PREPARING FOR THE TRANSITION: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) TOWARD S A MO RE EQ U I TA B L E A ND B E T T E R - P R E PA RE D P U B LI C P RI M A RY HE A LT H C A R E SYS T E M © 2019 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. ii Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Contributors This report was prepared by the World Bank’s Philippines Health, Nutrition, and Population team led by Tomo Morimoto and consisting of Chantelle Boudreaux, Vida Gomez, and Shanna Rogan. The field data collection was carried out by the Research Institute for Mindanao Culture under the leadership of Maria Teresa Sharon Linog. The authors would like to thank the following World Bank staff for their contributions to the report: Robert Oelrichs, Netsanet Workie, Ma. Melissa Miranda-Poot, Ica Fernandez, and Gabriel Demombynes for their valuable comments and insights as part of the Health, Nutrition, and Population team; Mickey Chopra, Ajay Tandon, and Matthew Stephens as peer reviewers; and Regina Calzado and Ed Alvinez for editing and overall administrative support for preparation and production of the report. The team is equally grateful to Toomas Palu and Enis Baris for the overall technical guidance as Practice Managers of the Health, Nutrition, and Population Global Practice. The team benefited from valuable feedback on the report from the Regional Government of the Autonomous Region in Muslim Mindanao (ARMM), in particular the team of Department of Health-ARMM (DOH-ARMM) led by Secretary Kadil Sinolinding Jr. The team has also benefited from inputs received from the Health Financing Systems Assessment Technical Working Group consisting of the DOH-ARMM, Department of Interior Local Government-ARMM, Regional Planning and Development Office, Regional Budget and Management Office and Technical Management Service, health authorities from the five provinces of ARMM, and local chief executives and their staff through a series of consultative workshops and meetings. The team is also grateful for the advice and comments received from the Bangsamoro authorities, including Moro Islamic Liberation Front Coordination Team for the Transition and Bangsamoro Development Agency. This report was prepared as part of the advisory services and analytics provided by the World Bank to the Government of the Philippines. The team acknowledges the generous contribution by the State and Peacebuilding Fund (SPF). The SPF is a global fund to finance critical development operations and analysis in situations of fragility, conflict, and violence. The SPF is kindly supported by: Australia, Denmark, Germany, The Netherlands, Norway, Sweden, The United Kingdom, as well as IBRD. The report is also supported by the Government of Australia through the regional Multi-donor Trust Fund for Integrated Donor Financing for Health Programs. iii iv Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table of Contents List of Figures vii List of Tables ix List of Boxes x Abbreviations and Acronyms xi A note on the geographic focus of this report 1 Executive Summary 2 Section 1. Background 7 BARMM: Political, Geographic, and Socioeconomic Challenges 8 BARMM Health Sector Organization at the Time of Data Collection 12 Health Service Utilization in BARMM 13 Financing Primary Care in BARMM at the Time of Data Collection 13 Establishing Health Care Quality Controls in BARMM 15 Section 2. Analytical Approach 17 Data Overview 17 Quality Control and Supervision 18 The SARA Framework 18 Section 3. General Service Availability 20 Facility Density 20 Personnel 22 Section 4. General Service Readiness 25 Overall Findings 25 Basic Amenities 26 Basic Equipment 31 Standard Precautions for Infection Prevention 33 Diagnostic Capacity 35 Essential Medicines 36 Performance by PhilHealth Accreditation Status 39 v Table of Contents Section 5. Specific Service Readiness Overview 41 Maternal and Child Health 41 Family Planning 42 Antenatal Care 46 Basic Obstetric and Neonatal Care 50 Immunization 57 Child Health 63 Noncommunicable Disease 69 Cardiovascular Disease 70 Diabetes 73 Chronic Respiratory Disease 77 Cervical Cancer Screening 82 Communicable Disease 85 Tuberculosis 85 Malaria 89 Section 6. Trends in Specific Service Readiness 93 Section 7. BARMM in the National Context 97 Section 8. Conclusions, Limitations and Areas for Further Work 100 Conclusions 100 Limitations and Areas for Further Work 102 Annex 1: List of facilities visited 104 Annex 2: Additional Details on Service Readiness – by Domain 105 Annex 3: Provincial Overview 113 Lanao del Sur 113 Maguindanao 115 Basilan and Lamitan City 118 Sulu 120 Tawi-Tawi 123 Annex 4: Patient Satisfaction 126 Summary 126 Overview of the survey instrument 126 Methods 127 Data Overview 127 Respondent profile 127 Service Details 128 Results 128 Bibliography 133 vi Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) List of Figures Figure 1. Map of BARMM 9 Figure 2. Poverty Incidence among Families over Time 11 Figure 3. Report Overview 19 Figure 4. The Location of RHUs across BARMM 21 Figure 5. RHU and BHS Density 21 Figure 6. Presence of MHO Physician at the Time of the Survey Visit 23 Figure 7. HRH by Source of Secondment 24 Figure 8. General Service Readiness, by Province 25 Figure 9. General Service Readiness: Basic Amenities 26 Figure 10. Availability of Electricity at RHUs 27 Figure 11. Source and Use of Primary Electricity 28 Figure 12. Improved Water Source Inside or Within the Ground of the Facility 29 Figure 13. Auditory and Visual Privacy at RHUs 30 Figure 14. General Service Readiness: Basic Equipment 32 Figure 15. General Service Readiness: Standard Precautions for Infection Prevention 33 Figure 16. General Service Readiness: Diagnostic Capacity 35 Figure 17. General Service Readiness: Essential Medicines 37 Figure 18. Modern Contraceptive Preferences - BARMM and National Preferences 43 Figure 19. Family Planning Service Readiness 44 Figure 20. FP: Staff and Guidelines 45 Figure 21. FP: Auxiliary Medicines and Commodities 45 Figure 22. ANC Service Readiness 47 Figure 23. ANC: Medicines and Commodities 48 Figure 24. ANC: Medicines and Commodities - Availability of Tetanus Toxoid Vaccine 49 Figure 25. Facility-Based Delivery 2013–2016 51 Figure 26. BONC Service Readiness 52 Figure 27. BONC: Staff and Guidelines 53 Figure 28. BONC: Equipment 53 Figure 29. BONC: Medicines and Commodities 54 Figure 30. Stock-outs of BONC Medicines and Commodities 55 Figure 31. BONC: Auxiliary Medicines and Commodities 56 Figure 32. Children Ages 12–23 Months with All Basic Vaccines - 1998–2018 58 Figure 33. Immunization Service Readiness 59 Figure 34. Immunization: Equipment 60 Figure 35. Stock-outs of NIP Vaccines 61 Figure 36. Stock-outs of Non-NIP Vaccines 62 Figure 37. Malnutrition in BARMM - Stunting, Underweight, and Wasting - 2013–2015 64 vii List of Figures Figure 38. Child Health Service Readiness 65 Figure 39. Child Health: Equipment 66 Figure 40. Child Health: Diagnostics 67 Figure 41. Child Health: Medicines and Commodities 67 Figure 42. Limited Availability of Child Health Medicines in Tawi-Tawi 68 Figure 43. CVD Service Readiness 71 Figure 44. CVD: Staff and Guidelines 71 Figure 45. CVD: Equipment 72 Figure 46. CVD: Medicines and Commodities 72 Figure 47. Diabetes Service Readiness 74 Figure 48. Diabetes: Staff and Guidelines 75 Figure 49. Diabetes: Equipment 75 Figure 50. Diabetes: Diagnostics 76 Figure 51. Diabetes: Medicines and Commodities 76 Figure 52. CRD Service Readiness 78 Figure 53. CRD: Staff and Guidelines 79 Figure 54. CRD: Equipment 79 Figure 55. CRD: Medicines and Commodities 80 Figure 56. Stock-out of CRD Medicines and Commodities 81 Figure 57. Cervical Cancer Screening Service Readiness 83 Figure 58. Cervical Cancer Screening: Staff and Guidelines, Equipment, and Medicines and Commodities 84 Figure 59. TB Service Readiness 86 Figure 60. TB: Staff and Guidelines 87 Figure 61. TB: Diagnostics 87 Figure 62. TB: Medicines and Commodities 88 Figure 63. Malaria Service Readiness 90 Figure 64. Malaria: Staff and Guidelines 90 Figure 65. Malaria: Diagnostics 91 Figure 66. Malaria: Medicines and Commodities 91 Figure 67. Facilities visited in Lanao del Sur 113 Figure 68. Proportion of the 172 total tracer indicators found at RHUs in Lanao del Sur 114 Figure 69. Facilities visited in Maguindanao 115 Figure 70. Proportion of the 172 total tracer indicators found at RHUs in Maguindanao 116 Figure 71. Facilities visited in Basilan and Lamitan City 118 Figure 72. Proportion of the 172 total tracer indicators found at RHUs in Basilan, including Lamitan City 119 Figure 73. Facilities visited in Sulu 120 Figure 74. Proportion of the 172 total tracer indicators found at RHUs in Sulu 121 Figure 75. Facilities visited in Tawi-Tawi 123 Figure 76. Proportion of the 172 total tracer indicators found at RHUs in Tawi-Tawi 124 Figure 77. Patient experience using the 7 satisfaction domains of the PSQ-18 128 viii Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) List of Tables Table 1. Descriptive Overview: The Provinces of ARMM 10 Table 2. Share of IRA in Total Operating Income, 2013–2017 (average) (percent) 12 Table 3. Health Infrastructure in ARMM and Nationwide, 2016 13 Table 4. Health Expenditure as a Percentage of Total Operating Expenditure of Municipalities and Cities, 2013–2017 (average) 15 Table 5. PhilHealth Accreditation Status, 2017 16 Table 6. Data Collection, by Province 17 Table 7. Health Facility Density 20 Table 8. Health Workforce Density 22 Table 9. Proportion of RHUs Meeting PhilHealth Accreditation Requirements 23 Table 10. Availability of Basic Amenities 31 Table 11. Availability of Basic Equipment 32 Table 12. Standard Precautions for Infection Prevention 34 Table 13. Diagnostic Capacity 36 Table 14. Availability of Essential Medicines 38 Table 15. General Service Readiness Scores by PCB Accreditation 40 Table 16. Neonatal, Infant, and Under-5 Mortality Rates, per 1,000 Live Births 41 Table 17. FP Service Readiness 46 Table 18. ANC Utilization Rates - Data Provided by DOH-ARMM 46 Table 19. ANC Service Readiness 50 Table 20. BONC Service Readiness 57 Table 21. Immunization Service Readiness 63 Table 22. Child Health Service Readiness 69 Table 23. CVD Service Readiness 73 Table 24. Diabetes Service Readiness 77 Table 25. CRD Service Readiness 82 Table 26. Cervical Cancer Screening Service Readiness 84 Table 27. TB Service Readiness 89 Table 28. Malaria