not shown. Basic Equipment refers to the availability of a BP apparatus. Medicines and Commodities refers to the availability of oral contraceptives, DMPA, and IUDs. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Table 16. Family planning service readiness score by region Basic Medicines & Overall Region Equipment Commodities (%) (%) (%) CAR 100 91 93 Region 1 75 97 93 Region 2 94 89 90 Region 3 100 94 95 Region 4A 100 98 99 Region 4B 100 97 98 Region 5 100 100 100 Region 6 96 92 93 Region 7 96 91 92 Region 9 100 98 99 Region 10 94 100 99 Region 11 100 100 100 Region 12 94 97 96 CARAGA 100 99 99 Total 96 96 96 Note: Relevant FP staffing indicators were not collected and are not shown. Basic Equipment refers to the availability of a BP apparatus. Medicines and Commodities refers to the availability of oral contraceptives, DMPA, and IUDs. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 55 Immunization Free universal distribution of vaccines in the Philippines has a long-standing legal mandate that began with the September 1976 Presidential Decree No. 996 providing for the compulsory basic immunization for infants and children below eight years. In 1994, this decree was amended by Republic Act No. 7846 to expand the package of mandatory vaccines and funds were appropriated for its implementation. The basic package of vaccines continues to be updated, most recently with the Mandatory Infants and Children Health Immunization Act of 2011, which mandates a comprehensive, mandatory, and sustainable immunization program. The 2016 National Immunization Program (NIP) includes the following antigens: (a) BCG vaccine, a single dose given at birth; (b) monovalent Hepatitis B vaccine, a single dose given at birth; (c) DPT-Hib-HepB 18 vaccines, three doses given at 6-10-14 weeks; (d) oral polio vaccine (OPV), three doses given at 6-10-14 weeks; (e) inactivated polio vaccine (IPV), a single dose given with the final OPV vaccine at 14 weeks; (f) pneumococcal conjugate vaccine (PCV), three doses given at 6-10-14 weeks; (g) measles containing vaccine, either monovalent or Measles- Mumps-Rubella, a single dose given at 9 months; (h) Measles-Mumps-Rubella vaccine given at 12 months; and (i) rotavirus vaccine series, to be given between 6 and 32 weeks. Mandatory basic immunization for children is provided for free at any government hospital or health center and national targets for each vaccine is determined and made public every six years in the DOH National Objectives for Health. Table 17 shows the status of the government’s efforts to improve child nutritional status as of 2014. The national FHSIS indicates that nearly one-quarter of children are not fully immunized—coverage ranges from 88 percent in Region 10 to just 62 percent in Region 3 (DOH 2014). Table 17. Immunization coverage by region, 2014 Total FIC (%) CAR 72.51 Region 1 76.77 Region 2 74.46 Region 3 62.40 Region 4A 64.38 Region 4B 82.39 Region 5 79.49 Region 6 73.39 Region 7 83.34 Region 9 82.18 Region 10 88.23 Region 11 79.25 Region 12 77.39 CARAGA 87.86 Overall 75.38 Source: DOH (2014). Note: FIC: Child must have completed BCG 1, DPT 1, DPT 2, DPT 3, OPV 1, OPV 2, OPV 3, Hepatitis B1, Hepatitis B2, Hepatitis B3, and measles vaccines before the child is 12 months of age. 18 DPT-Hib-HepB = Diphtheria, Pertussis, Tetanus, Haemophilus Influenza B and Hepatitis B. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 56 The WHO SARA tracer indicators include (a) the availability of guidelines on child immunization and staff who have been trained on the EPI in the two years prior to the survey; (b) a cold box, a functioning refrigerator, a sharps container, auto-disposable syringes, a temperature log for the refrigerator, immunization cards, and immunization tally sheets; and (c) current and continuous (over three months) stocking of all relevant vaccines as indicated by the national guidelines. The tracer indicators used and analysis presented here focus on the availability of a cold storage for medicines and vaccines, availability of a receptacle for sharp objects, and the supply of measles, DPT-Hib-HepB (separately or together as pentavalent), OPV, BCG, pneumococcal, rotavirus, and TT vaccines (Table 18). Table 18. Immunization tracer indicators: WHO SARA guidelines and indicators used for assessment Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Staff and  Guidelines for child immunization  Indicator Dropped - Data not Guidelines available  Staff trained in child immunization  Indicator Dropped - Data not available Equipment  Cold box/vaccine carrier with ice  Indicator Dropped - Data not packs available  Refrigerator: Functioning  Cold storage solely for medicines and refrigerator with sufficient storage vaccines capacity  Sharps container/safety box  Are there puncture proof receptacles for disposal or pointed/sharp objects? Safety vault  Auto-disposable syringes  Indicator Dropped - Data not available  Temperature monitoring device in  Indicator Dropped - Data not refrigerator: Thermometer or available recorder/logger  Adequate refrigerator temperature:  Indicator Dropped - Data not Temperature not out of range (2°C available to 8°C) in the last 30 days  Immunization cards  Indicator Dropped - Data not available  Immunization tally sheets  Indicator Dropped - Data not available Medicines  Rotavirus vaccine  Rotavirus (stock availability [Vaccine and available today]) Commodities  IPV: If part of the national schedule  Indicator Dropped - Data not available  Human papillomavirus (HPV): If  Indicator Dropped - Data not part of the national schedule available  Measles vaccine  Measles (supply shortage counts for the past 3 months [vaccine available today]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 57 Domain WHO SARA Tracer Indicators Tracer Indicators from Survey  DPT-Hib-HepB vaccine: Country-  DPT-Hib-HepB (supply shortage specific vaccine combination counts for the past 3 months [vaccine available today])  OPV  OPV (supply shortage counts for the past 3 months [vaccine available today])  BCG vaccine  BCG (supply shortage counts for the past 3 months [vaccine available today])  Pneumococcal vaccine: If part of  Pneumococcal vaccine (supply the national schedule shortage counts for the past 3 months [vaccine available today])  Rotavirus vaccine: If part of the  Rotavirus (supply shortage counts for national schedule the past 3 months [vaccine available today])  IPV  Indicator Dropped - Data not available  HPV  Indicator Dropped - Data not available  DPT  DPT (supply shortage counts for the past 3 months [vaccine available today])  Hepatitis B  Hepatitis B (supply shortage counts for the past 3 months [vaccine available today])  TT  TT (supply shortage counts for the past 3 months [vaccine available today]) Cold Chain  Cold chain minimum requirements:  Indicator Dropped - Data not Functional refrigerator, temperature available monitoring device, and the temperature has been maintained between 2°C and 8°C for the last 30 days.  Energy source and power supply  Indicator Dropped - Data not for vaccine refrigerator available  Types of power used for cold chain  Indicator Dropped - Data not refrigeration available Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. Most RHUs had refrigerators for vaccines, although there were gaps in Regions 1, 2 and 9, where approximately 20 percent of RHUs did not have refrigerators. Sharps containers, on the other hand, were frequently missing at RHUs. They were missing in one-quarter of the RHUs visited overall, and only 20 percent of RHUs had sharps containers in Region 4A. Half or fewer had them in Regions 1 and 12. In contrast, all RHUs in Regions 2 and 11 had the containers on the day of the survey (Figure 21). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 58 Figure 21. Immunization service readiness: Equipment availability Immunization Equipment 100 Providing he Service (%) Percent of Facilities 80 60 40 20 0 Refrigerator Sharps Container/Safety Box Most of the vaccines included in the survey were widely available. We did not identify any stock-outs of measles or TT19 vaccines, and BCG and OPV vaccines were both available at 97–98 percent of RHUs. However, shortages were noted for DPT, which was unavailable in either its stand-alone formation or as pentavalent (DPT-Hib-HepB). Pneumococcal and rotavirus vaccines have both been introduced to the NIP schedule relatively recently, and neither are yet universally available (Figure 22). Pneumococcal vaccine was available at just 45 percent of the facilities, although an additional 41 percent of facilities reported that they were currently out of stock—implying that they had carried the vaccine at one point. Rotavirus vaccine was available at only 24 percent of facilities and approximately 56 percent of facilities reported that they were out of stock on the day of the survey. In both cases, facilities that are out of stock report having been out of stock for up to the full three months prior to the survey. 19 TT not shown. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 59 Figure 22. Immunization service readiness: Medicines and commodities availability BCG OPV 100% 12 100% 12 Supply Shortage Counting Supply Shortage Counting 10 10 for the Past 3 Months Percent Availability 80% for the Past 3 Months Percent Availability 80% 8 8 (in weeks) 60% (in weeks) 60% 6 6 40% 40% 4 4 20% 2 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage Measles Hepatitis 100% 12 100% 12 Percent Availability Supply Shortage Counting Supply Shortage Counting 10 for the Past 3 Months 80% 10 for the Past 3 Months 80% Percent Availability 8 8 (in weeks) 60% (in weeks) 60% 6 6 40% 4 40% 4 20% 2 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage DPT-HiB-HepB Pentavalent DPT 100% 12 100% 12 Percent Availability Supply Shortage Counting Supply Shortage Counting 10 10 for the Past 3 Months for the Past 3 Months 80% 80% Percent Availability 8 8 (in weeks) (in weeks) 60% 60% 6 6 40% 40% 4 4 20% 2 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage Pneumococcal Vaccine Rotavirus Vaccine 100% 12 Percent Availability 100% 12 Supply Shortage Counting Supply Shortage Counting 10 for the Past 3 Months 80% 10 Percent Availability for the Past 3 Months 80% 8 60% 8 (in weeks) (in weeks) 6 60% 6 40% 4 40% 4 20% 2 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 60 Notably, there was little variation in the readiness to provide vaccination services by LGU income class, with all being quite low, although we did observe regional variations. Regions 1, 5, and 7 performed below the national average. This generally reflects differential stock-outs of commodities across regions, although there were also notable equipment gaps in Regions 1 and 4A (Table 19, Table 20). Table 19. Immunization service readiness score by LGU income group Basic Medicines & Income Equipment Commodities Overall (%) Level (%) (%) 1 85 79 80 2 88 79 80 3 88 77 79 4 81 78 78 5 85 76 77 6 71 79 77 Total 85 78 79 Note: Relevant immunization staffing indicators were not collected and are not shown. Basic Equipment refers to the availability of cold storage and sharps containers. Medicines and Commodities refers to the availability of the following vaccines: measles, DPT-Hib-HepB, OPV, BCG, pneumococcal, rotavirus, DPT, Hepatitis B, and TT. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Table 20. Immunization service readiness score by region Basic Medicines & Region Equipment Commodities Overall (%) (%) (%) CAR 78 77 77 Region 1 59 72 70 Region 2 91 76 78 Region 3 97 80 83 Region 4A 56 86 81 Region 4B 88 80 81 Region 5 78 74 74 Region 6 94 80 83 Region 7 96 68 73 Region 9 81 76 77 Region 10 88 83 84 Region 11 97 76 80 Region 12 75 84 82 CARAGA 97 82 85 Total 85 78 79 Note: Relevant immunization staffing indicators were not collected and are not shown. Equipment refers to the availability of cold storage and sharps containers. Medicines and Commodities refers to the availability of the following vaccines: measles, DPT-Hib-HepB, SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 61 OPV, BCG, pneumococcal, rotavirus, DPT, Hepatitis B, and TT. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Child Health Child health and survival has long been an important priority of the Philippines government. In addition to the NIP described in the last section, the government has worked to improve child nutrition status (including through improving infant and young child feeding practices, distributing important micronutrients, and assuring appropriate treatment of diarrhea). The government has also sought to encourage appropriate treatment for fevers and respiratory infections, particularly through the integrated management of childhood illness (IMCI), which was first introduced in the country in 1995, and helps to guide health staff in providing high-quality consultations. Table 21 shows the status of the government’s efforts to improve child nutritional status as of 2014. The national FHSIS indicates that nearly all infants were given vitamin A, but that prevalence dropped off with age. Nationwide, approximately three-quarters of children with diarrhea were given ORS, and half were given zinc (DOH 2014). Table 21. Access to child health and nutrition services by region, 2014 Region Infants 6–11 Children 12– Children ages Children 0– Children 0–59 months 59 months 12–59 months 59 months months with given given given with Diarrhea given Vitamin A Vitamin A Deworming Diarrhea ORS/ORT and Tablets/Syrup given ORS Zinc CAR 88.81 60.62 53.70 48.65 49.45 Region 1 76.27 34.04 15.77 88.33 55.53 Region 2 109.52 77.75 71.82 76.91 63.79 Region 3 77.53 13.60 5.25 76.56 53.11 Region 4A 111.73 30.98 20.40 85.56 36.97 Region 4B 72.47 29.79 5.63 81.28 36.48 Region 5 37.49 3.58 38.50 77.94 32.46 Region 6 88.64 36.59 23.26 87.61 59.50 Region 7 116.18 37.23 15.63 71.17 43.24 Region 9 98.57 12.72 — 80.31 46.90 Region 10 166.67 75.04 57.21 76.33 51.12 Region 11 92.78 94.48 — 48.26 38.92 Region 12 91.23 84.51 136.99 81.07 21.89 CARAGA 129.12 73.21 61.10 79.61 43.12 Overall 95.48 44.15 28.56 77.27 45.76 Source: DOH (2014). The SARA tracer indicators consist of (a) the availability of staff trained in IMCI and growth monitoring, as well as guidelines for each; (b) a child and infant scale, length and height monitoring board, thermometer, stethoscope, and growth chart; (c) Hb testing capacity, parasite testing capacity, and malaria diagnostic capacity; and (d) ORS, child dosage of amoxicillin, child dosage of co-trimoxazole, child dosage of paracetamol, vitamin A capsules, mebendazole, and zinc supplements. As shown in Table 22, the tracer SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 62 indicators used from the survey include all these except staffing and guidelines, length and height monitoring board, and vitamin A capsules. Table 22. Child health: SARA guidelines and indicators used for assessment Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Staff and  Guidelines for IMCI: Country adapts to  Indicator Dropped - Data not Guidelines which guidelines are required/accepted available  Guidelines for growth monitoring:  Indicator Dropped - Data not Country adapts to which guidelines are available required/accepted  Staff trained in IMCI: Country adapts to  Indicator Dropped - Data not which guidelines are required/accepted available  Staff trained in growth monitoring: At  Indicator Dropped - Data not least one staff providing the service available trained in some aspect of growth monitoring in the last two years Equipment  Child and infant scale: Weight  Weighing scale (infant) gradations at minimum 250 gm and 100 gm  Length/height measuring equipment:  Indicator Dropped - Data not Wooden boards or metal beams with a available mounted rule that permits measurement of crown-to-heel length (infants under 2 years, lying down) or height (older children, standing up) in centimeters Gradations at 1 mm or 5 mm  Thermometer  Non-mercurial thermometer  Stethoscope  Stethoscope (number of available instruments/equipment)  Growth chart  Indicator Dropped - Data not available Diagnostics  Hb: This may include colorimeter,  Hemoglobinometer kit/acid hematin hemoglobinometer, hemocue, or any (stock availability for today [lab other country-specific method supplies: Manual CBC])  Test parasite in stool (general  Microscope (number of functional microscopy): Microscope, slides, covers equipment)  Glass slides (stock availability for today [lab supplies: automated CBC])  Cover slips (stock availability for today [lab supplies: automated CBC])  Fecalysis  Malaria diagnostic capacity: Malaria  Diagnosis or treatment of malaria rapid test or smear (microscope, slides, (offered services) and stain) Medicines and  Oral rehydration solution packet: Any  ORS (stock availability Commodities child dosage or formulation [gastroenteritis])  Amoxicillin (dispersible tablet 250 mg  Amoxicillin (stock availability or 500 mg OR syrup/suspension): Any [antibacterial]) child dosage or formulation SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 63 Domain WHO SARA Tracer Indicators Tracer Indicators from Survey  Co-trimoxazole syrup/suspension: Any  Co-trimoxazole (stock availability child dosage or formulation. [antibacterial])  Paracetamol syrup/suspension: Any  Paracetamol (stock availability child dosage or formulation [others])  Vitamin A capsules: Any child dosage  Indicator Dropped - Data not or formulation available  Me-/albendazole capsule/tablet: Any  Deworming drugs (albendazole of child dosage or formulation mebendazole) (stock availability [others])  Zinc sulfate tablets, dispersible tablets,  Zinc supplements (stock availability or syrup: Any child dosage or [gastroenteritis]) formulation Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. Nearly all RHUs offered preventive and curative care services for children, and thermometers, stethoscopes, and child scales were widely available. However, there were gaps in diagnostic services. Hb testing was available at only 62 percent of RHUs and there, again, was very wide variability between regions. Only Region 5 had Hb testing available at all RHUs. Nearby Regions 4B and 6, on the other hand, had Hb testing available at less than a third of the RHUs. Tools for parasite testing were generally available. Microscopes were available at 99 percent of RHUs; glass slides were generally available. Slide cover slips were also generally available, although there were some gaps—only 35 percent of RHUs in Region 4B had slide covers on hand and 50 percent in Region 9 did so. Nonetheless, fecalysis was available at only 77 percent of RHUs overall, and fewer than 60 percent of RHUs in CAR and Regions 2, 4A, and 4B offered fecalysis (Figure 23). Medicines were also generally available. All RHUs had mebendazole in stock, and more than 95 percent had ORS, amoxicillin, co-trimoxazole, and paracetamol. Although zinc is centrally procured, it was unavailable at one out of every five RHUs visited. These stock- outs were concentrated in particular regions. While all RHUs in Regions 2, 10, and 11 had zinc on hand, less than 60 percent of RHUs in Regions 4A, 4B, and 5 had the supplement (Figure 24). Figure 23. Child health service readiness: Diagnostics availability Hemoglobinometer Test Parasite in Stool: Cover Slips 100% 14 100% 14 Equipment Availability (%) Supply Shortage Counting Equipment Availability (%) Supply Shortage Counting 12 12 80% for the Past 3 Months for the Past 3 Months 80% 10 10 60% 8 60% (in weeks) (in weeks) 8 40% 6 40% 6 4 4 20% 20% 2 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 64 Test Parasite in Stool Diagnosis or Treatment of Malaria (General Microscopy) 100 Providing Services or Equipment (%) Providing Services or Equipment (%) 100 80 80 60 Percent Facility Percent Facility 60 40 20 40 0 20 0 Fecalysis [Diagnostic Services] Microscope Figure 24. Child health service availability: Medicines and commodities availability Deworming Drugs Amoxicillin 100% 1 100% 10 Equipment Availability (%) Supply Shortage Counting Equipment Availability (%) Supply Shortage Counting for the Past 3 Months 80% 0.8 for the Past 3 Months 80% 8 60% 6 (in weeks) (in weeks) 60% 0.6 40% 0.4 40% 4 20% 0.2 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage Co-trimoxazole Parcetamol 100% 10 100% 10 Equipment Availability (%) Supply Shortage Counting Equipment Availability (%) Supply Shortage Counting for the Past 3 Months for the Past 3 Months 80% 8 80% 8 (in weeks) 60% 6 60% 6 (in weeks) 40% 4 40% 4 20% 2 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage ORS Zinc Supplement 100% 8 100% 14 Equipment Availability (%) Supply Shortage Counting Equipment Availability (%) Supply Shortage Counting 7 12 for the Past 3 Months for the Past 3 Months 80% 80% 6 10 5 (in weeks) 60% (in weeks) 60% 8 4 40% 3 40% 6 2 4 20% 1 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 65 Although performance in child health service readiness does not consistently increase with LGU income class, we again find higher aggregate performance in first class LGUs and relatively lower performance in sixth class LGUs (Table 23). Table 23. Child health service readiness score by LGU income classification Basic Medicines & Income Diagnostics Overall Equipment Commodities Class (%) (%) (%) (%) 1 97 85 96 93 2 100 66 94 89 3 99 71 96 90 4 100 61 92 86 5 98 50 94 84 6 95 54 98 86 Total 99 67 94 89 Note: Relevant child health staffing indicators were not collected and are not shown. Basic Equipment refers to the availability of a scale, a thermometer, and a stethoscope. Diagnostics refers to the availability of a hemoglobinometer kit, microscope, glass slides cover slips, fecalysis, and malaria diagnosis. Medicines and Commodities refers to the availability ORS, amoxicillin, co-trimoxazole, paracetamol, deworming drugs, and zinc supplements. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Regionally, the weakest scores were for Regions 4B and 7, due to their very low diagnostic capacity. Regions 6 and 9 also performed poorly on diagnostic capacity, but received higher overall scores due to stronger availability of equipment and medicines (Table 24). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 66 Table 24. Child health service readiness score by region Basic Medicines & Diagnostics Region Equipment Commodities Overall (%) (%) (%) (%) CAR 96 62 96 87 Region 1 96 64 97 88 Region 2 98 75 99 93 Region 3 100 73 91 89 Region 4A 100 68 88 86 Region 4B 100 34 92 79 Region 5 100 83 89 90 Region 6 100 42 96 83 Region 7 99 49 87 80 Region 9 98 59 96 87 Region 10 98 81 100 95 Region 11 100 91 100 98 Region 12 98 96 99 98 CARAGA 100 78 96 93 Total 99 67 94 89 Note: Relevant child health staffing indicators were not collected and are not shown. Basic Equipment refers to the availability of a scale, a thermometer, and a stethoscope. Diagnostics refers to the availability of a hemoglobinometer kit, microscope, glass slides cover slips, fecalysis, and malaria diagnosis. Medicines and Commodities refers to the availability ORS, amoxicillin, co-trimoxazole, paracetamol, deworming drugs, and zinc supplements. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 67 3. Noncommunicable Diseases (NCD) Prevention and Treatment The rise of NCD is among the most important challenges facing the Philippines in 2016. CVD, cancers, and CRDs account for more than half of all deaths annually, and hypertension is the number one cause of death in the country [20]. The burden is not only large in absolute terms, but is also growing at an alarming pace. In 1990, NCDs accounted for just under half of the total DALYs lost. By 2010, they accounted for two-thirds of DALYs lost. Because more years of life are lost when a condition affects a child, DALYs give greater weight to health conditions that predominately affect children. These tend to be CDs. It is also informative to assess the top causes of death. As shown in Table 25, NCDs are already the top three causes of death in the Philippines. The toll of NCDs is expected to continue to grow—in middle-income countries, including the Philippines, NCDs could account for up to 80 percent of deaths by 2030 (WHO, 2010). Table 25. Top ten causes of mortality in the Philippines, 2009 Diseases Number of Deaths Percent Share Heart disease 100,908 21.0 Cerebrovascular diseases 56,670 11.8 Malignant neoplasm 47,732 9.9 Pneumonia 42,642 8.9 TB 25,470 5.3 Chronic obstructive pulmonary disease (COPD) 22,755 4.7 Diabetes 22,345 4.6 Nephritis, nephrotic syndrome 13,799 2.9 Assault 12,227 2.5 Certain conditions arising from perinatal period 11,514 2.4 Source: Adapted from WHO 2010. The chronic nature of NCDs necessitates a highly organized and well-integrated health system that is capable of management and follow-up, often involving multiple service types and providers. Cost-effectively managing NCDs requires that primary care services play an effective role in screening services and provision of promotive services for early- disease-stage management. Perhaps even more importantly, many of these issues can be prevented and, through advocacy and patient education, primary health care workers play an important role in preventive health care. Indeed, a strengthened primary health care system has been emphasized as a crucial step in the pathway to universal health care. Strengthening the country’s response to NCDs was a core priority of the 2010–2016 Aquino Health Agenda; the third of its three pillars focused on ‘MDGs and NCDs’ which specifies that treatment packs for hypertension and diabetes should be obtained and distributed to all RHUs as part of improved access to quality health care at hospitals and SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 68 RHUs.20 Details related to NCD readiness and management were further detailed in the implementing guidelines on the institutionalization of the Philippine package of essential NCD interventions (PhilPEN), with a focus on hypertension and diabetes care.21 These guidelines prioritized a shift away from tertiary care, reemphasizing the importance of primary care in the management of chronic NCD conditions. With the national priority of reducing the impact of NCDs well established, PhilHealth integrated PhilPEN guidelines into the PCB Package, and both the DOH and PhilHealth have worked to increase PhilPEN training nationwide.22 Jointly, these efforts are expected to have greatly increased access to essential care for NCDs. PCB-accredited RHUs are required to establish or update an annual health profile of the covered population. During profiling, RHUs are required to follow the PhilPEN protocol to diagnose and manage NCDs. Survey results showed that NCD care is widely available: 98 percent of RHUs offered diabetes diagnosis or management, 96 percent offered these services for CVD and CRD. However, gaps remain. Although CCS is a component of the PCB Package, it was available at only 30 percent of the RHUs visited. Diabetes Mellitus The Philippines is ranked 15th worldwide for Diabetes Mellitus (DM or diabetes) prevalence, and diabetes is the seventh leading cause of death in the country. Diabetes prevalence in the Philippines is higher than both regional and global averages for all age groups and, while it is currently concentrated in the higher socioeconomic strata, prevalence is growing rapidly among the poor. Identification and management of diabetes in the population is an important part of the government’s health programming. While referral services for diabetes have long been an important component of PhilHealth’s benefits, there have been efforts to push the locus of diabetes identification and treatment to primary care. The government’s ComPacks aim to ensure the availability of key medicines for the poor and provide a number of diabetes medicines to facilities. Meanwhile, the current PCB Package calls for a comprehensive health profiling upon enlistment, which includes a risk assessment and lifestyle modification counseling for diabetes. While these services currently target the indigent, there are plans to expand this benefit package to all PhilHealth beneficiaries. The WHO SARA tracer indicators cover (a) the availability of guidelines for diabetes diagnosis and treatment and staff trained on the same; (b) BP apparatus, an adult scale, and a measuring tape; (c) blood glucose and urine dipstick (protein and ketones) testing; and (d) metformin, glibenclamide, injectable insulin, injectable glucose, and gliclazide. The national PhilPEN guidelines were developed to harmonize with international norms, 20 DOH, Administrative Order (AO) 2010-0036 (2010), The Aquino Health Agenda: Achieving Universal Health Care for all Filipinos. Development 63: 1–9. 21 DOH, Administrative Order (AO) 2012-002 (2012), Implementing Guidelines on the Institutionalization of the Philippine Package of Essential NCD Interventions (PhilPEN) on the Integrated Management of Hypertension and Diabetes for Primary Health Care Facilities. 22 PhilHealth, Circular No. 0020.s.2013 (2013) Adoption of the Philippine Package of Essential Non- Communicable Disease (NCD) Interventions (PhilPEN) In the Implementation of PhilHealth’s Primary Care Benefit Package. Available at: https://www.philhealth.gov.ph/circulars/2013/circ20_2013.pdf. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 69 particularly the WHO’s Package of Essential NCD Interventions (WHO PEN), and most of the indicators listed by SARA are explicitly mentioned in the national guidelines. The main exception to this is the availability of insulin. While insulin availability was not indicated for RHUs under earlier iterations of service guidelines, the DOH is currently in the process of making available insulin at all RHUs (Table 26). Table 26. DM tracer indicators: SARA guidelines and indicators used for assessment Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Staff and  Guidelines for diabetes diagnosis and  Indicator Dropped - Data not Guidelines treatment available  Staff trained in diabetes diagnosis and  Have you received any training on treatment: At least one staff providing PhilPEN guidelines? the service trained in diabetes diagnosis and treatment in the last two years Equipment  BP apparatus  Non- mercurial BP apparatus (number of available instruments/equipment)  Adult scale  Weighing scale (Adult)  Measuring tape (height  Indicator Dropped - Data not board/stadiometer) available Diagnostics  Blood glucose  Diagnostic services: Fasting blood glucose (offered services)  Urine dipstick-protein  Dipstick for qualitative urine analysis (stock availability for today [lab supplies: automated CBC])  Urine dipstick-ketones  Dipstick for qualitative urine analysis (stock availability for today [lab supplies: automated CBC]) Medicines and  Metformin capsule/tablet  Metformin (stock availability Commodities [diabetes])  Glibenclamide capsule/tablet  Sulfonylureas, for example, glibenclamide, gliclazide (stock availability [diabetes])  Insulin regular injectable  Indicator Dropped - Data not available  Glucose 50% injectable  Indicator Dropped - Data not available  Gliclazide tablet or glipizide tablet  Sulfonylureas, for example, glibenclamide, gliclazide (stock availability [diabetes]) Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. DM services are available at nearly all (98 percent) RHUs, as is training on diabetes care. In all regions except for Region 12 (93.8 percent), all doctors have undergone PhilPEN training. Diabetes drugs, including metformin and sulfonylureas, are also common (each available at 97 percent of RHUs). These drugs are part of the ComPacks that the DOH has been distributing to RHUs since 2011, which may help explain the widespread availability. However, RHUs continue to struggle with gaps in diagnostic service capacity. Fasting blood glucose testing was available at just 70 percent of RHUs visited overall, and at only 25 percent of RHUs in CAR and 38 percent of RHUs in Region 10. Similar gaps were SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 70 found in the ability to conduct urine analysis: 81 percent overall, and only 39 percent in CAR and 100 percent in Region 5 (Figure 25). Figure 25. DM service readiness: Diagnostics availability and medicines and commodities availability Fasting Blood Glucose [Diagnostic Service] 100 with Services Available (%) 80 Percent Facility 60 40 20 0 Diabetes - Service Readiness, Diagnosis, Dipstick Metformin Cap/Tabs Urine Analysis with Euipments Available (%) 100% 14 100% with Medicines Available (%) 14 Supply Shortage Counting for the Past 3 Months (in weeks) 12 12 for the Past 3 Months Percent Facility 80% 80% Supply Shortage Counting 10 10 Percent Facility (in weeks) 60% 8 60% 8 6 40% 6 40% 4 4 20% 20% 2 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage Sulfonylureas Diabetes - Medicines and Commodities 100% 2.5 100 with Commodities Available (%) for the Past 3 Months (in weeks) with Medicines Available (%) 80% 2 Supply Shortage Count 80 60% 1.5 Percent Facility Percent Facility 60 40% 1 40 20% 0.5 20 0% 0 0 Available Today Currently Out of Stock Metformin (Tablet/Capsule) Sulfunylureas (Tablet/Capsule) Never Had It Supply Shortage Despite the importance of PhilPEN, there was a substantial, 9 percentage point difference in overall readiness to provide diabetes care between RHUs in first class LGUs and RHUs in sixth class LGUs. This difference is almost entirely driven by differences in the availability of diagnostics (Table 27). Regionally, we saw that CAR and Regions 2, 4B, 9, and 11 significantly underperformed compared to their neighbors in the availability of diabetes-specific diagnostics (Table 28). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 71 Table 27. DM service readiness score by LGU income group Staff & Basic Medicines & Income Diagnostics Guidelines Equipment Commodities Overall (%) Level (%) (%) (%) (%) 1 100 98 83 99 93 2 100 98 80 94 91 3 98 99 80 98 92 4 100 99 76 97 91 5 100 99 56 99 85 6 100 95 57 100 84 Total 100 98 75 98 91 Note: Staff and Guidelines indicates that staff have received training on PhilPEN guidelines. Equipment includes acess to a BP apparatus and a weighing scale. Diagnostics includes access to fasting blood glucose tests and qualitative urine analysis. Medicines and Commodities includes metformin and sulfonylureas. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Table 28. DM service readiness score by region Staff & Basic Medicines & Diagnostics Region Guidelines Equipment Commodities Overall (%) (%) (%) (%) (%) CAR 100 98 34 98 77 Region 1 100 92 77 96 88 Region 2 100 98 73 100 90 Region 3 100 100 96 98 98 Region 4A 100 100 81 98 93 Region 4B 100 100 60 100 87 Region 5 100 100 92 100 97 Region 6 100 99 78 92 89 Region 7 100 99 82 100 94 Region 9 100 100 50 89 80 Region 10 100 98 91 100 96 Region 11 100 100 73 100 91 Region 12 94 96 75 100 90 CARAGA 100 100 82 100 94 Total 100 98 75 98 91 Note: Staff and Guidelines indicates that staff have received training on PhilPEN guidelines. Equipment includes acess to a BP apparatus and a weighing scale. Diagnostics includes access to fasting blood glucose tests and qualitative urine analysis. Medicines and commodities includes metformin and sulfonylureas. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Cardiovascular Disease CVD was the top cause of death in the Philippines in 2013, the most recent year for which there is data (IHME 2013). CVD is a broad group of diseases which includes hypertension (the single most important cause of YLL in the country in 2013), coronary heart disease, SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 72 cerebrovascular diseases, and peripheral arterial disease. Like many other NCDs, CVD is associated with the combination of biologic, social, and environmental factors. Risk factors include genetics, diets high in salt and fat and low in fruits and vegetables, physical inactivity, stress, and smoking. As effects of these accrue over time, individuals often exhibit intermediate risk factors, including high body mass index and high total cholesterol. Prevention and treatment of hypertension, high total cholesterol, and diabetes (which is often comorbid with CVD) is key to managing CVD and preventing premature mortality. With aging populations and rapidly changing diets, many countries in the region— including the Philippines, Indonesia, Vietnam, and Malaysia, among others—have struggled with the rapid emergence of CVD as a dominant cause of morbidity and mortality. According to the 2008 National Nutrition Survey (NNS), 1 percent of the adult population was, at that time, diagnosed with myocardial infarction, and 1 percent was diagnosed with coronary heart disease, with prevalence increasing among those age 60 and older (Food and Nutrition Research Institute 2008). Prevalence is expected to have increased over the intervening years. The Aquino Health Agenda specifies that treatment packs for hypertension should be obtained and distributed to all RHUs as part of improved access to quality hospitals and health care RHUs, and treatment for a number of issues related to the diagnosis and treatment of CVD were detailed in the PhilPEN guidelines. Generally, these guidelines prioritized a shift away from tertiary care, reemphasizing the importance of primary care in the management of chronic NCD conditions. WHO SARA recommends that indicators for CVD service readiness include (a) at least one staff in the RHU who has received training for diagnosis and treatment of chronic cardiovascular conditions in the previous two years, and national guidelines for the diagnosis and treatment of chronic cardiovascular conditions be available at the RHU; (b) health RHUs should have, at a minimum, stethoscopes, functional BP machines (either a digital BP machine or a manual sphygmomanometer with a stethoscope), and adult scale; and (c) ACE inhibitors, thiazides, beta-blockers, calcium channel blockers, aspirin, and metformin. The angiotensin receptor blockers, which are hypertensive medicines that are among those distributed in the DOH’s ComPacks, was asked in the survey and added as an indicator in this analysis. This set is well aligned with national guidelines, which specified similar lists of equipment and commodities, although training and guideline requirements were unspecified. The tracer indicators from the survey and this analysis include an overview of all equipment and data, with the exception of aspirin for which data are unavailable (Table 29). Table 29. CVD tracer indicators: SARA guidelines and indicators used for assessment Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Staff and  Guidelines for diagnosis and  Indicator Dropped - Data not Guidelines treatment of chronic cardiovascular available conditions  Staff trained in diagnosis and  Have you received any training on management of chronic PhilPEN guidelines? cardiovascular conditions: At least one staff providing the service trained in diagnosis and management of chronic SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 73 Domain WHO SARA Tracer Indicators Tracer Indicators from Survey cardiovascular conditions in the last two years Equipment  Stethoscope  Stethoscope (number of available instruments/equipment)  BP apparatus: Digital BP machine  Non-mercurial BP apparatus or manual sphygmomanometer (number of available with stethoscope instruments/equipment)  Adult scale  Weighing scale (adult) Diagnostics  n.a.  Availability of lipid profile reagents Medicines and  ACE inhibitor (for example,  ACE inhibitor (stock availability Commodities enalapril, lisinopril, ramipril, [hypertension]) perindopril)  Hydrochlorothiazide tablet or other  Diuretic, for example, thiazide diuretic tablet hydrochlorothiazide (stock availability [hypertension])  Beta-blocker (for example,  Beta-blocker (stock availability bisoprolol, metoprolol, carvedilol, [hypertension]) atenolol)  Calcium channel blockers (for  Calcium channel blocker (stock example, amlodipine) availability [hypertension])  Aspirin capsule/tablets  Indicator Dropped - Data not available  Metformin capsule/tablets  Metformin (stock availability [diabetes])  Angiotensin receptor blocker (stock availability [hypertension]) Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. Overall, RHUs included in this assessment were well prepared to handle primary care level CVD screening and treatment activities. Almost all RHUs had at least one staff who had received PhilPEN training and CVD diagnosis and treatment were widely available at the RHUs visited. Tracer equipment included stethoscopes, BP apparatus, and an adult scale, and all were widespread. The same was true for the medicines considered. ACE inhibitors, diuretics, beta-blockers, calcium channel blockers, and metformin (all components of the ComPacks distributed by the DOH) were available at a majority of the RHUs. However, a number of stock-outs were identified. RHUs in Region 9, in particular, reported stock-outs for each of the medicines in the assessment: ACE inhibitors, thiazide diuretics, beta- blockers, calcium channel blockers, metformin tablets, and angiotensin receptor blockers (Figure 27). While not indicated in the SARA guidelines, we also provide information on the availability of lipid profile reagents, which are available in only approximately half of the facilities visited (Figure 26). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 74 Figure 26. CVD service readiness: Diagnostics availability Lipid profile reagents Supply Shortage Counting for the Past 3 Months 100% 14 12 80% Percent Availability 10 60% 8 (in weeks) 40% 6 4 20% 2 0% 0 Available Today Currently Out of Stock Never Had It Supply Shortage Figure 27. CVD service readiness: Medicines and commodities availability ACE Inhibitor Beta-blocker Supply Shortage Counting for the Past 100% 14 100% 14 Supply Shortage Counting 12 12 Percent Availabiity Percent Availability 80% for the Past 3 Months 80% 10 10 60% 60% (in weeks) 8 8 (in weeks) 3 Months 40% 6 40% 6 4 4 20% 20% 2 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage Hydrochlorothiazide Tablet or Other Thiazide Calcium Channel Blocker Diuretic Tablet 100% 1 100% 14 Supply Shortage Counting Supply Shortage Counting 12 Percent Availability for the Past 3 Months Percent Availability 80% 0.8 for the Past 3 Months 80% 10 (in weeks) 60% 0.6 60% (in weeks) 8 40% 0.4 40% 6 4 20% 0.2 20% 2 0% 0 0% 0 Available Today Currently Out of Stock Available Today Currently Out of Stock Never Had It Supply Shortage Never Had It Supply Shortage The availability of equipment and medicines for CVD was very strong and we identified very little variability along either regional or income lines (Table 29, Table 30). However, diagnostic capabilities remain very low. CAR scored just 9 percent for CVD-specific diagnostics, and Regions 5 and 12 both scored below 20 percent. Region 3 had the highest diagnostic score with an aggregate score of just 65 percent. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 75 Table 30. CVD service readiness score by LGU income classification Staff & Basic Medicines & Income Diagnostics Overall Guidelines Equipment Commodities Class (%) (%) (%) (%) (%) 1 100 52 98 99 87 2 100 56 98 97 87 3 98 47 99 98 86 4 100 47 99 97 85 5 100 34 99 98 82 6 100 48 95 100 86 Total 100 48 99 98 86 Note: Staff and Guidelines indicates that staff have received training on PhilPEN guidelines. Diagnostics includes access to lipid profile reagents. Basic Equipment includes access to a stethoscope, BP apparatus, and a weighing scale. Medicines and Commodities includes availability of ACE inhibitors, diuretics, beta-blockers, calcium channel blockers, metformin, and angiotensin. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Table 31. CVD service readiness score by region Staff & Basic Medicines & Diagnostics Overall Region Guidelines Equipment Commodities (%) (%) (%) (%) (%) CAR 100 9 98 99 76 Region 1 100 62 92 100 88 Region 2 100 51 98 100 87 Region 3 100 65 100 98 90 Region 4A 100 52 100 99 88 Region 4B 100 51 100 99 87 Region 5 100 19 100 98 79 Region 6 100 48 99 99 86 Region 7 100 49 99 97 85 Region 9 100 55 100 94 86 Region 10 100 60 98 99 89 Region 11 100 49 100 97 86 Region 12 94 13 98 99 82 CARAGA 100 57 100 98 88 Total 100 48 99 98 86 Note: Staff and Guidelines indicates that staff have received training on PhilPEN guidelines. Diagnostics includes access to lipid profile reagents. Basic Equipment includes access to a stethoscope, BP apparatus, and a weighing scale. Medicines and Commodities includes availability of ACE inhibitors, diuretics, beta-blockers, calcium channel blockers, metformin, and angiotensin. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 76 Chronic Respiratory Disease CRDs, including asthma, COPD, and other diseases of the airways and lungs, are another NCD challenge. In 2008, asthma and COPD together accounted for more than 6 percent of all reported deaths (approximately 10,200) in the country. COPD is the most important CRD-related cause of morbidity and mortality, accounting for 57 percent of reported CRD- linked deaths. Asthma is linked to 41 percent of the CRD deaths, with the remaining uncategorized; between one in three and one in four Filipinos has definite or possible asthma. Asthma was introduced into the PhilHealth benefit package in 2011 as a part of PCB, and the policy around asthma treatment has most recently been updated in 2016.23 The current guidelines provide guidance on diagnosis and management of asthma at the primary care level and at higher-level facilities. The SARA tracer indicators for CRD consist of (a) the availability of guidelines and staff trained in the diagnosis and management of CRD in the previous two years; (b) a stethoscope, a peak flowmeter, space for inhalers, and oxygen; and (c) salbutamol inhalers, beclomethasone inhalers, beta-blockers, prednisolone tablets, hydrocortisone injection, and epinephrine injectables. We compare the WHO SARA guidelines to the PhilHealth policy statement for asthma care in Annex 5. The tracer indicators from the survey (Column 3 of Table 32) include only the availability of key equipment (stethoscope and peak expiratory flowmeter) and drugs (beta2-agonist, beclomethasone, and beta-blockers). Table 32. CRD tracer indicators: SARA guidelines and indicators used for assessment Domain WHO SARA Tracer Indicators Tracer Indicators from Survey Staff and  Guidelines for diagnosis and  Indicator Dropped - Data not Guidelines management of CRD: Country adapts available to which guidelines are required/accepted (can be NCD guidelines which contain information on CRD)  Staff trained in diagnosis and  Indicator Dropped - Data not management of CRD: At least one available staff providing the service trained in diagnosis and management of CRD in the last two years (can be an NCD training including a section on CRD) Equipment  Stethoscope  Stethoscope (number of available instruments/equipment)  Peak flowmeter  Diagnostic service: Peak expiratory flowmeter (offered services)  Spacers for inhalers  Indicator Dropped - Data not available 23 PhilHealth Circular No.2016-0004 (2016) Policy Statement on the Diagnosis and Management of Asthma in Adults as Reference by the Corporation in Ensuring Quality of Care. Available at: https://www.philhealth.gov.ph/circulars/2016/circ2016-004.pdf. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 77 Domain WHO SARA Tracer Indicators Tracer Indicators from Survey  Oxygen: Oxygen cylinders OR  Indicator Dropped - Data not concentrators OR central oxygen available supply with functioning flowmeter for oxygen therapy (with humidification) AND oxygen delivery apparatus Medicines  Salbutamol inhaler  Beta2-agonist for example, and salbutamol (stock availability Commodities [asthma]])  Beclomethasone inhaler  ICS, for example, beclomethasone or budesonide or fluticasone (stock availability [asthma])  Beta-blocker (for example,  Beta-blocker (stock availability bisoprolol, metoprolol, carvedilol, [hypertension]) atenolol)  Prednisolone capsules/tablets Indicator Dropped - Data not  available  Hydrocortisone injection  Indicator Dropped - Data not available  Epinephrine injectable  Indicator Dropped - Data not available Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. While almost all RHUs offer some sort of asthma care, this is largely limited to treatment, generally via beta2-agonists and beta-blockers, which are nearly universal. Inhaled corticosteroids (ICS), in contrast, are available at fewer than half of the RHUs, and necessary diagnostics equipment is generally missing from the RHUs visited. Only 4 percent of RHUs had a peak expiratory flowmeter in place on the day of the survey, despite the fact that the PhilHealth policy statement on asthma has required the use of peak expiratory flowmeter since May 2013 (Figure 28).24 Figure 28. CRD service readiness: Medicines and commodities availability and equipment availability Beta2-agonist ICS 100% 2.5 100% 14 Supply Shortage Counting Supply Shortage Counting 12 for the Past 3 Months Percent Availability for the Past 3 Months 80% 2 Percent Availability 80% 10 (in weeks) 60% 1.5 (in weeks) 60% 8 40% 1 40% 6 4 20% 0.5 20% 2 0% 0 0% 0 Available Today Available Today Currently Out of Stock Currently Out of Stock Never Had It Never Had It 24 PhilHealth, Quality Assurance Committee Resolution No. 05 s.2013; (2013) Resolution recommending the adoption of the CPG-based policy statement on bronchial asthma in adults in the outpatient setting. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 78 Beta-blocker Chronic Respiratory Disease: Equipment 100% 14 100 Supply Shortage Counting Providing he Service (%) Percent Availability 12 for the Past 3 Months 80% Percent of Facilities 10 80 60% (in weeks) 8 60 40% 6 40 4 20% 2 20 0% 0 0 Available Today Currently Out of Stock Stethoscope Never Had It Supply Shortage Peak Expiratory Flow Meter [Diagnostic Services] There was no clear association between readiness to provide CRD services and LGU income class (Table 33). We do, however, identify regional variation in the availability of CRD services, particularly linked to differences in the stocking of drugs and commodities, as the extremely low availability of peak expiratory flowmeters resulting in universally low equipment scores. CAR and CARAGA were among the lowest-performing regions (Table 34). Table 33. CRD service readiness score by LGU income group Basic Medicines & Income Equipment Commodities Overall (%) Level (%) (%) 1 53 84 71 2 50 78 67 3 51 80 69 4 54 81 70 5 50 83 70 6 57 81 71 Total 52 81 70 Note: Relevant CRD staffing indicators were not collected and are not shown. Basic Equipment indicates availability of stethoscope and a peak expiratory flowmeter. Medicines and Commodities indicates availability of beta2-agonists; beclomethasone, budesonide, or fluticasone; and beta-blockers. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Table 34. CRD service readiness score by region Basic Medicines & Region Equipment Commodities Overall (%) (%) (%) CAR 53 76 67 Region 1 56 85 74 Region 2 53 92 76 Region 3 59 75 69 Region 4A 50 87 72 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 79 Basic Medicines & Region Equipment Commodities Overall (%) (%) (%) Region 4B 56 81 71 Region 5 50 79 68 Region 6 50 85 71 Region 7 50 93 76 Region 9 50 76 66 Region 10 50 83 70 Region 11 53 74 66 Region 12 50 76 65 CARAGA 50 71 62 Total 52 81 70 Note: Relevant CRD staffing indicators were not collected and are not shown. Basic Equipment indicates availability of stethoscope and a peak expiratory flowmeter. Medicines and Commodities indicates availability of beta2-agonists; beclomethasone, budesonide, or fluticasone; and beta-blockers. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Cervical Cancer Screening In contrast to most other types of cancers, cervical cancer is largely preventable. Onset is associated with prior infection with the vaccine-preventable HPV and early diagnosis and treatment can prevent disease progression and avoid much of the morbidity and mortality associated with the disease. Nonetheless, cervical cancer is the fifth most common cancer among women and is responsible for 7 percent of all deaths due to malignancy in the Philippines. CCS is an emerging priority in the Philippines and, in 2016, the government ramped up its response. Regional centers to train providers to conduct CCS have recently opened, and the government is in the process of rolling out widespread trainings. As data presented here were collected in 2014, they provide a baseline snapshot of the policies and infrastructure in place prior to the government’s current efforts. While provision of CCS is included in the 2012 PCB Package, relatively few staff were trained in the screening protocol at the time of the survey. Later rounds of data collection are likely to reflect these more recent investments and efforts to expand access to screening. The SARA tracer indicators for CCS consist of (a) staff trained in cervical cancer prevention and control and the availability of guidelines; (b) a speculum; and (c) the availability of acetic acid. The MNCHN MOP guidelines specify the ability to conduct CCS using either VIA or a pap smear. Both a speculum and acetic acid are specified in the MNCHN MOP (Table 35). SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 80 Table 35. CCS tracer indicators: SARA guidelines and indicators used for assessment Domain Tracer Indicators from Survey WHO SARA Tracer Indicators Staff and Guidelines  Indicator Dropped - Data not  Guidelines for cervical cancer prevention and control available  Have you attended a training on visual  Staff trained in cervical acetic acid? cancer prevention and control Equipment  Speculum  Vaginal speculum (big) (number of available instruments/equipment) Diagnostics  Acetic acid  3% to 5% acetic acid (availability of supply today) Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. Many RHUs did not yet offer screening services at the time of the survey. While necessary equipment (speculum) was widespread, fewer than half of the RHUs visited offered screening. Acetic acid, which is needed for screening, was not available at many RHUs (Figure 29). Figure 29. CCS service readiness: Equipment availability and diagnostics availability Cervical Cancer Screening: Training on Visual Acetic Acid 100 Providing he Service (%) Percent of Facilities 80 60 40 20 0 Cervical Cancer Screening: 3% to 5% Acetic Acid Vaginal Speculum 100% 14 100 Supply Shortage Counting 12 for the Past 3 Months 80% Providing he Service (%) Percent Availability 80 10 Percent of Facilities (in weeks) 60% 8 60 40% 6 40 4 20% 20 2 0% 0 0 Available Today Big Small Currently Out of Stock Never Had It The nature of the inputs for cervical screening merit some discussion. Acetic acid is sold as table vinegar, and is readily available at low cost from many stores. Thus, the current low availability of acetic acid is likely an indication that these facilities do not offer this service rather than gaps in the supply chain. Once the provider undergoes training on visual SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 81 screening for cervical cancer, the availability of acetic acid is not expected to be an issue. Speculums, by contrast, are needed for other services routinely offered at RHUs. Thus, its general availability likely points to the strength of other maternal and women’s health programs, rather than cervical screening readiness. CCS services are, generally, least available among RHUs in sixth class LGUs and most available among RHUs in first class LGUs. While the equipment is widely available, access to inputs such as acetic acid and staff training vary by income class. The same is true regionally. At the time of the survey, no staff at the RHUs visited in Region 12 reported having attended training on CCS, while nearly two-thirds of staff in Region 3 had received training. Access to medicines and commodities was also higher in Region 3, and the region received an aggregate commodities score of 94 percent, compared to the sample average of 60 percent (Table 37). Table 36. CCS service readiness score by LGU income classification Medicines Staff & Basic Income & Guidelines Equipment Overall (%) Class Commoditie (%) (%) s (%) 1 29 100 76 68 2 21 97 43 53 3 20 98 63 60 4 30 98 70 66 5 23 97 38 53 6 29 100 43 57 Total 25 98 60 61 Note: Staff & Guidelines refers to facilities having at least one staff who attended training on visual acetic acid. Basic Equipment refers to availability of a speculum. Medicines and Commodities refers to the availability of 3 percent to 5 percent acetic acid. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Table 37. CCS service readiness score by region Staff & Basic Medicines & Region Guidelines Equipment Commodities Overall (5) (%) (%) (%) CAR 38 100 53 64 Region 1 7 94 44 48 Region 2 7 100 75 61 Region 3 63 100 94 85 Region 4A 38 100 87 75 Region 4B 6 100 38 48 Region 5 40 100 69 70 Region 6 22 92 67 60 Region 7 8 100 33 47 Region 9 8 94 56 53 Region 10 44 100 79 74 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 82 Staff & Basic Medicines & Region Guidelines Equipment Commodities Overall (5) (%) (%) (%) Region 11 46 100 53 66 Region 12 0 100 60 53 CARAGA 35 100 53 63 Total 25 98 60 61 Note: Staff & Guidelines refers to facilities having at least one staff who attended training on visual acetic acid. Basic Equipment refers to availability of a speculum. Medicines and Commodities refers to the availability of 3 percent to 5 percent acetic acid. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. 4. Tuberculosis Although the epidemiologic transition toward a preponderance of NCDs is well under way in the Philippines, the country continues to face a substantial CD burden, and addressing this burden is an explicit priority of the national government. TB is among the top causes of morbidity and the fourth leading cause of mortality in the country. Despite a robust DOTS program and generalized reduction in prevalence of TB, much remains to be done and the MDG target was not met. National data indicate a TB case detection rate of 83 percent (exceeding the national target of 70 percent) and treatment success rate of 90 percent (Philippines Statistical Authority, MDG Watch, September 2015).25 Meanwhile, the increase in multi-drug resistant (MDR) TB, both globally and domestically, necessitates the availability of a robust screening, diagnosis, and treatment system. The 2014 FHSIS indicates a national case detection rate of 41.62. PhilHealth first introduced coverage for TB care in 2002 with the passage of Resolution Nos. 485 and 490, which detailed reimbursements to RHUs for consultation, diagnostics, and medicines associated with TB care. In 2003, Circular Nos. 17 and 19 expanded these services to include coverage for DOTS and coverage for pediatric and extra-pulmonary TB. The current 2010–2016 Philippine Plan against Tuberculosis outlines a plan to achieve an 85 percent case detection rate and at least 90 percent treatment success rate. The SARA tracer indicators for TB consist of (a) guidelines and staff trained on diagnosis and treatment of TB, management of HIV and TB coinfection, MDR-TB treatment (or referral), and TB infection control; (b) TB microscopy, HIV diagnostic capacity, a system for diagnosis of HIV among TB clients, and sputum microscopy; and (c) first-line TB medications (Table 38). Sputum microscopy is the only diagnostic required in the TB- DOTS protocol in the Philippines, hence only sputum microscopy and first-line drugs are the only tracer indicators used in this analysis. The survey was not able to capture any indicators on staff and guidelines. 25 http://nap.psa.gov.ph/mdg/MDGWatchasofSeptember2015.pdf. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 83 Table 38. TB tracer indicators: SARA guidelines and indicators used for assessment Domain WHO SARA Tracer Tracer Indicators from Survey Indicators Staff and  Guidelines for diagnosis  Indicator Dropped - Data not available Guidelines and treatment of TB  Guidelines for  Indicator Dropped - Data not available management of HIV and TB coinfection  Guidelines related to  Indicator Dropped - Data not available MDR-TB treatment (or identification of need for referral)  Guidelines for TB  Indicator Dropped - Data not available infection control  Staff trained in TB  Indicator Dropped - Data not available diagnosis and management  Staff trained in  Indicator Dropped - Data not available management of HIV and TB coinfection  Staff trained in client  Indicator Dropped - Data not available MDR-TB treatment or identification of need for referral  Staff trained in TB  Indicator Dropped - Data not available infection control Diagnostics  TB microscopy  Indicator Dropped - Data not available  HIV diagnostic capacity  Indicator Dropped - Data not available  System for diagnosis of  Indicator Dropped - Data not available HIV among TB clients  Sputum microscopy  Diagnostic service: Sputum testing for TB (offered services) Medicines  First-line TB medications  Isoniazid+Rifampicin+Pyrazinamide+Ethambutol and fixed-dose tablets, tablet/capsule (observed Commodities available preparation [TB drugs]) Note: Column 1 indicates the SARA domain; Column 2 indicates SARA tracer indicators; and Column 3 indicates the precise wording of the I3QUiP survey question or, when applicable, that a given indicator has been dropped. Sputum microscopy was available at 85 percent of the 240 RHUs. Some form of first-line treatment was similarly widespread. Nearly all (97 percent) of the 240 facilities visited during the survey offered isoniazid-rifampicin-pyrazinamide-ethambutol combination tablets. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 84 Figure30. Equipment availability and medicines and commodities availability TB diagnosis by sputum smear microscopy Isoniazid+Rifampicin+Pyrazinamide+Ethambutol examination, sputum microscopy fixed dose tablets 100% 14 Supply Shortage Counting 100 12 for the Past 3 Months 80% Percent Availability Providing he Service (%) 80 10 Percent of Facilities 60% 8 60 40% 6 40 4 20% 2 20 0% 0 0 Available Today Currently Out of Stock Never Had It Supply Shortage Although there was high overall readiness to provide TB services, we see a difference in overall readiness depending on the LGU income class. Facilities in sixth class LGUs scored an average of 86 percent on access to the diagnostic tools, compared to 100 percent among first, second, and third class LGUs. Regionally, CAR and Region 6 underperformed compared to other regions, although there was no one input that appeared to drive gaps in service readiness for TB (Table , Table 40). Table 39. TB service readiness score by LGU income group Medicines & Income Diagnostics Commodities Overall (%) Level (%) (%) 1 100 98 99 2 100 97 98 3 100 100 100 4 92 95 93 5 92 97 95 6 86 86 86 Total 96 97 97 Note: Relevant TB staffing indicators were not collected and are not shown. Diagnostics refers to the availability of sputum smear microscopy. Medicines and Commodities refers to the availability of Isoniazid-Rifampicin-Pyrazinamide-Ethambutol tablets. Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 85 Table 40. TB service readiness score by region Medicines & Diagnostics Region Commodities Overall (%) (%) (%) CAR 88 94 91 Region 1 100 100 100 Region 2 100 94 97 Region 3 100 100 100 Region 4A 94 100 97 Region 4B 88 100 94 Region 5 100 94 97 Region 6 92 88 90 Region 7 96 100 98 Region 9 100 94 97 Region 10 94 100 97 Region 11 100 100 100 Region 12 100 100 100 CARAGA 100 100 100 Total 96 97 97 Note: Relevant TB staffing indicators were not collected and are not shown. Diagnostics refers to the availability of sputum smear microscopy. Medicines and Commodities refers to the availability of Isoniazid-Rifampicin-Pyrazinamide-Ethambutol tablets. Color- coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. 