Service Readiness 92 Table 29. Specific Service Readiness: Overall Performance 93 Table 30. Specific Service Readiness: Guidelines and Staffing 94 Table 31. Specific Service Readiness: Equipment 95 Table 32. Specific Service Readiness: Diagnostic Capacity 95 Table 33. Specific Service Readiness: Essential Medicines 96 Table 34. General Service Readiness: Comparison to the National Context - 2014 Data and a Condensed Set of Tracer Indicators 98 Table 35. Specific Service Readiness in the National Context - 2014 Data and a Condensed Set of Tracer Indicators 99 ix List of Tables Table 36. General Service Readiness: Overview 105 Table 37. Service Specific Staff and Training 105 Table 38. Service Specific Equipment 108 Table 39. Service Specific Diagnostics 110 Table 40. Service Specific Medicines and Commodities 110 Table 41. Top causes of morbidity and mortality in Lanao del Sur 113 Table 42. Availability of tracer indicators at the high and low performing RHUs, Lanao del Sur 115 Table 43. Top causes of morbidity and mortality in Maguindanao 116 Table 44. Availability of tracer indicators at the high and low performing RHUs, Maguindanao 117 Table 45. Top causes of morbidity and mortality in Basilan AND Lamitan City; Information provided by the DOH-ARMM 118 Table 46. Availability of tracer indicators at the high and low performing RHUs, Basilan and Lamitan City 120 Table 47. Top causes of morbidity and mortality in Sulu 121 Table 48. Availability of tracer indicators at the high and low performing RHUs, Sulu 122 Table 49. Top causes of morbidity and mortality in Tawi-Tawi 123 Table 50. Availability of tracer indicators at the high and low performing RHUs, Tawi-Tawi 125 Table 51. The PSQ-18 126 Table 52. General Satisfaction Score 129 Table 53. Satisfaction with Technical Quality 130 Table 54. Satisfaction with Interpersonal Manner 130 Table 55. Satisfaction with Communication 131 Table 56. Satisfaction with Financial Aspects 131 Table 57. Satisfaction with time spent with doctos 132 Table 58. Satisfaction with Access and Convenience 132 List of Boxes Box 1. Family Planning Service Readiness Indicators 43 Box 2. ANC Service Readiness Indicators 47 Box 3. BONC Service Readiness Indicators 51 Box 4. Immunization Service Readiness Indicators 58 Box 5. Child Health Service Readiness Indicators 65 Box 6. CVD Service Readiness Indicators 70 Box 7. Diabetes Service Readiness Indicators 74 Box 8. CRD Service Readiness Indicators 78 Box 9. Cervical Cancer Screening Service Readiness Indicators 82 Box 10. Tuberculosis Service Readiness Indicators 85 Box 11. Malaria Service Readiness Indicators 89 x Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Abbreviations and Acronyms A.O. Administrative Order ACE Angiotensin-converting-enzyme ANC Antenatal Care ARMM Autonomous Region in Muslim Mindanao BARMM Bangsamoro Autonomous Region in Muslim Mindanao BCG Bacillus Calmette–Guérin BHS Barangay Health Station BOL Organic Law for the BARMM or Bangsamoro Organic Law BONC Basic Obstetric and Neonatal Care BP Blood Pressure BTA Bangsamoro Transition Authority CAR Cordillera Administrative Region CCS Cervical Cancer Screening CHO City Health Office COPD Chronic Obstructive Pulmonary Disease CRD Chronic Respiratory Disease CVD Cardiovascular Disease DHS Demographic and Health Survey DOH Department of Health DOTS Directly Observed Treatment, Short-Course DMPA Depot Medroxyprogesterone Acetate DTTB Doctor to the Barrios E.O. Executive Order EPI Expanded Program on Immunization FHSIS Field Health Service Information System FP Family Planning GIDA Geographically Isolated and Disadvantaged Area GoP Government of the Philippines HDI Human Development Index HepB Hepatitis B HFEP Health Facilities Enhancement Program HPV Human Papillomavirus HRH Human Resources for Health IDF International Diabetes Federation IIP Immunization in Practice IMCI Integrated Management of Childhood Illness IPHO Integrated Provincial Health Office xi Abbreviations and Acronyms IPT Intermittent Preventive Treatment IPV Inactivated Polio Vaccine IRA Internal Revenue Allotment ITN Insecticide-treated Net IUCD Intrauterine Contraceptive Device LGC Local Government Code LGU Local Government Unit MCH Maternal and Child Health MCP Maternity Care Package MDR Multi-drug-resistant MECA Midwives in Every Community in ARMM MMR Maternal Mortality Rate MOH Ministry of Health NCD Noncommunicable Disease NCP Newborn Care Package NCR National Capital Region NDHS National Demographic and Health Survey NDP Nurse Deployment Program NIP National Immunization Program NNS National Nutrition Survey NTPS National Tuberculosis Prevalence Survey OPV Oral Polio Vaccine ORS Oral Rehydration Solution PCB Primary Care Benefit PEN Package of Essential Noncommunicable Disease Interventions PPP Purchasing Power Parity RED Reaching Every District RHMPP Rural Health Midwives Placement Program RHU Rural Health Unit SARA Service Availability and Readiness Assessment SDG Sustainable Development Goal STI Sexually Transmitted Infection TB Tuberculosis UHC Universal Health Care UNICEF United Nations Children’s Fund WHO World Health Organization xii Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) A note on the geographic focus of this report This report was developed with the aim of informing health policy during the political transition from the Autonomous Region in Muslim Mindanao (ARMM) to the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM). This transition began with the ratification of the Bangsamoro Organic Law (BOL) in January 2019. Data collection and much of the drafting of this report took place over the year before, prior to the BOL, when the area was governed under the ARMM political entity. Given the recency of this transition, the findings continue to reflect the current status of the new region and, throughout this report, we generally refer to our findings as reflecting the situation in BARMM. An exception is made for any reference to programs that were specific to the region’s prior government and legal framework. In those cases, we refer to the policies, legal frameworks, or institutions that were specific to ARMM. The BOL delegates a number of powers to the BARMM regional government. Within the constraints of the national Constitution, the BOL endows the BARMM government with rights to self-determination over how the region is governed, how revenue is generated, and, to some extent, how resources are allocated. While the region is subject to the control of the national parliament and President, the BARMM government nonetheless has some privileges not available to other regions within the Philippines. The BOL has major implications for the health sector. The interim cabinet includes a restructured Ministry of Health (MOH), created to replace the previous Department of Health-ARMM (DOH-ARMM). To ensure uninterrupted delivery of services, the MOH core staffing will be kept intact throughout the transition. The BOL will also significantly restructure the region’s health financing arrangements by establishing a number of block grants and special development funds over which the region will have significant autonomy. It also provides BARMM with a larger share of the taxes collected by the government. This is a significant departure from the ARMM’s previous budgetary processes. This report provides an overview of the current capacities and challenges facing the public primary health care system as the BARMM government enters into its new role. By providing a detailed look at the availability of inputs needed to deliver priority services, it highlights current strengths, and also indicates areas that need to be strengthened if the national and subnational health goals are to be realized. Historically, health outcomes have been far worse in BARMM than elsewhere in the country. While health outcomes are complex and multi-dimensional, weaknesses in health governance have exacerbated the geographic and socio-cultural challenges associated with health care delivery. While the authors recognize that the transition is likely to introduce some challenges, it is hoped that the findings documented in this report can guide health policy, including investments towards high-impact priorities and in this way, help lay the foundation for better health care – and better health – for the people of BARMM. 1 Executive Summary Executive Summary Background The Philippines has made remarkable progress in the last decades in improving its health outcomes. Infant mortality dropped by more than one-third, from 35 deaths per 1,000 live births in 1998 to 21 deaths per 1,000 live births in 2017 (National Demographic and Health Survey (NDHS), 1998 and 2017). Average life expectancy at birth increased by approximately three years, from 67 years in 2000-2005 to 70 years in 2010-2015.1 However, performance is still poor compared regionally and with similar economies. The recent 2017 NDHS estimated children receiving all age-appropriate vaccinations at 61.2 percent with a notable regional inequity, ranging from 8.9 percent in the Autonomous Region in Muslim Mindanao (ARMM)2 to a high of 78.0 percent in Davao region. While maternal health outcomes have improved, inequity by region persists with ARMM lagging far behind: while 91.9 percent of births in the National Capital Region (NCR) were in a health facility and 96.1 percent assisted by skilled providers, these figures in ARMM were 28.4 percent and 34 percent, respectively. The prevalence of malnutrition among children is also very high, with over 33.6 percent of children under five years being stunted (Food and Nutrition Research Institute – Department of Science and Technology (FNRI-DOST) 2016). This report was developed with the aim of informing health policy during the transition from the Autonomous Region in Muslim Mindanao (ARMM) to the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM). This transition began with the ratification of Organic Law for the BARMM or the Bangsamoro Organic Law (BOL) in January 2019. ARMM was first created in 1989 under Republic Act 6734 and strengthened in 2001 through Republic Act No. 9054. From early on, the region maintained higher levels of autonomy than other regions of the Philippines. Delivery of health services fell under the responsibility of the ARMM Regional Government through its Department of Health-ARMM (DOH-ARMM), according to the 2001 Republic Act 9054, which mandated the ARMM Regional Government to “provide, maintain, and ensure the delivery of, among other things, basic and responsive health programs.” However, the region has been home to long-standing armed conflicts , creating peace and security challenges that exacerbate weak local governance. ARMM has long been the poorest of all the administrative regions in the country—in 2006, the incidence of poverty in the region was twice that of the national population and, while the national incidence of poverty has slowly declined since then, it has increased by nearly 20 percent in BARMM over the same time. The region’s geographic spread and remoteness result in difficult transportation and communication channels. The significant regional inequity seen today in BARMM is a reflection of long-standing political, geographic, and socioeconomic challenges that this region has faced. This report on supply-side assessment of service readiness provides for the first time a systematic assessment of readiness to deliver primary health care services in BARMM. Data were collected from nearly all rural health 1 From computation of authors of National Objectives for Health 2017-2022, using data from Philippine Statistics Authority, 2016e. 2 Survey work and drafting for this report was conducted when the geographic region was the Autonomous Region of Muslim Mindanao (ARMM). BARMM was created in 2019.The data referenced here comes from national survey results for ARMM. 2 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) units (RHUs) in the five provinces of BARMM.3 While national surveys provide information on demographic and epidemiological trends in the area, there is little existing information on the status of the region’s capacity to provide primary health care services. The causes of poor health outcomes in BARMM are complex and multidimensional. However, the results of this survey highlight the critical importance of equipping the region’s public primary health sector to deliver on essential preventive and curative services. The survey builds upon the Service Availability and Readiness Assessment (SARA), a framework developed by the World Health Organization (WHO) to assess the capacity of health facilities to provide care.4 The SARA framework provides an overview of general readiness to provide primary health care services, as well as customized assessments for 11 key specific services. These include five maternal and child health (MCH) care services (family planning [FP], antenatal care [ANC], basic obstetric and neonatal care [BONC], immunization services, and child health care), four noncommunicable disease (NCD) services (diabetes, cardiovascular disease [CVD], chronic respiratory disease [CRD], and cervical cancer screening), and two communicable disease services (tuberculosis [TB] and malaria). The report is of particular importance at a time when ARMM is transitioning to BARMM. BARMM was formed through the ratification of the BOL and the swearing in of the Bangsamoro Transition Authority (BTA) in March 2019, as a result of decades-long peace negotiations between the Muslim separatist groups and the Philippine Government. The BOL abolishes ARMM and creates the new BARMM by virtue of its autonomous status, the BARMM will continue to maintain a different administrative structure from other regions in the country. In the health sector, this has two major implications. First, the BOL provides for a BTA interim cabinet composed of 15 primary ministries, including a Ministry of Health (MOH) replacing the previous DOH-ARMM. The MOH is also one of three agencies whose core staffing will be kept intact throughout the transition to ensure uninterrupted delivery of services. While the new organizational structure is yet to be determined, establishment of the BARMM regional government after the transitional period presents an opportunity to implement organizational reform in the MOH to deliver its tasks and services optimally, including the management of the region’s health resources. The study presented here provides a comprehensive baseline of the current status of health sector capacity to deliver key services which will inform policy decisions of the MOH-BARMM. Second, a key feature of the BOL in terms of financing is the provision of block grants and special development funds, with which the region will have larger autonomy in programming and allocating its resources. This is a significant change from the budgetary process in ARMM, where the region had to defend its proposed budget including its line items, as national agencies do. BARMM will also have a bigger share of the taxes collected by the government in the region for ARMM. These larger fiscal responsibilities make it imperative for BARMM to have a sound basis for its financial decisions. This report is intended to inform future investments to be made for primary health care delivery based on evidence. At the national level, the recent signing of the Universal Health Coverage (UHC) Law by the President of the Philippines on February 20, 2019 confirms the country’s commitment to ensuring that every Filipino is entitled to 3 The provinces of BARMM include the two ‘mainland provinces’ of Maguindanao and Lanao del Sur and three ‘island provinces’ of Basilan, Sulu, and Tawi-Tawi. The municipality of Lamitan City falls within the province of Basilan but has a separate administrative structure due to its status as a city. Thus, data from the two facilities in Lamitan City are presented separately when possible. 4 “WHO | Service Availability and Readiness Assessment (SARA).” WHO (Online). Available: http://www.who.int/healthinfo/systems/sara_introduction/en/. Accessed: March 23, 2018. 3 Executive Summary healthy living and is guaranteed equitable access to quality and affordable health services without facing financial hardships. The law also calls for a people-oriented approach for the delivery of health services and reorganization of local health systems into province-wide and citywide health systems. This will include resource pooling and managing a special health fund for all health services. Rigorous monitoring of quality of care will also be enforced. As BARMM embarks on this integrated care approach espoused in the UHC Law, this report provides important baseline data on the readiness for primary health care delivery in BARMM. Key findings The survey findings suggest evidence of recent improvement for the delivery of primary care in the region and also critical shortcomings in the availability of health services. The number of health facilities has substantially increased in the last years (both for RHUs and Barangay Health Stations [BHSs]), yet there is a significant shortfall. Overall, the number of RHUs would need to increase by nearly 50 percent for the region to achieve the national target of one RHU per 20,000 people. Workforce density is similarly low. Despite recent efforts in augmenting the capacity through different human resources deployment programs, there are gaps in human resources for health (HRH) in all five of the provinces; the island province of Sulu has the lowest workforce density. The number of government doctors would need to nearly triple to reach the national target. The assessment found that basic equipment is generally available. This likely reflects a combination of the long-lasting nature of these investments and broad applicability of a small number of items. Inputs such as blood pressure (BP) apparatuses, stethoscopes, thermometers, and adult scales are all nearly universal, as are height and length measures, lights, beds, syringes, safety boxes, and gloves. There were, however, widespread and systematic gaps in the basic amenities needed to provide services. Approximately 15 percent of RHUs in Sulu, for example, lack access to running water. The five provinces also face widespread gaps in the power supply; nearly 20 percent of RHUs in Lanao del Sur have no source of electricity. Fewer than half of the RHUs in BARMM have access to communication equipment, such as telephones or short-wave radios, and even fewer have computers with Internet access. Emergency transportation, too, is lacking. Across BARMM, one in three facilities lacks transportation to evacuate patients; in Tawi-Tawi, this number jumps to two out of every three RHUs. Gaps in the availability of critical consumables reflect challenges in the underlying supply chain. Essential first-line drugs including thiazide to reduce BP for patients with hypertension, glibenclamide to control blood sugar for patients with diabetes, and beclomethasone to improve breathing for patients with asthma were available in less than 10 percent of the facilities. Overall, just 11 of the 75 medicines and commodities assessed across the 11 services were available at more than half of the RHUs in all five provinces. There are similar gaps in diagnostic capacity across every service that was examined. Basic diagnostic tests such as urine dipsticks for protein and glucose were available in fewer than half of the RHUs. Just under 30 percent of the RHUs provide diagnostic services for TB and fewer than one quarter offer cervical cancer screening. Supply chain issues reflect poor coordination within the health sector. The public health system relies heavily on verticalized programs, many of which have internal logistic arrangements to distribute medicines and diagnostics. 