5. Variation in Service Readiness In this section, we present evidence of macro trends in service readiness and availability. As shown in Table , regions that perform poorly in one health service category often struggle across multiple categories. CAR and Region 9 both underperformed across nearly all of the health service categories, while Region 10 and CARAGA both performed at or above the mean in nearly all the categories. Table 41. Variation in service readiness score by region Immun Child ANC FP DM CVD CRD CCS TB Region ization Health (%) (%) (%) (%) (%) (%) (%) (%) (%) CAR 80 93 77 87 77 76 67 64 91 Region 1 89 93 70 88 88 88 74 48 100 Region 2 88 90 78 93 90 87 76 61 97 Region 3 95 95 83 89 98 90 69 85 100 Region 4 A 85 99 81 86 93 88 72 75 97 Region 4 B 82 98 81 79 87 87 71 48 94 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 86 Region 5 93 100 74 90 97 79 68 70 97 Region 6 86 93 83 83 89 86 71 60 90 Region 7 87 92 73 80 94 85 76 47 98 Region 9 81 99 77 87 80 86 66 53 97 Region 10 97 99 84 95 96 89 70 74 97 Region 11 95 100 80 98 91 86 66 66 100 Region 12 96 96 82 98 90 82 65 53 100 CARAGA 92 99 85 93 94 88 62 63 100 Total 89 96 79 89 91 86 70 61 97 Note: Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Table shows that there is a clear relationship between service readiness and the resource base of the LGUs where the surveyed facility is located. In general, the table suggests improving performance with increasing LGU resources. Facilities in first income class municipalities perform at or above the sample means for all health service categories and have the top performance for several categories, while RHUs from the poorest LGUs, in fifth and sixth income classes, each had the lowest score for five domains. Between them, RHUs in fifth and sixth class municipalities perform at or above the sample mean for only one health service category: CRD. Although we cannot clearly link this outcome with any particular policy, it is notable that CRD benefits from ComPacks’ central procurement. Table 2. Variation in service readiness score by LGU income group Immuni Child Income ANC FP DM CVD CRD CCS TB zation Health Level (%) (%) (%) (%) (%) (%) (%) (%) (%) 1 94 96 80 93 93 87 71 68 99 2 88 94 80 89 91 87 67 53 98 3 91 97 79 90 92 86 69 60 100 4 88 96 78 86 91 85 70 66 93 5 84 95 77 84 85 82 70 53 95 6 78 91 77 86 84 86 71 57 86 Total 89 96 79 89 91 86 70 61 97 Note: Color-coding indicates relative performance, with those performing above the mean shaded in green and those below the mean shaded in beige. Finally, these tables also highlight the high variability in average performance across the different health service categories. The average category scores for FP and TB were nearly 100 percent. Reflecting their relatively new status in the PhilHealth benefit package, readiness to provide both CRD and CCS scores were far lower, at 70 percent and 61 percent, respectively. With an average score of 79 percent, readiness to provide immunization services is also relatively low. As with CRD and CCS scores, this low average is a reflection of the difficulty of rapidly attaining high coverage at the scale of more newly introduced vaccines such as rotavirus and pneumococcal vaccines. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 87 Figure 31. Regional variation in ANC service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 88 Figure 32. Regional variation in FP service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 89 Figure 33. Regional variation in immunization service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 90 Figure 34. Regional variation in child health service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 91 Figure 35. Regional variation DM service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 92 Figure 36. Regional variation in CVD service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 93 Figure 37. Regional variation in CRD service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 94 Figure 38. Regional variation in CSS service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 95 Figure 39. Regional variation in TB service readiness SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 96 IV. Discussion, Limitations, and Areas for Further Work Results from a nationally representative survey have identified a number of strengths in the delivery of primary care in the Philippines. Basic equipment, including adult and child scales, BP apparatuses, sterile gloves, thermometers, and stethoscopes, were all commonly available. Many medicines and commodities are also widely available. Very few stock-outs were identified for several high-priority items, including TT, BCG, and OPV vaccines, oral and injectable contraceptives, mebendazole, ORS, amoxicillin, co- trimoxazole, and paracetamol. Therapies are also generally available for the NCDs, including the diabetes drugs metformin and sulfonylureas; ACE inhibitors, diuretic, beta- blockers, calcium channel blockers, metformin, and angiotensin receptor blockers for CVD; and beta2-agonists and beta-blockers for asthma. The average overall scores for both FP and TB were nearly 100 percent. There were, however, a number of important gaps. The survey identified issues with the basic infrastructure and equipment at the facilities: 49 percent of RHUs had experienced some power outage in the week leading up to the survey, and 20 percent of facilities did not have refrigerators for vaccines. While there were some shortages in the availability of drugs and commodities (for example, the relatively newly introduced pneumococcal and rotavirus vaccines were each available at fewer than half of the facilities, as was ICS for asthma), the main gaps were in diagnostic capacity. Hb testing was available at only 62 percent of RHUs and fecalysis was available at 77 percent. Fasting blood glucose testing was available at just 70 percent of RHUs visited overall, and at only 25 percent of RHUs in CAR and 38 percent of RHUs in Region 10. Similar gaps were found in the ability to conduct urine analysis: 77 percent of RHUs overall could provide this test; only 31 percent of RHUs in CAR and 56 percent in Region 5 could do so. Only 4 percent of RHUs had a peak expiratory flowmeter in place for asthma diagnosis on the day of the survey and only one-fourth of RHUs have staff trained on CCS at the time of the survey. Overall domain scores for CRD, CCS, and immunization are low, at 70 percent, 61 percent, and 79 percent respectively. To some degree, these low averages reflect the difficulty of rapidly attaining high coverage at the scale of more newly introduced services. This includes, in the case of vaccination, the new and contentious introduction of rotavirus and pneumococcal vaccines. In other cases, it reflects disconnect between the determination of a benefit package and the health sector’s capacity to deliver on the resulting entitlements. CCS has been a component of the PCB since its launch in 2012. However, capacity to delivery screening was very low at baseline and, until recently, efforts to support PBC implementation have focused on strengthening access to other elements, including diabetes and hypertension care. There was substantial regional variation in readiness to provide some services. This has important implications for equity in the distribution of and access to national resources. Although immunization and diabetes services are intended to be universally available, regional immunization scores varied from 70 percent to 85 percent, and diabetes scores ranged from a low of just 67 percent in CAR to a high of 98 percent in Region 3. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 97 Some regions consistently under- or over-performed when compared to their neighbors. For example, CAR performed at or below the sample mean in all but three domains, as did Region 2. Meanwhile, Region 10 and CARAGA performed better than others in almost all the domains. A better understanding of why these regions fall short is needed to ensure that the LGUs in those regions are better able to deliver services over the medium term. However, it would also be important to go beyond the regional average to see what is going on within particular regions, as there is likely to be substantial subregional variation across RHUs. We also find inequalities in supply-side readiness across relatively more prosperous and relatively less prosperous LGUs. RHUs located in first or second income class municipalities tend to have better basic infrastructure, more basic equipment, and higher diagnostic capacity than RHUs in fifth and sixth income class municipalities. Looking at the health service-specific category scores, RHUs located in first class LGUs perform well above the sample means for all categories except FP (which has a very high overall average score of 97 percent) and have the top performance for several categories. While RHUs located in poorer LGUs performed slightly better than their wealthier counterparts on infection prevention and for availability of general essential medicines, RHUs located in the sixth class LGUs have the lowest performance in five of the nine health service categories (ANC, FP, immunization, diabetes, and TB), and are above the sample mean for only one category—CRD. The explanation for this poor performance is outside the scope of this study, but it is reasonable to hypothesize that wealthier LGUs may have larger health budgets, find it easier to attract qualified staff, and—given the concentration of poorer LGUs in remote areas—face fewer logistics and supply chain issues. Better targeting of special national programs that deploy staff in underserved areas is urgently required to overcome supply-side gaps in human resources. While programs such as DTTB and the NDP have compensated for human resource shortages in some areas, our data suggest that deployment of these staff does not correspond to the regions with personnel gaps. As the differences across regions and income class groups indicate, further effort is needed to efficiently reduce disparities in staffing across LGUs, especially in remote and hard-to-access areas. In some cases, national programs to centrally procure and distribute commodities and equipment appear to have been effective in getting many supplies even to far- flung areas. Even in regions where average LGU performance was poor in most health service categories, LGUs tended to score well on the availability of medicines that are made available through the ComPacks program. Given the significant decentralization of the Philippines’ health system, central programs will not be a long-term solution but, at least in the case considered here, they do appear to provide an important stopgap. Future data may permit us to assess more recent efforts to improve infrastructure via central procurement. For example, the government has recently committed to procuring and distributing Hb tests. Ability to conduct Hb testing was particularly weak among RHUs visited in this survey, with only 30 percent of facilities having the test in stock. The next round of data collection may be useful to assess whether initiatives such as this are successful. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 98 However, decentralization poses a particular challenge to delivering on national entitlements. The various decrees and circulars documented in this report represent entitlements granted at the central level; however, local-level commitment and investments are generally required to deliver upon these promises. Central-level procurement can only serve to achieve targeted goals and, even with those, it is unclear whether they succeed in reaching more remote RHUs. The majority of investments come from municipalities and provinces that are subject to varying resource availability and to competing non-health priorities. And, while municipalities on average spend about 9 percent of their General Fund to health, the bulk of these resources (78 percent) are allocated for personal services, leaving a meager 22 percent of the 9 percent for operating expenses and capital outlays (Department of Finance: Bureau of Local Government Finance, n.d.)—including the supplies and infrastructure requirements that are assessed in this report. Local inter-sectoral competition for resources is exacerbated by weak accountability relationships. No institution can hold LGUs accountable for delivering on their mandate, and accreditation does not appear to be sufficient to ensure availability of inputs. All facilities included in this survey were accredited with PhilHealth, yet we documented a number of gaps in infrastructure and supply availability that would seem to contraindicate accreditation. Performance-based payment mechanisms may hold LGUs accountable for basic service delivery. PhilHealth has already introduced an incentive structure wherein capitation payments are paid based on obtaining the health profile of the population. This can be modified to further strengthen the incentive structure by linking the payments to the delivery of specific services.26 Such performance-based mechanism may force LGUs to ensure that the facilities are properly maintained long after they receive accreditation, thereby also ensuring a minimum standard of care in LGUs across the country. Supply-side readiness is essential if the planned increase in the generosity of the primary care benefit package is not to be an empty promise. The Philippines has made remarkable strides in ensuring PhilHealth coverage, and needs to also ensure that it is matched by the readiness of the supply side to deliver on it. The country currently subsidizes coverage for 45 million poor people, and has repeatedly enacted plans to expand the benefit package over the past decade. The country’s current plan to expand the PhilHealth package such as in the Tsekap package as contained in PhilHealth Circular No. 02-2015 is both welcome and needed, and implementation of certain elements of Tsekap This is likely to be quite achievable. Coverage of hypertension and diabetes care, for example, are already high. However, as this analysis clearly shows, there are some gaps, such as on equipment for asthma management and training of RHU staff on CCS, that need to be addressed to ensure that all RHUS in all regions are able to deliver the package. There were also gaps documented in electricity and Internet access which are critical in implementing the electronic medical reporting component of the package. The electronic recording aims to aid in service delivery, monitoring, and to take into effect a performance- 26 For example, an ongoing study is evaluating the impact of paying based on (a) quantity of specific services delivered and (b) quality of care based on assessment of availability of supplies and management of tracer conditions, in boosting the utilization and quality of PCB services. It is for this impact evaluation that data presented for this report, which was co-funded by the World Bank and the Korean government, were initially collected. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 99 based payment mechanism. It is important to note that such payment mechanism proposed in the Tsekap package incentivizes the LGUs and RHUs to ensure that all these necessities for the package are made available, again underscoring that implementation of such a benefit package is achievable. Limitations and Areas for Further Work This paper highlights gaps in benefit entitlements and service readiness. A key objective of this report is to stimulate policy dialogue on ways to enhance health service delivery in public primary care facilities in the country. However, as indicated in preceding sections of this report, there are a number of important limitations. One such limitation stems from the sampling frame, which is limited to PhilHealth-accredited RHUs, and the sampling methodology, in which only the largest (main) RHU in each municipality was eligible for selection. Thus, the RHUs surveyed are likely to represent the best RHU in each municipality and our findings on service readiness will be biased upwards, representing a more optimistic picture of supply-side readiness than that which prevails across RHUs in general. Even within the sample, this report does not provide an exhaustive or even ideal list of the services and indicators that would have been examined had we set out with the main purpose of investigating supply-side readiness. This study was limited to the data collected during the baseline survey for a study on the PhilHealth PCB Package and has focused on tracer indicators across the nine health service categories examined. Nonetheless, the data that are available are broad, providing a number of insights into service readiness across the country, and we are able to draw relevant and important conclusions. Future studies can provide a fuller examination of the key determinants—including demand-side determinants—of the maternal health, CD, and NCD tracer conditions considered here. A supply-side examination of quality of care that combines information on the availability of supply-side inputs (such as those discussed here) with information on the availability and performance of health care providers would be particularly useful. A separate and equally useful study would examine the cause of existing gaps in availability. Stock-outs might reflect issues with funding, unusually high utilization, poor forecasting, issues with logistics and supply chain, issues with procurement processes, or a combination of these challenges. Adequate stocks, on the other hand, might reflect a well-functioning supply chain or, alternatively, slow turnover of commodities due to lower-than-average utilization. While anecdotal evidence suggests that poor forecasting has led to oversupply of a number of commodities in some areas, this report is unable to make any causal assessments and additional information will help strengthen policy suggestions. Some of these questions might be explored during the I3QUiP end line data collection, which is planned to take place in late 2018 and will cover the same LGUs as were visited during the baseline. The end line survey will provide an opportunity to conduct a second round of analysis on supply-side readiness at the primary care level—potentially with an expansion of scope to include tracer indicators that could not be captured here. The follow-up analysis may, thus, allow us to offer some measure of the impact of policy changes or interventions that are implemented between the two points in time. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 100 References Department of Finance: Bureau of Local Government Finance. n.d. http://blgf.gov.ph/lgu-fiscal-data/#LFD. ———. 2008. “DOF Order No. 23-08, dated July 29, 2008.” Department of Health (DOH). 2010. Toward Financial Risk Protection. Health Care Financing Strategy of the Philippines 2010-2020. Health Sector Reform Agenda – Monographs (DOH HSRA Monograph No. 10)., Manila, Philippines. ______. 2011. The MNCHN Manual of Operations 2011. Manila, Philippines. ———. 2014. Field Health Service Infromation System (FHSIS). Food and Nutrition Research Institute. 2008. “2008 National Nutrition Survey.” ———. 2013. “8th National Nutrition Survey.” IHME (Institute of Health Metrics and Evaluation). 2013. IHME Country Philippines: 1– 8. Lavado. 2016. Working Draft: Review of Local Health Sector in the Philippines. Onishi, J., et al. 2016. Impact or Incentives and Information on Quality and Utilization in Primary Care. Baseline Report. PhilHealth (Philippine Health Insurance Corporation). 2012. “PhilHealth Circular No.010, s. 2012: Implementing Guidelines for Universal Health Care Primary care Benefit I (PCB1) Package for Transition Period CY 2012-2013.” ———. 2015. “2015 Stats and Charts.” ______. 2015. “PhilHealth Circular No. 002-2015: Governing Policies on the Expanded Coverage of the Primary Care Benefit Package: Tamang Serbisyo sa Kalusugan ng Pamilya (Tsekap).” Philippine Statistics Authority. 2013. “National Demographic Health Survey.” Presidential Decree (PD) No. 996 (n.d.) Providing For Compulsory Basic Immunization For Infants And Children Below Eight Years Of Age. Racelis, R. 2016. National Health Accounts-System of Health Accounts 2011 (NHA-SHA) – Philippine Health Accounts Based on the 2011 System of Health Accounts for CY2012 (Revised), 2013 and 2014 (Provisional): Tables, Estimates and Analysis. Republic Act (RA) No. 7846 (1994) An Act Requiring Compulsory Immunization Against Hepatitis-B for Infants and Children Below Eight (8) Years Old, Amending for the Purpose P.D. No. 996, and Appropriating Funds Therefor: 1–38. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 101 Republic Act Number 10152 (n.d.) Mandatory Infants and Children Health Immunization Act of 2011. Romualdez Jr. A. G, J. F. E. dela Rosa, J. D. Flavier, S. L. Quimbo, K. Y. Hartigan-Go, et al. 2011. “The Philippines Health System Review.” Health Systems in Transition 1: 1–114. http://www.wpro.who.int/asia_pacific_observatory/Philippines_Health_System_R eview.pdf. WHO (World Health Organization). 2014. Service Availability and Readiness Assessment (SARA): An Annual Monitoring System for Service Delivery Reference Manual. 2014.5. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 102 Annexes Annex 1: Standards for Accreditation of PhilHealth’s PCB Package Providers; Diagnostic and Service Availability Service Capability  Consultation o Medicine o General surgery o Obstetrics and gynecology o Pediatrics  CCS: VIA  Regular BP measurements  Breastfeeding program education  Periodic clinical breast examination  Counseling for lifestyle modification  Counseling for smoking cessation  Body measurements  Digital rectal examination (for males) Diagnostic Services  CBC  Urinalysis  Fecalysis  Sputum microscopy  FBS  Lipid profile  Chest X-ray Source: PhilHealth Circular No. 010, s. 2012: Implementing Guidelines for Universal Health Care Primary Care Benefit I (PCB1) Package for Transition Period CY 2012-2013. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 103 Annex 2: Standards for Accreditation of PhilHealth’s PCB Package Providers; Infrastructure and Supplies Requirements General Infrastructure  Sign bearing name of RHU  Sign indicating RHU is PhilHealth provider  Sign enumeration health services provided, including components of PCB Package  Smoke-free, generally clean environment  Adequate lighting/electric supply  Sufficient seating for patients in well-ventilated area  Examination area  Consultation area separate from examination area  Safe area for record storage  Toilet  Adequate signages (entrance and exit)  Emergency preparedness plans (exit/evacuation plans)  Fire safety provision  Puncture-proof receptacles for disposal of pointed/sharp objects  Properly segregated and labeled waste bins for different kinds of waste  Non-slippery floors  Provision for hand hygiene/washing  Area for cleaning instruments  Safe storage for drugs and medicines  Safe storage of laboratory reagents (if applicable)  Well-ventilated sputum collection area (if applicable) Equipment and Supplies SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 104  Non-mercurial BP apparatus  Non-mercurial thermometer  Stethoscope  Weighing scale (adult)  Weighing scale (infant)  Tape measure  Nebulizer  Lubricating jelly  Disposable needles and syringes  Sterile cotton balls  Sterile cotton swabs  Applicator stick  Disposable gloves  Specimen cups/bottles  Sterilizer or its equivalent  Vaginal speculum (big)  Vaginal speculum (small)  Decontamination solution  70% isopropyl alcohol  3% to 5% acetic acid  Glass slides  Storage cabinet for sterile instruments and supplies Drugs and Medicines  For asthma o Inhaled corticosteroids o Short acting beta2-agonists o Oral or systemic corticosteroids  For acute gastroenteritis o ORS  For upper respiratory tract infection/pneumonia o Amoxicillin o Macrolide o Beta lactams with beta lactamase inhibitors and/pr o Second generation cephalosporins  For urinary tract infection o Oral fluroquinolones o Co-trimoxazole Human Resources  Licensed doctor  Licensed nurse  Licensed midwife  Licensed medical technologist (if with laboratory services)  Licensed radiology technician (if with X-ray services) Training  Training on VIA  Training on sputum microscopy Source: PhilHealth Circular No. 010, s. 2012: Implementing Guidelines for Universal Health Care Primary Care Benefit I (PCB1) Package for Transition Period CY 2012-2013. SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 105 Annex 3: RHU Personnel Region Full-time Health RHU Personnel Medical Sanitary Admin Driver Dental Dentist Nutrition Technician Inspector Staff Aide Officer CAR 0.31 0.94 1.56 0.81 0.31 0.19 0.50 Region 1 0.38 1.88 0.19 0.50 0.20 0.19 0.50 Region 2 0.44 1.06 0.00 0.56 0.06 0.31 0.38 Region 3 1.06 0.88 0.31 0.44 0.56 0.69 0.31 Region 4A 0.44 1.06 0.56 0.38 0.44 0.81 0.44 Region 4B 0.31 1.31 0.31 0.81 0.19 0.69 0.19 Region 5 1.00 1.19 0.19 0.56 0.25 0.31 0.31 Region 6 0.71 1.42 1.17 0.96 0.63 0.58 0.29 Region 7 0.88 1.00 0.38 0.83 0.75 0.79 0.25 Region 9 0.87 1.50 0.62 0.47 0.33 0.50 0.31 Region 10 1.13 1.88 2.00 0.94 0.81 0.94 0.25 Region 11 1.13 1.20 0.64 1.10 0.62 0.77 0.73 Region 12 1.25 1.31 1.25 0.81 0.75 1.00 0.14 CARAGA 1.12 1.65 0.65 0.71 1.00 1.06 0.35 Total 0.79 1.30 0.71 0.71 0.51 0.64 0.34 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 106 Annex 4: Provinces and Municipalities Included In This Survey LGU Region Province (Municipality/City) CAR 1 Abra 1 Bucay 2 Dolores 3 Lagangilang 4 Manabo 5 Penarrubia 6 Sallapadan 7 San Juan 8 San Quintin 9 Tayum 10 Tubo 2 Ifugao 1 Aguinaldo 2 Alfonso Lista 3 Hingyon 4 Lagawe 5 Mayoyao 6 Tinoc Region 1 1 Ilocos Sur 1 Alilem 2 Bantay 3 Caoayan 4 Lidlidda 5 Magsingal 6 Salcedo 7 San Ildefonso 8 Vigan, City Of 2 La Union 1 Agoo 2 Aringay 3 Balaoan 4 Burgos 5 Naguilian 6 San Fernando 7 San Gabriel 8 Tubao Region 2 1 Batanes 1 Itbayat 2 Ivana 3 Mahatao 4 Sabtang 5 Uyugan 2 Nueva Vizcaya 1 Alfonso Castaneda 2 Ambaguio SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 107 LGU Region Province (Municipality/City) 3 Bagabag 4 Bambang 5 Diadi 6 Dupax Del Norte 7 Dupax Del Sur 8 Kayapa 9 Quezon 10 Santa Fe 11 Solano Region 3 1 Aurora 1 Baler 2 Dipaculao 3 Maria Aurora 4 San Luis 2 Nueva Ecija 1 Aliaga 2 Cabiao 3 Cuyapo 4 Laur 5 Llanera 6 Palayan City 7 San Antonio 8 San Isidro 9 San Leonardo 10 Sto. Domingo 11 Talavera 12 Talugtug Region 4A 1 Quezon 1 Agdangan 2 Atimonan 3 Candelaria 4 Dolores 5 Infanta 6 Macalelon 7 Mulanay 8 Padre Burgos 9 Perez 10 Real 11 San Andres 12 San Antonio 13 Tayabas City 14 Unisan 2 Rizal 1 Jala-Jala 2 Taytay Region 4B 1 Oriental Mindoro 1 Baco SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 108 LGU Region Province (Municipality/City) 2 Bansud 3 Calapan, City Of 4 Gloria 5 Naujan 6 Pola 7 San Teodoro 8 Victoria 2 Romblon 1 Alcantara 2 Banton 3 Cajidiocan 4 Calatrava 5 Ferrol 6 Odiongan 7 San Agustin 8 Santa Fe Region 5 1 Camarines Norte 1 Capalonga 2 Daet 3 Jose Panganiban 4 Labo 5 Paracale 6 San Vicente 7 Santa Elena 8 Talisay 9 Vinzons 2 Catanduanes 1 Bagamanoc 2 Baras 3 Gigmoto 4 Pandan 5 Caramoran 6 San Miguel 7 Virac Region 6 1 Antique 1 Hamtic 2 Libertad 3 Pandan 4 Patnongon 5 San Jose 6 Sebaste 7 Sibalom 8 Tibiao 2 Capiz 1 Cuartero 2 Dumalag 3 Dumarao 4 Jamindan 5 Ma-Ayon SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 109 LGU Region Province (Municipality/City) 6 Mambusao 7 Ivisan 8 Panay 9 Pilar 10 Pontevedra 11 President Roxas 12 Sigma 3 Guimaras 1 Buenavista 2 Jordan 3 Nueva Valencia 4 San Lorenzo Region 7 1 Cebu 1 Alegria 2 Boljoon 3 Carmen 4 Minglanilla 5 Oslob 6 Pinamungahan 7 San Fernando 8 Santa Fe 9 Toledo City 10 Ronda 2 Negros Oriental 1 Basay 2 Bindoy (Payabon) 3 Canlaon City 4 Dauin 5 La Libertad 6 Mabinay 7 Tayasan 8 Valencia 9 Vallehermoso 10 Zamboanguita 3 Siquijor 1 Enrique Villanueva 2 Larena 3 Lazi 4 Siquijor Region 9 1 Zamboanga Del Norte 1 Dipolog City 2 Godod 3 La Libertad 4 Pinan (New Pinan) 5 Polanco 6 Salug 7 Sibutad 8 Sindangan SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 110 LGU Region Province (Municipality/City) 2 Zamboanga Del Sur 1 Aurora 2 Dimataling 3 Bayog 4 Lapuyan 5 Mahayag 6 Pitogo 7 Ramon Magsaysay (Liargo) 8 Tabina Region 10 1 Bukidnon 1 Damulog 2 Impasug-Ong 3 Kibawe 4 Kitaotao 5 Pangantucan 6 Malaybalay, City Of 7 Maramag 8 San Fernando 2 Misamis Occidental 1 Aloran 2 Clarin 3 Ozamis City 4 Panaon 5 Plaridel 6 Sapang Dalaga 7 Tangub City 8 Tudela Region 11 1 Davao Del Norte 1 Asuncion (Saug) 2 Carmen 3 Kapalong 4 New Corella 5 Panabo, City Of 6 Tagum, City Of 7 Santo Tomas 2 Compostela Valley 1 Compostela 2 Mabini 3 Maco 4 Maragusan (San Mariano) 5 Mawab 6 Montevista 7 Nabunturan 8 New Bataan Region 12 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 111 LGU Region Province (Municipality/City) 1 Cotabato (North Cotabato) 1 Antipas 2 Banisilan 3 Kabacan 4 Kidapawan, City Of 5 Makilala 6 Magpet 7 Pikit 8 President Roxas 2 South Cotabato 1 Banga 2 Koronadal, City Of 3 Surallah 4 Norala 5 Tampakan 6 Tantangan 7 T'boli 8 Tupi CARAGA 1 Surigao Del Norte 1 Bacuag 2 Claver 2 Surigao Del Sur 1 Barobo 2 Bislig, City Of 3 Cagwait 4 Cantilan 5 Carrascal 6 Cortes 7 Hinatuan 8 Lanuza 9 Lianga 10 Madrid 11 Marihatag 12 San Agustin 13 San Miguel 14 Tagbina 15 Tandag SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 112 Annex 5: Indicators in WHO SARA Guidelines and National Guidelines, and Data Availability Annex 5.1. General service readiness tracer indicators National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) Basic  Power  Adequate  Is the electricity Infrastructure lighting and always available electric supply; or is it sometimes standby interrupted? generator or (battery-operated rechargeable emergency light)  Improved water  Adequate clean  Does the source inside OR water supply laboratory have within the ground running water? of the facility  Room with auditory  Private  There is visual and visual privacy consultation/exa privacy AND for patient mination auditory privacy consultations room/cubicle in the doctor's consultation room  Access to adequate  Toilet (minimum  Is there a toilet in sanitation facilities of 1 for 1 to 6 the RHU that is for clients beds and available for additional 1 toilet general client for every 6 use? additional beds  Communication  —  Does this facility equipment (phone have a or SW radio) functioning landline telephone?  Facility has access  Typewriter/  Does this facility to computer with computer have a email/Internet functioning access computer? Is Internet connection available in the facility?  Emergency  Available  Does this facility transportation transport vehicle have a functional for emergency ambulance or cases (facility- other vehicle for SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 113 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) owned or emergency contracted out) transportation for clients? Basic  Adult scale  Adult weight  Weighing scale Equipment Scare (adult)  Child scale  Infant weighing  Weighing scale scale; clinical (infant) weighing scale (for newborn)  Thermometer  Non-mercurial  Non-mercurial thermometer thermometer  Stethoscope  Stethoscope  Stethoscope (adult and pediatric)  BP apparatus  Non-mercurial  Non-mercurial BP apparatus; BP apparatus Sphygmomanom eter (non- mercurial) with adult cuff and neonatal cuff  Light source  Gooseneck lamp  Indicator (2) dropped as the SARA definition is a ‘spotlight source that can be used for patient examinations’ whereas baseline survey only tracked "enough light" Infection  Safe final disposal  —  Indicator Prevention of sharps Dropped - No relevant variable  Safe final disposal  —  How does this of infectious wastes facility dispose of contaminated waste (for example, used syringes)?  Safety vault  Appropriate storage  Puncture-proof  Are there of sharps waste receptacles for puncture-proof disposal of receptacles for SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 114 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) pointed/sharp disposal of objects pointed/sharp objects?  Appropriate storage  —  Indicator of infectious waste Dropped - No relevant variable  Disinfectant  —  Skin disinfectant (stock availability [BEmONC])  Skin disinfectant (supply shortage counts for the past 3 months [BEmONC])  Single-use standard  —  Disposable disposable or auto- needles and disposable syringes syringes (availability of supply today)  Disposable needles and syringes (supply shortage counts for the past 3 months)  Soap and running  70% isopropyl  Does the water or alcohol- alcohol laboratory have based hand rub running water?  Does the delivery room have running water?  70% isopropyl alcohol (availability of supply today)  70% isopropyl alcohol (supply shortage counts for the past 3 months)  Latex gloves  Disposable  Disposable gloves gloves (availability of supply today)  Disposable gloves (supply SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 115 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) shortage counts for the past 3 months)  Guidelines for  —  Indicator standard Dropped - No precautions relevant variable Diagnostics  Hb  CBC  Hemoglobinomet er kit/acid hematin (stock availability for today [lab supplies: Manual CBC])  —  —  Hemoglobinomet er kit/acid hematin (supply shortage counts for the past 3 months [lab supplies: Manual CBC])  Blood glucose  Glucometer with  Diagnostic test strips; blood services: Fasting glucose blood glucose monitoring (offered services) through blood glucose meters  —  —  FBS testing? (do you provide the following services?)  