4 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) The impact of this was evident in the assessment of immunization readiness. While routine vaccines were more available than nonroutine vaccines, one-third of the facilities did not have measles or pentavalent vaccines in stock, and oral polio vaccine (OPV) was available at fewer than half of the facilities. Vaccines not included on the national immunization program (NIP) schedule, such as the human papillomavirus (HPV) and rotavirus vaccines, were rarely available. These gaps are of particular concern given the alarmingly low vaccination rates in BARMM. Among the specific services considered, capacity to deliver MCH services was strong across the region although wide variation was observed depending on the services. Of the MCH services examined here, the RHUs in BARMM were the best prepared to provide FP services and the least prepared to provide immunization services. NCD services lag significantly behind due, in large part, to the limited availability of medicines and commodities for NCDs. Vertical MCH programs have also been more effective in rolling out training for health staff. More than half of the RHUs did not stock a single cervical cancer screening tracer indicator on the day of the survey, and more than 95 percent of the RHUs had fewer than half of the CRD tracer indicators on the day of the survey. While diabetes and CVD service readiness are generally higher, fewer than half of the RHUs stocked more than 75 percent of diabetes inputs on the day of the survey. Among the communicable diseases, medicines and commodities for TB were nearly universal, reflecting the priority of the government and its relatively well-functioning centralized distribution system. Readiness to diagnose and treat malaria tracks with the incidence of the disease. Hence, aggregate scores were the highest in Sulu, Tawi-Tawi, and Maguindanao. There were no clear geographic trends in performance across the provinces. While the island provinces of Basilan, Sulu, and Tawi-Tawi underperformed compared to the mainland provinces in the readiness to provide NCD services, the mainland province of Lanao del Sur underperformed compared to its island neighbors in the readiness to provide MCH services. Lanao del Sur had the lowest service-specific readiness score for ANC, BONC, and immunization and nearly ties Basilan’s low score for FP. The drivers of the differences in performance across the province varied by service, but there were consistently large differences in the availability of trained staff and service-specific guidelines across the provinces. Investments in supply-side readiness are essential if the Philippines is to address poor health outcomes in BARMM. Some concrete recommendations arising from the study are summarized as follows: • To increase health workforce density, the numbers in all cadres need to be increased, especially in rural and remote areas. Better distribution of existing health staff could be achieved through incentive mechanisms to promote deployment in underserved areas. Moreover, the current reliance on nationally supported deployment programs is much needed but risks the long-run sustainability of HRH in the region. A complete HRH needs assessment would provide a definitive picture of existing gaps. • Addressing the critical shortcomings in the logistics and supply chain is an utmost priority. In particular, better mechanisms should be developed to ensure timely delivery of medicines and supplies to the RHUs across the region. Potential interventions may involve designating personnel to establish standardized logistics systems and parallel efforts to adequately monitor the logistics systems. Such an effort should be one of the priorities for MOH-BARMM, which will have larger autonomy in planning and allocating its resources as well as access to increased revenues from taxes and block grants that may fund health sector reform. 5 Executive Summary • Major improvement is needed to ensure the availability of basic amenities such as power, emergency transportation, and communication channels that are critical for health service delivery at the frontline level. Given the remoteness of some of the provinces, creative ways to improve emergency transportation and ensure access to permanent power supply should be sought, in close collaboration with the regional authorities. • PhilHealth should strengthen accreditation systems for the RHUs in BARMM. Expanding access to care is among PhilHealth’s key priorities. Findings suggest that most public facilities have been accredited in advance of meeting the formal infrastructural requirements, likely as part of an aim to rapidly expand its provider network. While this is an important initiative, it risks the creation of an empty entitlement, where patients are granted coverage for care that local facilities cannot provide. It is, therefore, critical that facilities rapidly move to improve their capacity to deliver high-quality services to meet actual accreditation requirements. • Significant delays in the release of PhilHealth capitation payments need to be addressed. Predictability in the timing of these payments can greatly aid in the planning and sustainability of operations. Improving the reliability of the payments will increase the incentive for facilities to meet accreditation standards. Moreover, in the context of the recent UHC Law, PhilHealth’s mandate becomes increasingly important as an eventual single purchaser of health services. • Local government units (LGUs) should be encouraged to play a larger role in health service delivery. The national government provides internal revenue allotment (IRA) transfers to LGUs to support social services, including health care. While LGUs are authorized to determine the specific allocation of these transfers, few of those in BARMM choose to fund health care services. Coordination between health officers and the LGU through a functional local health board can help raise the local profile of the health sector and clarify the specific support that LGUs might provide. Potential support includes distribution of commodities, non-personnel operating expenses, infrastructure or equipment investments, or expansion and capacity building of local HRH. Accountability mechanisms should be introduced to ensure that all parties meet their respective financial obligations to the health sector. • The use of real-time information systems using modern technology would greatly aid in monitoring and decision making for service delivery. The national DOH and PhilHealth are working to roll out electronic medical records, but currently, availability of this system is limited to a small part of the five provinces. As evidenced from this assessment, availability of internet connection and other basic communication channels remains a constraint particularly in the island provinces and more investment in these areas is urgently needed. • While the availability of inputs is a critical component of health care, the overall quality of care depends on many additional factors, including provider knowledge and skills. While a part of this is captured in the patient satisfaction survey conducted as part of this study, possibly linked to performance-based payments, efforts to gain a more comprehensive understanding of the quality of care of health services in BARMM would benefit from a more detailed assessment. Currently, there are no mechanisms to assess the quality of care, and these should be instituted as part of the regular supervision process by districts and provinces, in addition to the more detailed assessments (Annex 4). 6 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Section 1. Background The Philippines has made significant progress in health outcomes. Over recent decades, infant mortality dropped by more than one-third, from 35 deaths per 1,000 live births in 1998 to 21 deaths per 1,000 live births in 2017 (National Demographic and Health Survey (NDHS), 1998 and 2017). Average life expectancy at birth increased by approximately three years, from 67 years in 2000-2005 to 70 years in 2010-2015.5 However, the country lags behind its neighbors in its efforts to achieve the health-related Sustainable Development Goals (SDGs) (WHO 2018). Of the reproductive health indicators, only efforts to reduce child and neonatal mortality are on track to achieve the targets. Maternal mortality remains high, and coverage of key maternal and child health (MCH) services, including skilled attendance at birth and immunization coverage, is low. Meanwhile, noncommunicable diseases (NCDs) are a large and growing burden and currently account for approximately two-thirds of premature mortality in the country.6 Despite the growing importance of PhilHealth as a purchaser of health services, out-of-pocket spending remains very high. The sector also struggles with weak governance; decentralization has frequently resulted in unclear roles and fragmented, often overlapping, lines of responsibility—particularly with regard to who holds the responsibility for funding services. Health outcomes have long been far worse in the Autonomous Region in Muslim Mindanao (ARMM) than elsewhere in the country. Child mortality is of particular concern. At 55 deaths per 1,000 live births, under-5 mortality in the region is nearly 80 percent higher than the national average of 31 deaths per 1,000 live births (Australia DFAT and World Bank 2015). While regional information on maternal health outcomes is generally unreliable (Mujer Quintos 2017), it is thought that maternal mortality also remains higher than other regions in the country. While the health sector of the Philippines is defined by a very significant degree of decentralization, ARMM’s health sector has long been subject to different set of laws, with much of the power concentrated at the regional rather than municipal level. In either case, the highly devolved nature of health service delivery in the Philippines has historically contributed to large annual fluctuations and geographic inequities in resource allocations for the sector. This report is being developed in the context of a significant reorganization of the region’s governance and financing. In February 2019, as this report was being drafted, the ARMM was abolished and BARMM was formed7 through the ratification of the Organic Law for the BARMM (also known as Bangsamoro Organic Law or BOL). 5 From computation of authors of National Objectives for Health 2017-2022, using data from Philippine Statistics Authority, 2016e. 6 Institute for Health Metrics and Evaluation (Online). Available: http://www.healthdata.org/acting-data/resources-decision-making-diabetes. Accessed: February 25, 2018. 7 Geographically, the same provinces of ARMM also comprise the BARMM. However, a plebiscite still has to determine 39 barangays in North Cotabato, six municipalities in Lanao del Norte, and the cities of Cotabato in Maguindanao and Isabela in Basilan will be included in the Bangsamoro territory. 7 Section 1. Background The BOL has major implications for the health sector. The interim cabinet includes a restructured Ministry of Health (MOH), created to replace the previous Department of Health-ARMM (DOH-ARMM). To ensure uninterrupted delivery of services, the MOH is one of the agencies whose core staffing will be maintained throughout the transition.8 The BOL will also significantly restructure the region’s health financing arrangements by establishing a number of block grants and special development funds over which the region will have significant autonomy. It also provides BARMM with a larger share of the taxes collected by the government. This is a significant change from the budgetary process of ARMM, where the region has had to defend its proposed budget, as national agencies do. These changes are expected to introduce some challenges. Historically, the ARMM-DOH maintained a relatively low budget execution rate, exacerbated by suboptimal procurement processes. Bottlenecks of the system emerged prominently when a significant surge of sin tax revenues increased the budget to the department. In the wake of organizational and financing reforms that will accompany the transition from ARMM to BARMM, the study presented here provides an important baseline of the current status of the region’s supply-side readiness in primary health care, one important spoke of the wheel that determines health outcomes. The Government of the Philippines (GoP) has emphasized the critical importance of a high-quality and responsive health sector to address these challenges. This is most recently reflected in the Universal Health Coverage (UHC) Bill that was signed into law by the President of the Philippines in February 2019. The UHC Law confirms the country’s commitment to ensuring that every Filipino is entitled to healthy living and is guaranteed equitable access to quality and affordable health services without facing financial hardships. The bill also calls for a people-oriented approach for the delivery of health services and reorganization of local health systems into province- and city-wide health systems with them pooling and managing a special health fund intended for all health services. Until the recent transition from ARMM to BARMM, the health sector policy directions in ARMM have been well aligned with these national efforts. The 2016–2019 ARMM health sector road map focused on three pillars: financial risk protection for the poor, achieving the health-related development goals, and ensuring access to quality health services. Strengthening services delivered at the primary care level has also been an important component of the region’s road map to improving health outcomes, with particular emphasis on MCH services. While the new health sector policy of the transition government is yet to be developed, these priorities will most likely remain to be the same and fully aligned with the UHC Law. BARMM: Political, Geographic, and Socioeconomic Challenges BARMM is the southernmost region in the Philippines. The administrative jurisdiction of ARMM included five provinces (Maguindanao, Lanao del Sur, Basilan, Sulu, and Tawi-Tawi); two cities (Marawi and Lamitan); 116 municipalities; and 2,490 barangays.9 The ‘mainland provinces’ of Maguindanao and Lanao del Sur are the largest provinces and are both located on the island of Mindanao. The three smaller ‘island provinces’, Basilan, Sulu, and, Tawi-Tawi, are each scattered across a number of islands in the Celebes and Sulu Seas. The new region 8 The other two ministries are the Department of Social Welfare and Development-ARMM (now Ministry of Social Services-BARMM) and Department of Education-ARMM (now Ministry of Education-BARMM). 9 C. W. D. Team. “Official COMELEC Website: Commission on Elections.” Commission on Elections (COMELEC) (Online). Available: http://www.comelec.gov.ph. Accessed: June 19, 2018. 8 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) BARMM includes all of these areas; in addition, administrative jurisdiction now also includes the following in the ‘mainland’: another city (Cotabato City, an independent city of Maguindanao) and 63 barangays in the province of North Cotabato (Figure 1). Figure 1. Map of BARMM After decades of struggle for self-determination, ARMM had been granted political and fiscal autonomy. The region was created in 1989 under Republic Act 6734 and later amended with the 2001 Republic Act 9054. ARMM’s government first, and now the government of BARMM, has been empowered with significant fiscal autonomy not granted to other regions in the Philippines, and BARMM builds on this foundation today. ARMM has long faced a combination of political, geographic, and socioeconomic challenges that contribute to lagging health indicators. Transportation and communication channels are weaker than those found in other regions. The geographical spread and isolation result in complex logistical challenges that often overwhelm the supply chain capacity and, as the poorest of the 17 administrative regions, the region is subject to severe resource constraints. Ongoing peace and security challenges introduce unpredictability and exacerbate weak local governance. The region has also endured long-standing conflicts between the GoP and Muslim separatist groups. In the most recent, in May 2017 severe fighting erupted in Marawi City, Lanao del Sur. The structural, financial, and sociocultural barriers in BARMM are reflected in the health and well-being of its population (Table 1). For example, the 2000 Census estimates suggest a nearly 15-year gap in life expectancy between BARMM, which has the lowest life expectancy in the country, and Region 1, which has the highest life expectancy.10 This dramatic difference reflects a range of disadvantages affecting the health and well-being of BARMM population. Indeed, these inequities are among the most critical challenges to the nation’s health sector (WHO 2011). The Human Development Index (HDI) is intended to provide a measure of overall well-being by compiling average family income, life expectancy at birth, and adult literacy. While the national HDI has been on an upward trajectory, those for the provinces of Lanao del Sur and Maguindanao have deteriorated in recent years.11 10 This analysis was not done as a part of the more recent census. Philippine Statistics Authority. Life Expectancy at Birth of Women (Online). Available: https://psa.gov.ph/content/life-expectancy-birth-women. Accessed: February 25, 2018. 11 “2012/2013 Philippine Human Development Report.” United Nations Development Programme in Philippines (Online). Available: http://www.ph.undp.org/content/philippines/en/home/library/human_development/2012-2013_PHDR.html. Accessed: June 19, 2018. 9 Section 1. Background Table 1. Descriptive Overview: The Provinces of BARMM Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi BARMM Philippines Population (2015) 1,045,429 1,173,933 346,579 824,731 390,715 3,781,387 100,981,437 Number of 39 36 11 19 11 116 1,489 Municipalities municipalities, municipalities municipalities, municipalities municipalities municipalities, municipalities, and Cities (2018) 1 city 1 city 2 cities 145 cities (17 regions, 81 provinces) Annual Family — — — — — PHP 139,000 PHP 267,000 Income (2015) Annual Family — — — — — PHP 111,000 PHP 215,000 Expenditure (2015) Human 0.217 0.309 0.419 0.303 0.403 — 0.644 Development Index (HDI) 2012 Life Expectancy at 60.7 59.5 63.5 58.0 54.4 — 73.4 birth (years) 2012 Mean years of 7.3 6.3 6.7 6.7 8.1 — 9.2 Schooling 2012 Expected years of 11.2 11.1 10.8 12.5 10.7 — 12.2 Schooling 2012 Per Capita Income 19,139 23,464 30,989 22,773 31,489 — 49,903 2012 (purchasing power parity [PPP] National Capital Region [NCR] 2012 pesos) Source: Capuno 2017. Poverty is also pervasive in BARMM. In 2006, the incidence of poverty in the geographical area of BARMM was twice that of the national population and, while the national incidence of poverty has slowly declined since then, it has increased by nearly 20 percent in BARMM over the same time. As a result, the incidence of poverty in BARMM is now nearly three times that of the national population (Figure 2, Panel A). Localized increases in poverty in Lanao del Sur, Maguindanao, and Sulu drive much of this divergence (Figure 2, Panel B). Tawi-Tawi, the province that is least affected by violent conflict, is the only region to have experienced a consistent decline in poverty over this period (Capuno 2017). 10 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 2. Poverty Incidence among Families over Time Panel A Panel B 100 100 90 90 80 80 70 70 67.3 66.3 60 60 Percent 54.5 50 50 49.6 50.2 48.7 48.2 48.7 48.8 46.4 40 40.5 39.9 40 43.3 40.2 38.6 35.2 35.5 30 30 32.1 29.4 28.2 28.8 28.3 20 21.0 20.5 19.7 20 21.9 16.5 10 10 10.6 0 0 2006 2009 2012 2015 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi* Philippines BARMM 2006 2009 2012 2015 Source: Poverty and Human Development Statistics Division of the Philippine Statistics Authority (PSA). 2016. “2015 Full Year Official Poverty Statistics of the Philippines.” Note: Panel A shows a slow but steady decline in the national incidence of poverty between 2006 and 2015, while poverty increased in BARMM (then known as ARMM) over the same period. Panel B shows that this trend is driven by localized increases in poverty in Lanao del Sur and Sulu. *Note that the 2015 data for Tawi-Tawi should be interpreted with caution due to the high variance found in the source data. Although ARMM had formally been granted fiscal autonomy for several decades,12 the region has historically relied heavily on the national government for funding and had limited flexibility in programming and allocation. At the time of this writing, national government funds account for more than 99 percent of BARMM resources, with locally generated revenues accounting only for less than 1 percent (Australia DFAT and World Bank 2015; INCITEGov 2007). A little more than half of the funds from the national government has been going directly to the ARMM Government and the other half of national funding has been going directly to local government units (LGUs) as internal revenue allotment (IRA),13 which the LGUs have the power to program, allocate, and appropriate (INCITEGov 2007). The overall impact of this funding reality has been that LGUs within ARMM—the provinces, cities, and municipalities—have maintained more flexibility in allocating and spending their funds than the ARMM Regional Government (Table 2). The intention of the BOL is for the region to have larger autonomy in programming and allocating its resources under BARMM. The IRA, on the other hand, will continue to be provided by the National Government directly to the LGUs. 12 Republic Act No. 9054 vests ARMM with fiscal autonomy, formally permitting the region to generate revenue and make decisions on how to budget different categories of funds including locally generated revenue, the regional share of the internal revenue taxes, and block grants and subsidies received from the central government or through donor sources. 