Malaria diagnostic  —  Diagnosis or capacity treatment of malaria (offered services)  Urine dipstick-  Urinalysis  Indicators protein Merged: Dip  Urine dipstick-  — stick for glucose qualitative urine analysis (stock availability for today [lab supplies: Automated CBC]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 116 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap)  HIV diagnostic  —  HIV counseling capacity and testing services (offered services)  Syphilis rapid test  —  Diagnosis or treatment of STIs, excluding HIV  Urine test for  —  Indicator pregnancy Dropped - No relevant variable Essential  Amlodipine tablet  Calcium channel  Calcium channel Medicines or alternative blockers blocker, for calcium channel (sustained release example, blocker formulation) amlodipine, nifedipine  Amoxicillin  Amoxicillin  Amoxicillin syrup/suspension or (stock dispersible tablet availability [antibacterial])  Amoxicillin, liquid/bottle/drop s (observed available preparation [antibacterial])  Amoxicillin, tablet/capsule (supply shortage counts for the past 3 months [antibacterial])  Amoxicillin tablet  Amoxicillin  Amoxicillin (stock availability [antibacterial])  Amoxicillin, tablet/capsule (observed available preparation [antibacterial])  Amoxicillin, tablet/capsule (supply shortage counts for the SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 117 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) past 3 months [antibacterial])  Ampicillin powder  Intravenous  Indicator for injection antibiotics Dropped - No (ampicillin, relevant variable gentamicin); syringe with needle  Aspirin  Aspirin  Indicator capsule/tablet Dropped - No relevant variable  Beclomethasone  Fluticasone  ICS, for example, inhaler inhaler beclomethasone or budesonide or fluticasone (stock availability [asthma])  Beclomethasone or budesonide or fluticasone, nebule (observed available preparation [asthma])  Beclomethasone or budesonide or fluticasone, sachet/powder (observed available preparation [asthma])  Beclomethasone or budesonide or fluticasone, others specify (observed available preparation [asthma])  Beclomethasone or budesonide or fluticasone, nebule (supply shortage counts for the past 3 months [asthma]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 118 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap)  Beta-blocker (for  Beta-blockers  Beta-blocker example, (stock bisoprolol, availability metoprolol, [hypertension]) carvedilol, atenolol)  Beta-blocker, tablet/capsule (observed available preparation [hypertension])  Beta-blocker (supply shortage counts for the past 3 months [hypertension])  Carbamazepine  —  Indicator tablet Dropped - No relevant variable  Ceftriaxone  —  Indicator injection Dropped - No relevant variable  Diazepam injection  —  Injectable diazepam (supply shortage counts for the past 3 months [BEmONC])  Enalapril tablet or  ACE inhibitors  ACE inhibitor alternative ACE (stock inhibitor, for availability example, lisinopril, [hypertension]) ramipril, perindopril  ACE inhibitor, tablet/capsule  ACE inhibitor (supply shortage counts for the past 3 months [hypertension])  Fluoxetine tablet  —  Indicator Dropped - No relevant variable  Gentamicin  Intravenous  Indicator injection antibiotics Dropped - No (ampicillin, relevant variable SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 119 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) gentamicin); syringe with needle  Glibenclamide  Glibenclamide  Sulfonylureas, tablet for example, glibenclamide, gliclazide (observed available preparation [hypertension])  Sulfonylureas, for example, glibenclamide, gliclazide (supply shortage counts for the past 3 months [diabetes])  Haloperidol tablet  —  Indicator Dropped - No relevant variable  Insulin regular  Insulin now  Indicator injection being distributed Dropped - No – check most relevant variable recent administrative orders (AOs)  Magnesium sulfate  Magnesium  Magnesium injectable sulfate vials; sulfate (stock syringe with availability needle; [BEmONC]) Magnesium sulfate ampoule  Magnesium sulfate, ampoule/vial (observed available preparation [BEmONC])  Magnesium sulfate, injectable/syringe (observed available SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 120 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) preparation [BEmONC])  Magnesium sulfate (supply shortage counts for the past 3 months [BEmONC])  Metformin tablet  Metformin  Metformin (stock availability [diabetes])  Metformin, tablet/capsule (observed available preparation [diabetes])  Metformin (supply shortage counts for the past 3 months [diabetes])  Omeprazole tablet  —  Indicator or alternative such Dropped - No as pantoprazole, relevant variable rabeprazole  ORS  ORS  ORS (stock availability [gastroenteritis])  ORS, sachet/powder (observed available preparation [gastroenteritis])  ORS (supply shortage counts for the past 3 months [gastroenteritis])  Oxytocin injection  Uterotonics:  Oxytocin (stock oxytocin, availability ergotamine, [BEmONC]) oxytocin- ergotamine, methylergotamin e, prostaglandin SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 121 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) tabs (misoprostol); oxytocin 10 units per ampoule or oxytocin in pre- filled, single- dose, non- reusable injection  Oxytocin, injectable/syringe (observed available preparation [BEmONC])  Oxytocin (supply shortage counts for the past 3 months [BEmONC])  Salbutamol inhaler  Short acting  Beta2-agonist, beta2-agonists for example, (inhalation salbutamol (sock solution or availability metered dose [asthma]) inhaler)  Beta2-agonist, for example, salbutamol (supply shortage counts for the past 3 months [asthma])  Simvastatin tablet  Simvastatin  Indicator or other statin, for Dropped - No example, relevant variable atorvastatin, pravastatin, fluvastatin  Thiazide (for  Thiazide  Diuretic, for example, diuretics example, hydrochlorothiazide hydrochlorothiazi ) de  Diuretic, for example, hydrochlorothiazi de (supply shortage counts SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 122 National Guidelines (PhilPEN, MNCHN, Tracer Indicators Used for WHO SARA Guidelines Annex C of DOH AO Indicator Assessment No. 2012-0012, PCB1, or Tsekap) for the past 3 months [hypertension])  Zinc sulfate tablets,  Zinc supplements  Zinc supplements dispersible tablets (stock or syrup availability [gastroenteritis])  Zinc supplements, tablet/capsule (observed available preparation [gastroenteritis])  Zinc supplements, liquid/bottle/drop s (observed available preparation [gastroenteritis])  Zinc supplements (supply shortage counts for the past 3 months (gastroenteritis]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 123 Annex 5.2. ANC tracer indicators National Guidelines: Tracer MNCHN Strategy Manual Indicators Used for WHO SARA Guidelines Indicator or Operations (2011) or Assessment BHFS Annex C Staffing and  ANC guidelines  MNCHN MOP — Training  ANC checklists and/or  IEC materials for Unang job aids Yakap/END and breastfeeding  Staff trained in ANC  Training Equipment  BP apparatus  Non-mercurial BP  Non-mercurial BP apparatus; apparatus Sphygmomanometer (non- mercurial) with adult cuff  Stethoscope and neonatal cuff  Stethoscope  Stethoscope Diagnostics  Hemoglobin  ‘CBC testing’ with ‘well-  Hemoglobinometer equipped lab that can run kit/acid hematin these tests’ (stock availability for  ‘Urinalysis’ with ‘well- today)  Urine dipstick-protein equipped lab that can run  Dipstick for these tests’ qualitative urine analysis (stock availability for today) Medicines and  Iron folate acid tablets  TT ampoules  TT vaccine (stock Commodities availability)  TT vaccination  Iron/folate 60 mg  Iron and folic acid elemental iron/400 ug folic combination tablets acid tablet OR (iron tablets AND folic acid tablets); (stock availability for today) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 124 Annex 5.3. BEmONC tracer indicators National Guidelines: Tracer Maternity & Newborn Indicators Used for WHO SARA Guidelines Indicator Care Package (Annex) Assessment or BHFS (Annex) Staff and  Guidelines for  —  Indicator Dropped - No Training essential childbirth relevant variable care  Checklists and/or job  —  Indicator Dropped - No aids for essential relevant variable childbirth care  Guidelines for  —  Indicator Dropped - No essential newborn relevant variable care  Staff trained in  Required: Skilled  Indicator Dropped - No essential childbirth staff (MW or MD) on relevant variable care call  Staff trained in ANC  Required: Skilled  Attended BEmONC staff on call training?  Attended BEmONC training? (nurse)  Attended BEmONC training? (midwife) Equipment  Emergency transport  Emergency transport  A vehicle stationed in system the RHU  Availability of fuel for an emergency  Sterilization  Autoclave/sterilizer  Sterilizer or its equipment equivalent (number of available instruments/equipment)  Examination light  Gooseneck lamp (2)  Indicator Dropped - No relevant variable  Delivery pack  NSD set (minimum  Indicator Dropped - No of 2 sets) consisting relevant variable of: 2 hemostatic forceps, 1 needle holder, 1 pick-up forcep, 1 tissue forcep, 1 surgical scissor; delivery set  Suction apparatus  Suction  Indicator Dropped - No (mucus extractor) apparatus/rubber bulb relevant variable suction (minimum of 2)  Manual vacuum  —  Indicator Dropped - No extractor relevant variable  Vacuum aspirator or  —  Indicator Dropped - No D&C kit (with relevant variable speculum)  Neonatal bag and  Neonatal ambu bag  Indicator Dropped - No mask and mask, relevant variable laryngoscope SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 125 National Guidelines: Tracer Maternity & Newborn Indicators Used for WHO SARA Guidelines Indicator Care Package (Annex) Assessment or BHFS (Annex)  Delivery bed  Delivery table with  Indicator Dropped - No stirrups and provision relevant variable for semi-upright position of the mother  Partograph  Partograph  Indicator Dropped - No relevant variable  Gloves  Sterile gloves  Disposable gloves (availability of supply today)  Infant weighting scale  2 weighing scales  Weighing scale (infant) (adult and infant); Clinical weighing scale (for newborn)  BP apparatus  Sphygmomanometer  Non-mercurial BP (non-mercurial) with apparatus (number of adult cuff and available neonatal cuff instruments/equipment)  Soap and running  Adequate clean water  Does the delivery room water OR alcohol- supply have running water? based hand rub  70% isopropyl alcohol (availability of supply today) Drugs and  Antibiotic eye  Erythromycin or  Antibiotic eye ointment Commodities ointment for newborn oxytetracycline for newborn (stock ophthalmic ointment availability [BEmONC])  Injectable uterotonic  Uterotonics:  Oxytocin (stock oxytocin, ergotamine, availability [BEmONC]) oxytocin-ergotamine, methylergotamine, prostaglandin tablets (misoprostol); oxytocin 10 units per ampoule or oxytocin in pre-filled, single- dose, non-reusable injection  Injectable antibiotic  Intravenous  Injectable antibiotics antibiotics (stock availability (ampicillin, [BEmONC]) gentamicin); syringe with needle  Magnesium sulfate  Magnesium sulfate  Magnesium sulfate (injectable) vials; syringe with (stock availability needle; magnesium [BEmONC]) sulfate ampoule  Skin disinfectant  70% isopropyl  Skin disinfectant (stock alcohol; povidone availability [BEmONC]) iodine solution SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 126 National Guidelines: Tracer Maternity & Newborn Indicators Used for WHO SARA Guidelines Indicator Care Package (Annex) Assessment or BHFS (Annex)  Intravenous solution  IV tubing; IV fluids:  Indicator Dropped - No with infusion set D5 LR or Plain LR 1 relevant variable; IV not L bottle/Plain NSS 1 allowed at RHUs L per bottle Annex 5.4. FP tracer indicators National Guidelines: WHO SARA Maternity & Newborn Indicators Used for Tracer Indicator Guidelines Care Package (Annex) Assessment or BHFS (Annex) Staff and Guidelines  Guidelines on FP  —  Indicator Dropped - No relevant variable  FP checklists  IEC materials on  Indicator Dropped and/or job aids FP - No relevant variable  Staff trained in FP  —  Indicator Dropped - No relevant variable Equipment  BP apparatus  Non-mercurial BP  Non-mercurial BP apparatus; apparatus (number sphygmomanomete of available r (non-mercurial) instruments/equip with adult cuff and ment) neonatal cuff Medicines and  Combined estrogen  Adequate supply of  Oral contraceptives Commodities progesterone oral pills (stock availability contraceptive pills [FP])  Progestin-only  —  Indicator Dropped contraceptive pills - No relevant variable  Injectable  Adequate supply of  DMPA (stock contraceptives: DMPA availability [FP]) Either combined estrogen progesterone injectable contraceptives or progestin-only injectable contraceptives  Condoms  Adequate supply of  Indicator Dropped condoms - No relevant variable Auxiliary  Combined estrogen  —  DMPA (stock Commodities progesterone availability [FP]) injectable contraceptives SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 127 National Guidelines: WHO SARA Maternity & Newborn Indicators Used for Tracer Indicator Guidelines Care Package (Annex) Assessment or BHFS (Annex)  Progestin-only  —  Indicator Dropped injectable - No relevant contraceptives variable  Female condoms  —  Indicator Dropped - No relevant variable  Implants: For  Dropped from  Indicator Dropped example, national guidelines - No relevant levonorgestrel or variable etonogestrel implant  Emergency  —  Indicator Dropped contraceptive: For - No relevant example, variable levonorgestrel tablet or ulipristal acetate tablet or mifepristone tablet 10–25 mg  IUD  Adequate supply of  IUD (stock NFP IUD availability [FP]) Annex 5.5. Immunization tracer indicators WHO SARA National Guidelines: Indicators Used for Tracer Indicator Guidelines MCHN Annex H/I Assessment Staff and Guidelines  Guidelines for  Immunization  Indicator Dropped child immunization schedule - No relevant variable  Staff trained in  —  Indicator Dropped child immunization - No relevant variable Equipment  Cold box/vaccine  —  Indicator Dropped carrier with ice - No relevant packs variable  Refrigerator:  Vaccine  Cold storage solely Functioning refrigerator for medicines and refrigerator with vaccines sufficient storage capacity to accommodate all needed vaccines  Sharps  —  Are there puncture- container/safety proof receptacles box: A puncture- for disposal of resistant, rigid, pointed/sharp leak-resistant objects? Safety container designed vault (disposal of to hold used sharps non-contaminated safely during waste) collection, disposal, and SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 128 WHO SARA National Guidelines: Indicators Used for Tracer Indicator Guidelines MCHN Annex H/I Assessment destruction; sharps containers should be made of plastic, metal, or cardboard and have a lid that can be closed; sharps containers should be fitted with a sharps aperture, capable of receiving syringes and needle assemblies of all standard sizes, together with other sharps; boxes must be clearly marked with the international biohazard warning not less than 50 mm diameter, printed in black or red on each of the front and back faces of the box  Auto-disable  3 cc and tuberculin  Indicator Dropped syringes syringes - No relevant variable  Temperature  —  Indicator Dropped monitoring device - No relevant in refrigerator: variable Thermometer or recorder/logger  Adequate  —  Indicator Dropped refrigerator - No relevant temperature: variable Temperature is monitored twice daily and has not been out of the range 2°C to 8°C, including in the last 30 days/record verification  Immunization  Immunization  Indicator Dropped cards cards - No relevant variable  Immunization tally  Patient registry?  