13 IRA is the annual share of local governments out of the proceeds from national internal revenue taxes. This is automatically appropriated and automatically released to the LGUs. 11 Section 1. Background Table 2. Share of IRA in Total Operating Income, 2013–2017 (average) (percent) Province 97 95 95 95 95 95 78 City 85 — 95 — — 90 42 Municipalities (total) 98 93 97 98 92 96 77 Source: Statements of Receipts and Expenditures of LGUs, from the website of the Bureau of Local Government Finance. http://blgf.gov.ph/lgu-fiscal-data/ BARMM Health Sector Organization at the Time of Data Collection At the time of data collection, before the transition from ARMM to BARMM, the region’s health sector was unique for its relatively high level of its own control. Outside of the region, the national DOH is the national authority on health while the LGUs are responsible for managing and implementing local health programs and services. The national DOH provides policy direction and strategic plans, regulatory services, standards and guidelines for health, and highly specialized and specific tertiary-level hospital services at national level (Dayrit et al. 2018). The LGUs, on the other hand, are mandated to ensure effective access to health care. In the decentralized system organized by the Local Government Code (LGC), the provincial governments are tasked with providing primary and secondary hospital care, while the city and municipal governments are tasked with providing primary health care, promotive and preventive health programs, and basic ambulatory clinical care. In the case of ARMM, this structure differed in that the responsibility for the health system had been with the regional Department of Health (DOH-ARMM). While the national DOH maintained the responsibility for establishing standards and guidelines, administrative control over facilities and provision of health programs and services were the responsibilities of the DOH-ARMM.14 The Republic Act 9054 specified that the ARMM Regional Government should ‘provide, maintain, and ensure the delivery of, among other things, basic and responsive health programs’. On this account—and in contrast to other regions in the Philippines—the public health services in the provinces of ARMM were managed by DOH-ARMM, rather than the LGUs. However, LGUs were still subject to the 1991 LGC mandate that they ensure effective access to health care. This apparent ambiguity in the sharing of responsibility between the DOH-ARMM and LGUs often resulted in confusion in the accountability structure in health service delivery. The creation of the MOH-BARMM under the BOL offers an opportunity to reorganize and clarify this structure. Unlike other parts of the country, the private sector did not figure prominently in ARMM. The country has mixed public-private provision of hospital care and primary health care. Nationally, the private sector has overtaken the government sector in terms of the number of hospital beds, comprising 53 percent of the hospital beds in 2016 from 46 percent in 2003 (Table 3) (Dayrit et al. 2018). In BARMM, however, the number of public sector hospitals beds is still more than three times that of private hospital beds and the majority of care is still delivered by the public sector. According to the 2017 National Demographic and Health Survey (NDHS), 1 out of 13 (7.6 percent) Filipinos visited a health care provider in the 30 days before the survey. While almost 60 percent of these visits were in public facilities nationwide, the public sector accounted for as much as 82 percent of the 14 The administrative structures of Basilan and Marawi City differ from other parts of ARMM as they became part of ARMM only in 2001, well after the region’s governance structure was laid out by the LGC of 1991. Thus, unlike the rest of ARMM where the ARMM Regional Government is the formal owner and steward of public health services, the LGUs own and run the facilities in Basilan and Marawi City. 12 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 3. Health Infrastructure in BARMM and Nationwide, 2016 BHSs RHUs Government Government Private Private Total Total Average Beds Hospitals Beds Hospitals Beds Hospitals Beds per Hospital BARMM 464 131 18* 715 7 200 25 915 36.6 Philippines 20,216 2,587 434 47,371 790 54,317 1,224 101,688 83.1 Source: Department of Health - Health Facilities and Services Regulatory Bureau, as cited in Dayrit et al (2018). Note: An inventory of hospitals as consulted with the DOH-ARMM shows that there are in fact 28 government hospitals in ARMM: 23 provincial/district/municipal hospitals operated by the DOH-ARMM; 2 district hospitals operated by the province of Basilan; and 3 national DOH-retained hospitals. visits in the area now known as BARMM. The rural health units (RHUs) and barangay health stations (BHSs) were the most utilized at 40 percent nationwide and 64 percent in BARMM (PSA and ICF International 2018).15 Health Service Utilization in BARMM Utilization trends suggest concerning gaps in coverage of critical maternal and child health services. The national contraceptive utilization rate is approximately twice that found in BARMM (54.3 percent, relative to 26.3 percent) (PSA and ICF International 2018), and BARMM has the lowest ANC utilization rate in the country. While 86.5 percent of pregnant women nationwide attended the recommended four ANC visits in 2017, less than half of pregnant women did so in BARMM. Just 28.4 percent of pregnant women gave birth at a facility, compared to the national average of 77.7 percent (PSA and ICF International 2018). Meanwhile, there is evidence that access to some services has deteriorated over time. Coverage of all basic vaccines has plummeted from 47 percent in 1998 to just 18 percent in 2017 (NSO, DOH, and MI 1999; PSA and ICF International 2018). While these utilization statistics cannot be directly translated into health outcomes, they highlight concerning gaps in the coverage of basic health care services. Financing Primary Care in BARMM at the Time of Data Collection Health care financing under ARMM was fragmented and heavily dependent on national government funds; RHUs were particularly dependent on the national DOH and PhilHealth for providing for and funding operations. National government appropriations for ARMM health services were detailed in the national General Appropriation Act. At the time of data collection, appropriations were allocated for the regional DOH, the Integrated Provincial Health Offices (IPHOs), and the 20 hospitals operated by the regions. Provisions for the RHUs from this funding were limited and, generally, took the form of personnel support, were included in the allocations for the corresponding referral hospital, or arrived as ad hoc funding from the IPHO for public health activities. Similarly, the RHUs received little support from ARMM’s locally generated revenue. The region allocated relatively little to health, and the DOH-ARMM and LGUs used these resources sparingly.16 The health financing reforms to be introduced by the BOL will require. 15 There are no records on the number of private clinics or primary care facilities. But, as will also be seen later, few private clinics are accredited by PhilHealth to deliver various benefit packages. 16 For example, in 2016, there was an appropriation of PHP 10 million for health-related projects, of which only PHP 6 million was used. 13 Section 1. Background The national DOH have been a critical financing source, providing cash and in-kind commodities, human resource, and capital outlay support to the RHUs in what is now BARMM.17 National health programs (for example, maternal health or NCD programs) provided cash to the DOH-ARMM for the implementation of public health programs in ARMM. These contributions also included training to upgrade the skills of existing primary health care personnel, while targeted deployments funded by the DOH-ARMM programs augmented the health workforce. While the government initiated these targeted deployment programs18 as a stopgap measure to fill critical needs, they expanded over the years. The national DOH also provided a number of in-kind resources to ARMM. One prominent example is vaccines, which have been procured centrally before distribution to the RHUs through the IPHOs. Finally, the national DOH’s Health Facilities Enhancement Program (HFEP) provided capital outlay (infrastructure and equipment) support for facilities; this was mostly provided to hospitals but has included facility upgrades for the RHUs.19 The high reliance on support from the national DOH and weak supply chain system has affected the RHU’s ability to provide effective and quality health services.20 PhilHealth, the national health insurance program, is also an important source of funding for operations of the RHUs. PhilHealth has developed a number of distinct service packages, including the Primary Care Benefit (PCB) Package, the Maternity Care Package (MCP), and the Tuberculosis (TB) Directly Observed Treatment, Short-Course (DOTS) Package. Packages are commonly available at the RHUs. The payment structure for these services varies. For example, PhilHealth pays the MCP and TB DOTS packages on a per-case basis and pays modified capitation payments (that is, fixed maximum amount per enrolled family per year) for the PCB package. Although capitation payments have been prone to frequent and lengthy delays—by as much as two years in some cases—receipts from PhilHealth have been substantial for the operations of the facilities.21 Notably, 20 percent of the PhilHealth payments can be used as incentives for the RHU staff, while the remaining 80 percent is used for necessary operating expenditure. Unlike elsewhere in the country, the LGUs have played little role in funding health care in the region. Between 2013 and 2017, municipalities in the Philippines devoted, on average, about 9 percent of their total expenditure to health. Over the same period, ARMM municipalities allotted less than 2 percent for health (Table 4). The two cities in ARMM likewise fared behind other cities in terms of health spending. It is notable that the municipalities and the city in Basilan, which joined ARMM only after implementing the LGC of 1991, devoted relatively more resources for health over this period than the other ARMM provinces. Historically, the ARMM LGUs—whether provinces, cities, or municipalities—were much more dependent on the IRA22 than the non-ARMM LGUs. 17 An estimated PHP 770 million cash was downloaded by the various public health programs to the DOH-ARMM for each of 2016 and 2017. It cannot be estimated what proportion is for primary health care. Estimates on the in-kind support (supplies and commodities, personnel deployment, and capital outlay) are not available. 18 These include programs such as Doctor to the Barrios (DTTB) and the Nurse Deployment Program (NDP). 19 In 2018, HFEP allocation in the General Appropriations Act provides for PHP 20 million for upgrades in the BARMM RHUs and BHSs. 20 For example, due to the lack of reliable cold chain at the RHUs, the IPHOs maintain vaccine stocks intended for lower-level facilities. As a result, the RHUs must arrange procurement to support individual vaccine activities. 21 Total capitation received by all accredited RHUs in BARMM ranged from PHP 63 million to PHP 76 million per year in 2015–2017. Payments to the RHUs for other outpatient benefits, on the other hand, amount to a range of PHP 89 million to PHP 107 million, with about 95 percent accounted for by the MCP. 22 IRA is the annual share of the local governments out of the proceeds from the national internal revenue taxes. This is automatically appropriated and automatically released to the LGUs. 14 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 4. Health Expenditure as a Percentage of Total Operating Expenditure of Municipalities and Cities, 2013–2017 (average) Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi BARMM Philippines Municipalities 1.7% 0.7% 5.2% 1.0% 1.6% 1.5% 8.6% City 3.9% Marawi n.a. 5.0% Lamitan n.a. n.a. 4.5% 10.8% City (2013 to City 2016 only) Source: Statements of Receipts and Expenditure, Bureau of Local Government Finance (2017 figures are preliminary). There is scope for increasing the LGU funds allocation to strengthen health services in their area. For the municipality and city LGUs with health allocations, spending was generally used to augment personnel in the RHUs or to implement public health initiatives. The limited investment is mainly due to the apparent ambiguity in the accountability structure to deliver health services. IRA transfers paid by the national government to the LGUs include allocations for devolved social services such as health. Establishing Health Care Quality Controls in BARMM PhilHealth plays an essential role in establishing the quality standards for facilities, as there are no licensing requirements for the RHUs in the Philippines. While individual health programs supported by the national DOH establish basic requirements of care, they exist as unfunded mandates and lack enforcement mechanisms. By contrast, PhilHealth circulars often provide a detailed accounting of the infrastructure and service standards required for accreditation. As facilities must be accredited to be included in PhilHealth’s network, PhilHealth is well positioned to implement effective quality controls to the health sector by expanding and enforcing its accreditation requirements. The agency’s strategy of accrediting facilities for specific services lowers the bar for accreditation and helps expand the number of accredited facilities in the short run—an important factor in access to care. Facilities can be authorized to deliver services for which they have sufficient capacity while building up readiness to provide more complex care. As conditions improve, the RHUs can apply for accreditation for additional services. Table 5 provides a summary of the accreditation status of facilities in BARMM for several important benefit packages. Notably, a large percentage of BARMM’s RHUs are Primary Care Benefit (PCB) and Maternity Care Package (MCP) accredited; 112 of 124 (90.3 percent) RHUs are accredited for PCB and 98 (79.0 percent) RHUs are MCP accredited. Relatively few facilities are accredited to deliver the Outpatient Malaria Package. There are strong geographic patterns in accreditation for the Outpatient Malaria Package. While most RHUs in Tawi-Tawi are accredited to deliver these services, none of those in Basilan or Lamitan City are accredited to do so. However, evidence in this report suggests that many facilities are formally accredited before meeting the minimum standards. This appears to reflect a conscious effort on the part of PhilHealth to increase access to care—with few accredited facilities, the insured population would have no access to care. 15 Section 1. Background Table 5. PhilHealth Accreditation Status, 2017 Accredited for Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi Marawi City Total No. of 39 36 11 1 19 11 1 Municipalities/ Cities Total No. of RHUs 39 37 12 2 19 14 1 PCB 39 RHUs 36 RHUs 6 RHUs 2 RHUs 18 RHUs 10 RHUs 1 RHU 1 BHS 1 government 1 BHS 1 other hospital government facility 1 government hospital MCP 33 RHUs 34 RHUs 6 RHUs 2 RHUs 12 RHUs 10 RHUs 1 RHU 1 private clinic 6 BHS 2 other 1 BHS 1 other 2 other government government government birthing facility birthing centers centers 1 private 27 private 1 private hospital clinics clinic 2 private clinics TB DOTS 37 RHUs 35 RHUs 6 RHUs 2 RHUs 13 RHUs 10 RHUs 1 RHU 1 BHS 1 government 1 BHS 1 government 2 government hospital 1 government hospital hospitals hospital Outpatient 1 RHU 3 RHUs — — 5 RHUs 9 RHUs — Malaria Package 16 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Section 2. Analytical Approach Data Overview Data included in this survey are collected from almost all of the RHUs across BARMM. Teams collected data from a total of 123 public facilities in the five provinces of Basilan, Lanao del Sur, Maguindanao, Sulu, and Tawi-Tawi; 120 of the facilities visited are RHUs. Based on the recommendation of the DOH-ARMM, surveyors also visited two City Health Offices (CHOs) in Lamitan City and one BHS in Tawi-Tawi. Survey teams did not visit facilities in Marawi City as the Marawi siege was ongoing at the time of the survey fieldwork. Annex 1 to this report includes a complete list of the facilities visited. Although Lamitan City falls within the geographic boundaries of Basilan, it has a separate administrative structure stemming from its status as a city. To assist in comparability with similar reports, data from the two CHOs visited in Lamitan City are presented separately from Basilan whenever possible. Surveyors collected data on a range of indicators. Local enumerators translated the surveys into six local languages (Maranao, Tagalog, Maguindanao, Cebuano, Tausog, and Sama) and conducted the surveys. Survey teams visited facilities between July and October 2017 and assessed health facility infrastructure and equipment, as well as medicines and commodities. Facility audits were based on the Service Availability and Readiness Assessment (SARA) survey of the World Health Organization (WHO).23 The surveys underwent two rounds of field testing in selected municipalities of Lanao del Norte, an area outside of the survey region that borders Lanao del Sur. As shown in Table 6, survey teams visited a total of 123 facilities in 117 municipalities across the five provinces. Table 6. Data Collection, by Province Province Number of Facilities Assessed Number of Cities/Municipalities* Lanao del Sur 39 39 Maguindanao 37 36 Basilan 12 11 Lamitan City 2 1 Sulu 19 19 Tawi-Tawi 14 11 TOTAL 123 117 *Only Marawi City was not included in the survey among the 118 ARMM cities and municpalities. 23 “WHO | Service Availability and Readiness Assessment (SARA).” WHO (Online). Available: http://www.who.int/healthinfo/systems/sara_introduction/en/. Accessed: March 23, 2018. 17 Section 2. Analytical Approach Quality Control and Supervision Total enumeration of almost all RHUs in BARMM meant that caution was key as the whole endeavor hinged on the fragile security condition. This was made more evident with the timing of the start of fieldwork happening few days after the Marawi siege. Furthermore, past experiences proved the difficulty in validating data, especially in the island provinces of Sulu and Basilan where higher risks have affected research studies. To ensure quality data and efficient field work, strict adherence to field protocol and monitoring of the research teams were done. The principal investigator and the core team were involved in all the phases of the entire field operation— field pretesting, recruitment and training of both field enumerators and data encoding team. The deployment plan included identifying the most efficient routes and areas to be entered first and the ones for last. During actual data collection, supervisors were responsible for identifying the appropriate respondent/respondents for each domain in the core questionnaire and in most cases also did the actual interviewing of municipal health officers. A 100 percent field edit of the core questionnaires was done and supervisors were required to make daily routine calls to the survey management team to report field progress and problems requiring the principal consultant’s inputs. As part of the quality control procedure, the research team also made a number of callbacks to clarify entries. The SARA Framework The WHO’s SARA is a framework for assessing the key aspects of health service delivery along three dimensions: (a) service availability, (b) service readiness, and (c) service utilization.24 Availability focuses on the physical access to and distribution of health facilities. Readiness considers the ability of facilities to deliver specific types of care. Utilization considers the uptake of services. This report primarily focuses on the second dimension, service readiness. Service readiness assesses whether or not the RHUs have the basic infrastructure, equipment, diagnostic capacity, medicines, and commodities to provide services in general and for specified conditions. In addition to general service readiness, we consider 11 specific services. These include five MCH services (family planning [FP], antenatal care [ANC], basic obstetric and neonatal care [BONC], immunization services, and child health care), four NCD services (diabetes, cardiovascular disease [CVD], chronic respiratory disease [CRD], and cervical cancer screening), and two communicable disease services (TB and malaria).25 The SARA framework is not intended to reflect an exhaustive list of inputs needed to deliver services but to offer a succinct list of items that can be realistically captured during survey visits while also reflecting the broader system. Operationally, domain-specific SARA indicators were reviewed and compared against available data. Because survey instruments were adapted to reflect local policies and priorities, not all SARA indicators were included. Some adjustments were also made such as adding PhilHealth data and revising the formulation of some indicators to align with national protocols. However, the SARA framework was the foundational framework for the survey and alterations were limited. 