Indicator Dropped sheets - No relevant variable Medicines and  Measles vaccine  ‘Vaccines’  Measles (stock Commodities availability [vaccine available today]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 129 WHO SARA National Guidelines: Indicators Used for Tracer Indicator Guidelines MCHN Annex H/I Assessment  DPT-Hib-HepB  ‘Vaccines’  DPT-Hib-HepB vaccine (country- (stock availability specific vaccine [vaccine available combination) today])  OPV  ‘Vaccines’  OPV (stock availability [vaccine available today])  BCG vaccine  ‘Vaccines’  BCG (stock availability [vaccine available today])  Pneumococcal  ‘Vaccines’  Pneumococcal vaccine vaccine (stock availability [vaccine available today])  Rotavirus vaccine  —  Rotavirus (stock availability [vaccine available today])  IPV: If part of the  ‘Vaccines’  Indicator Dropped national schedule - No relevant variable  HPV: If part of the  —  Indicator Dropped national schedule - No relevant variable  DPT  ‘Vaccines’  DPT (stock availability [vaccine available today])  Hepatitis B  ‘Vaccines’  Hepatitis B (stock availability [vaccine available today])  TT  “Vaccines”  TT (stock availability [vaccine available today])  Measles vaccine  —  Measles (supply shortage counts for the past 3 months [vaccine available today])  DPT-Hib-HepB  —  DPT-Hib-HepB vaccine: Country- (supply shortage specific vaccine counts for the past combination 3 months [vaccine available today])  OPV  —  OPV (supply shortage counts for the past 3 months [vaccine available today]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 130 WHO SARA National Guidelines: Indicators Used for Tracer Indicator Guidelines MCHN Annex H/I Assessment  BCG vaccine  —  BCG (supply shortage counts for the past 3 months [vaccine available today])  Pneumococcal  —  Pneumococcal vaccine: If part of vaccine (supply the national shortage counts for schedule the past 3 months [vaccine available today])  Rotavirus vaccine:  —  Rotavirus (supply If part of the shortage counts for national schedule the past 3 months [vaccine available today])  IPV  —  Indicator Dropped - No relevant variable  HPV  —  Indicator Dropped - No relevant variable  DPT  —  DPT (supply shortage counts for the past 3 months [vaccine available today])  Hepatitis B  —  Hepatitis B (supply shortage counts for the past 3 months [vaccine available today])  TT  —  TT (supply shortage counts for the past 3 months [vaccine available today]) Cold Chain  Cold chain  —  Indicator Dropped minimum - No relevant requirements: The variable minimum adequate cold chain requirements are available (there is a functional refrigerator, there is a temperature monitoring device, and the temperature has been maintained between 2°C and 8°C checked for the last 30 days) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 131 WHO SARA National Guidelines: Indicators Used for Tracer Indicator Guidelines MCHN Annex H/I Assessment  Energy source and  —  Indicator Dropped power supply for - No relevant vaccine variable refrigerator: Energy provided to the vaccine refrigerator through any source that supplies power to the refrigerator 24 hours a day and for 7 days in the week  Types of power  —  Indicator Dropped used for cold chain - No relevant refrigeration: Grid variable or generator solar gas kerosene mixed other Annex 5.6. Child health tracer indicators National Guidelines: Tracer Indicators Used for WHO SARA Guidelines MNCH MOP or Indicator Assessment Tsekap Staff and  Guidelines for IMCI:  IMCI manual  Indicator Dropped Guidelines Country adapts to which - No relevant guidelines are variable required/accepted  Guidelines for growth  —  Indicator Dropped monitoring: Country adapts - No relevant to which guidelines are variable required/accepted  Staff trained in IMCI:  —  Indicator Dropped Country adapts to which - No relevant guidelines are variable required/accepted  Staff trained in growth  —  Indicator Dropped monitoring: At least one staff - No relevant member providing the service variable trained in some aspect of growth monitoring in the last two years Equipment  Child and infant scale:  —  Weighing scale Weight gradations at (infant) minimum of 250 gm and 100 gm  Length/height measuring  —  Indicator Dropped equipment: Wooden boards - No relevant or metal beams with a variable mounted rule that permits measurement of crown-to- heel length (infants under 2 SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 132 National Guidelines: Tracer Indicators Used for WHO SARA Guidelines MNCH MOP or Indicator Assessment Tsekap years, lying down) or height (older children, standing up) in centimeters; gradations at 1 mm or 5 mm  Thermometer  —  Non-mercurial thermometer  Stethoscope  —  Stethoscope (number of available instruments/equipm ent)  Growth chart  —  Indicator Dropped - No relevant variable Diagnostics  Hb: This may include  CBC  Hemoglobinometer colorimeter, kit/acid hematin hemoglobinometer, hemocue, (stock availability or any other country-specific for today [lab method. supplies: Manual CBC])  Test parasite in stool (general  Stool Exam?  Microscope microscopy): Microscope, (number of slides, covers functional equipment)  —  —  Glass slides (stock availability for today [lab supplies: Automated CBC])  —  —  Fecalysis  Malaria diagnostic capacity:   Diagnosis or Malaria rapid test or smear treatment of (microscope, slides, and malaria (offered stain) services) Medicines  ORS packet: Any child  ORS  ORS (stock and dosage or formulation availability Commodities [gastroenteritis])  Amoxicillin (dispersible  Oral antibiotics for  Amoxicillin (stock tablet 250 mg or 500 mg OR child; amoxicillin availability syrup/suspension): Any child (not specified for [antibacterial]) dosage or formulation child)  Co-trimoxazole  Oral antibiotics for  Co-trimoxazole syrup/suspension: Any child child; co- (sock availability dosage or formulation trimoxazole, not [antibacterial]) specified for child  Paracetamol  Oral antibiotics for  Paracetamol (stock syrup/suspension: Any child child; paracetamol availability dosage or formulation not specified for [others]) child SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 133 National Guidelines: Tracer Indicators Used for WHO SARA Guidelines MNCH MOP or Indicator Assessment Tsekap  Vitamin A capsules: Any  Vitamin A capsules  Indicator Dropped child dosage or formulation - No relevant variable  Me-/albendazole  Mebendazole  Deworming drugs capsule/tablet: Any child (albendazole of dosage or formulation mebendazole) (stock availability [others])  Zinc sulfate tablets,  Zinc supplements  Zinc supplements dispersible tablets or syrup: (stock availability Any child dosage or [gastroenteritis]) formulation Annex 5.7. DM tracer indicators National Guidelines: Tracer WHO SARA PhilPEN, PCB1, or Variable Description Indicator Guidelines Tsekap Service  Diabetes diagnosis  —  Diagnosis or Availability and/or management management of diabetes (offered services) Staff and  Guidelines for  NCD Risk Assessment  Indicator Dropped - Guidelines diabetes diagnosis and Screening Form No relevant variable and treatment  Staff trained in  —  Have you received any diabetes diagnosis training on PhilPEN and treatment: At guidelines? least one staff providing the service trained in diabetes diagnosis and treatment in the last two years (can be an NCD training including a section on diabetes) Equipment  BP apparatus  BP measurement  Non-mercurial BP device, non-mercurial apparatus (number of available instruments/equipment )  Adult scale  Weighing scale (adult)  Weighing scale (adult)  Measuring tape  Measuring tape, non-  Indicator Dropped - (height extensible No relevant variable board/stadiometer) Diagnostics  Blood glucose  Glucometer with test  Diagnostic services: strips; blood glucose Fasting blood glucose monitoring through (offered services) blood glucose meters SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 134 National Guidelines: Tracer WHO SARA PhilPEN, PCB1, or Variable Description Indicator Guidelines Tsekap  Urine dipstick-  Cholesterol meter with  Dipstick for qualitative protein test strips; Urinalysis urine analysis (stock availability for today [lab supplies: Automated CBC])  Urine dipstick-  Test strips for checking  Dipstick for qualitative ketones urine ketones and urine analysis (stock proteins/test tube or availability for today glass container for the [lab supplies: urine; urinalysis Automated CBC]) Medicines  Metformin  Metformin  Metformin (stock and capsule/tablet availability [diabetes]) Commodities  Glibenclamide  Glibenclamide  Sulfonylureas, for capsule/tablet example, glibenclamide, gliclazide (stock availability [diabetes])  Insulin regular  Insulin now being  Indicator Dropped - injectable distributed - check No relevant variable most recent AOs  Glucose 50% injectable  —  Indicator Dropped - No relevant variable  Gliclazide tablet or  Gliclazide  Sulfonylureas, for glipizide tablet example, glibenclamide, gliclazide (stock availability [diabetes]) Annex 5.8. CVD tracer indicators National Guidelines: Tracer Indicator WHO SARA Guidelines PhilPEN, PCB1, or Variable Description Tsekap Staff and  Guidelines for  Country adapts to  Indicator Dropped - Guidelines diagnosis and which guidelines are No relevant variable treatment of chronic required/accepted cardiovascular (can be NCD conditions: Country guidelines which adapts to which contain information guidelines are on CVD) required/accepted (can be NCD guidelines which contain information on CVD) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 135 National Guidelines: Tracer Indicator WHO SARA Guidelines PhilPEN, PCB1, or Variable Description Tsekap  Staff trained in  At least one staff  Have you received diagnosis and providing the service any training on management of trained in diagnosis PhilPEN guidelines? chronic and management of cardiovascular chronic conditions: At least cardiovascular one staff providing conditions in the last the service trained in two years (can be an diagnosis and NCD training management of including a section chronic on CVD) cardiovascular conditions in the last two years (can be an NCD training including a section on CVD) Equipment  Stethoscope  Stethoscope  Stethoscope (number of available instruments/equipme nt)  BP apparatus: Digital  BP measurement  Non-mercurial BP BP machine or device, non- apparatus (number of manual mercurial available sphygmomanometer instruments/equipme with stethoscope nt)  Adult scale  Weighing scale  Weighing scale (adult) (adult) Medicines and  ACE inhibitor (for  ACE inhibitors;  ACE inhibitor (stock Commodities example, enalapril, enalapril availability lisinopril, ramipril, [hypertension]) perindopril)  Hydrochlorothiazide  Thiazide diuretics;  Diuretic, for tablet or other hydrochlorothiazide example, thiazide diuretic hydrochlorothiazide tablet (stock availability [hypertension])  Beta-blocker (for  Beta-blockers;  Beta-blocker (stock example, bisoprolol, Metoprolol availability metoprolol, [hypertension]) carvedilol, atenolol)  Calcium channel  Calcium channel  Calcium channel blockers (for blockers (sustained blocker (stock example, release availability amlodipine) formulations); [hypertension]) amlodipine  Aspirin  Aspirin  Indicator Dropped - capsule/tablets No relevant variable  Metformin  Metformin  Metformin (stock capsule/tablets availability [diabetes]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 136 Annex 5.9. CRD tracer indicators National Tracer Guidelines: Indicators Used for WHO SARA Guidelines Indicator Tsekap or Annex Assessment C BHFS Service  CRD diagnosis and/or  —  Diagnosis of CRD Availability management (offered services) Staff and  Guidelines for diagnosis and  —  Indicator Dropped - No Guidelines management of CRD: relevant variable Country adapts to which guidelines are required/accepted (can be NCD guidelines which contain information on CRD)  Staff trained in diagnosis  —  Indicator Dropped - No and management of CRD: relevant variable At least one staff providing the service trained in diagnosis and management of CRD in the last two years (can be an NCD training including a section on CRD) Equipment  Stethoscope  Stethoscope  Stethoscope (number of available instruments/equipment)  Peak flowmeter  Peak  Diagnostic service: Peak expiratory expiratory flowmeter flowmeter (offered services) testing (Diagnostic Service 11, PhilHealth Circular 002- 2015)  Spacers for inhalers  —  Indicator Dropped - No relevant variable  Oxygen: Oxygen cylinders  —  Indicator Dropped - No OR concentrators OR relevant variable central oxygen supply with functioning flowmeter for oxygen therapy (with humidification) AND oxygen delivery apparatus (key connecting tubes and mask/nasal prongs), available at any time during the past 3 months Drugs  Salbutamol inhaler  Salbutamol  Beta2-agonist, for inhaler example, salbutamol (stock availability [asthma]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 137 National Tracer Guidelines: Indicators Used for WHO SARA Guidelines Indicator Tsekap or Annex Assessment C BHFS  Beclomethasone inhaler  Fluticasone  Beclomethasone or inhaler budesonide or fluticasone (stock availability [asthma])  Beta-blocker (for example,  Short acting  Beta-blocker (stock bisoprolol, metoprolol, beta2-agonists availability carvedilol, atenolol) [hypertension])  Prednisolone capsule/tablets  —  Indicator Dropped - No relevant variable  Hydrocortisone injection  —  Indicator Dropped - No relevant variable  Epinephrine injectable  —  Indicator Dropped - No relevant variable Annex 5.10. CCS tracer indicators Tracer National Guidelines: Indicators Used for WHO SARA Guidelines Indicator MCHN Annex H/I Assessment Service  Cervical cancer  Cervical cancer  VIA (offered services) Availability diagnosis screening using VIA  Diagnostic test: CCS or pap smear (additional interventions: postpartum) Staff and  Guidelines for  —  Indicator Dropped - Guidelines cervical cancer No relevant variable prevention and control  Staff trained in  Staff competencies:  Have you attended a cervical cancer Pap smear and VIA training on VIA? prevention and control wash technique Equipment  Speculum  Speculum  Vaginal speculum (big) (number of available instruments/equipment) Diagnostics  Acetic acid  Acetic acid: 3% to 5%  3% to 5% acetic acid (availability of supply today) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 138 Annex 5.11. TB tracer indicators Tracer National Guidelines: Indicators Used for WHO SARA Guidelines Indicator MCHN Annex H/I Assessment Staff and  Guidelines for  Circ 14 s. 2014:  Indicator Dropped - Guidelines diagnosis and Revised Guidelines No relevant variable treatment of TB for the PhilHealth Outpatient Anti- Tuberculosis DOTS Benefit Package  Guidelines for  —  Indicator Dropped - management of HIV No relevant variable and TB co-infection  Guidelines related to  —  Indicator Dropped - MDR-TB treatment No relevant variable (or identification of need for referral)  Guidelines for TB  —  Indicator Dropped - infection control No relevant variable  Staff trained in TB  Duly licensed by PRC  Indicator Dropped - diagnosis and certified by PhilCAT No relevant variable treatment or trained by NTP in DOTS  Staff trained in  —  Indicator Dropped - management of HIV No relevant variable and TB co-infection  Staff trained in client  —  Indicator Dropped - MDR-TB treatment or No relevant variable identification of need for referral  Staff trained in TB  —  Indicator Dropped - infection control No relevant variable Diagnostics  TB microscopy  Referral to a  Indicator Dropped - microscopy center that No relevant variable has acquired quality assurance certification from the NTP  HIV diagnostic  —  Indicator Dropped - capacity No relevant variable  System for diagnosis  —  Indicator Dropped - of HIV among TB No relevant variable clients  Sputum microscopy  Sputum smear  Diagnostic service: Sputum testing for TB (offered services) Medicines  First-line TB  Isoniazid+Rifampicin  Isoniazid+Rifampicin and medications +Pyrazinamide+Etha +Pyrazinamide+Etha Commodities mbutol mbutol fixed dose tablets (stock availability [TB drugs]) SUPPLY-SIDE READINESS OF PRIMARY HEALTH CARE IN THE PHILIPPINES 139