24 “WHO | Service Availability and Readiness Assessment (SARA).” WHO (Online). Available: http://www.who.int/healthinfo/systems/sara_introduction/en/. Accessed: March 23, 2018. 25 The survey was initially designed to include Sexually Transmitted Infection (STI) care under the specific services. However, this information was dropped from the final report as STI diagnosis and management is formally managed by designated social hygiene clinics. Capacity to diagnose syphilis and HIV are included in the reviews of ANC and TB, respectively. 18 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) To structure the assessment of service readiness, indicators are organized into domains. 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 four domains: staffing and training, equipment, diagnostics, and medicines and commodities. For each domain, we report both province-specific and aggregate results (Figure 3). Figure 3. Report Overview Health Services Categories Domain Inputs Population Estimates General Service Facility Density 1 Health Worker Density Number of Facilities Availability Number of Staff Basic Infrastructure General Service Basic Equipment 2 Infection Prevention Tracer indicators Readiness Diagnostic Capacity Essential Medicines Maternal and Child Health Services (MCH) 3 • FP • Immunization • ANC • Child Health • BONC Noncommunicable Diseases (NCD) Staffing and Training • Diabetes Mellitus Equipment 4 Diagnostics Tracer indicators • CVD • CRD Medicines & Commodities • Cervical Cancer Screening Communicable Diseases 5 • TB • Malaria Health Service Category score Domain score • By province • By province 19 Section 3. General Service Availability Section 3. General Service Availability To assess service availability, survey teams collected information on the distribution of public health facilities and workforce. In some cases, we supplement survey data with publicly available information on population distribution and national workforce estimates. Facility Density The low facility density across BARMM suggests that large portions of the local population have limited or no access to public primary care. The target under DOH-ARMM, aligned with national target, was a density of 1 RHU per 20,000 population and 1 BHS per barangay. Table 7 shows both an overall shortage and an uneven distribution of the RHUs within BARMM. Overall, the region needs to increase the number of RHUs by nearly 50 percent to reach the target density. While Basilan is the closest to the national target for RHU coverage (approximately 1 RHU per 22,650 population), Sulu has just one facility per 43,400 population and would need to double the number of RHUs to meet this target.26 Table 7. Health Facility Density Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM (2017) Ratio of Health 1:26,806 1:31,728 1:22,650 1:37,391 1:43,407 1:27,908 1:30,743 Facility to Population Provincial averages conceal important variation in the catchment size—and the associated workload—of individual RHUs (Figure 4). As shown in Figure 5, 68 percent of the facilities failed to meet the target catchment population of 20,000; 32 percent of the RHUs in BARMM have catchment areas of 30,000 or larger, and nearly a quarter of the RHUs serve catchment populations of more than 60,000 people—a population that should, by the DOH norms, be served by three RHUs.27 At the other end of the distribution, 10 facilities (8 percent of the sample) serve populations of 10,000 or less (Figure 5, Panel A). We also identify gaps in the coverage of BHS across BARMM. Survey teams asked RHUs about the number of BHS serving each of their catchment areas. Panel B shows the ratio of BHS to barangays at the 123 health facilities visited. While the DOH-ARMM had established a standard of one BHS per barangay, just seven RHUs (5.7 percent) meet this standard; 74 percent of RHUs have fewer than one BHS for every two barangays (Figure 5, Panel B). 26 Butig, Lumbaca Unayan, and Mulondo RHUs did not provide data on catchment populations. 27 Datu Odin Sinsuat, Parang, Sultan Kudarat, Bongao, and Jolo RHUs all report catchment areas of 90,000 or larger. Jolo has the largest reported population: 145,503. 20 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 4. The Location of RHUs across BARMM RHU location by municipal population density Source: The RHUs are indicated by black circles on the map. The population density of the municipality is indicated in shades of blue, with the most densely populated areas shaded in navy. Areas with no population data are indicated in white. Figure 5. RHU and BHS Density Panel A Panel B 30 1 BHS per barangay 7 Number of RHUs Availability of BHS 20 1 BHS per 1-3 barangay 50 1 BHS per 3-5 barangay 23 10 1 BHS per 5-10 barangay 17 1 BHS per 10+ barangay 17 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 Catchment population 9 Pop < 20,000 Pop > 20,000 0 10 20 30 40 50 Average number of Barangays served per BHS Source: BARMM SARA, 2019 Note: Panel A shows the ratio of the RHUs to the population. Bars shaded in blue indicate the number of RHUs with catchment area populations less than 20,000. Those shaded in rose indicate the number of RHUs with catchment area populations greater than 20,000. Individual bars are in increments of 5,000. For example, the first blue bar indicates that six RHUs indicated a catchment population of 0–5,000 people. The first rose-colored bar indicates that 27 RHUs serve catchment populations of 20,000–25,000 people. Panel B shows the ratio of the BHSs to barangays for each RHU. For example, 7 RHUs report 1 BHS per barangay, while 50 RHUs report one BHS for every 2–3 barangays. 21 Section 3. General Service Availability Personnel The survey identifies significant gaps in the availability of human resources for health (HRH). Staffing requirements for the RHUs mirror the standards set for facility density across the country: 1 doctor per 20,000 population, 1:10,000 for nurses, and 1:5,000 for midwives. Data on population and health workforce from national sources suggest that the country suffers from a shortage of HRH—nationally, there is just 1 doctor per 35,580 population, 1 nurse per 22,067 population, and 1 midwife per 5,791 population. However, the distribution of personnel is highly uneven across the country. For example, the density of civil servant doctors in the Cordillera Administrative Region (CAR) is more than twice that found in Region XI. Relative to its neighbors, BARMM has a very low health workforce density with just 1 doctor per 49,755 people, 1 nurse per 29,087 people, and 1 midwife per 7,458 people.28 The distribution of HRH within BARMM is uneven. While there are gaps in coverage in all five of the provinces, Sulu has the lowest density of government doctors and would need to nearly triple the number of doctors to reach the target coverage rate. Only the more densely populated Lamitan City achieves the goal previously set by DOH-ARMM. Among the provinces, with 1 doctor for approximately every 25,000 population, Lanao del Sur comes the closest to meeting the target (Table 8). Table 8. Health Workforce Density Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM (2017) Ratio of 1:24,891 1:46,957 1:33,975 1:18,696 1:58,909 1:32,560 1:36,013 Government Doctors to Populationa Ratio of Nursing 1:4,605 1:6,146 1:2,363 1:4,399 1:6,598 1:4,765 1:4,995 Professional to Population Ratio of 1:4,688 1:3,703 1:2,384 1:37,391b 1:5,426 1:3,203 1:4,066 Midwives to Population Note: a. Includes both generalist and specialist medical doctor; b. Lamitan City has only two midwives for its population of 74,782. Although 90 percent of the RHUs are PCB accredited, nearly half of the RHUs in BARMM fail to meet the staffing standards established by PhilHealth operational documents. Implementing guidelines for the PCB package stipulates that clinics should be staffed with at least 1 licensed doctor, 1 licensed nurse, 1 licensed midwife, 1 licensed medical technologist able to perform routine laboratory procedures (if the facility houses a laboratory), and 1 licensed radiology technician (if the facility offers x-ray services). At least one member of the RHU staff should be able to conduct sputum microscopy. Across BARMM, less than half of the RHUs meet these requirements. The gaps are the largest in Sulu, where nearly two out of every three RHUs fail to meet this standard. By contrast, nearly 70 percent of the facilities in Lanao del Sur meet these minimum standards (Table 9). Notably, on the day of the survey, physicians were away from the facility at 40 percent of the RHUs 28 Compared to approximately 1 doctor for every 35,580 people, 1 nurse for every 22,000 people, and 1 midwife for every 5,800 people—author’s calculations based on data from DOH (2015) and NSO (2012). 22 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) reporting that doctors are on staff. Among those who were out of the office, most (56 percent) were away for between one and five days. About 10 percent were away for less than one day, 12 percent were traveling for between one and two weeks, and more than 20 percent were traveling for more than two weeks (Figure 6). Table 9. Proportion of RHUs Meeting PhilHealth Accreditation Requirementsa Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Percentage of the 69.2 40.5 25.0 0.0b 36.8 57.1 48.8 RHUs meeting PCB1 staffing requirements Note: PCB1 = Primary care benefit package -1; a. Accreditation Requirements - RHU with at least 1 doctor, 1 nurse, 1 midwife, and 1 medical technologist; b. Neither of the two Lamitan RHUs has a medical technologist. Note: Numbers represent percent. Figure 6. Presence of Municipal Health Office (MHO) Physician at the Time of the Survey Visit 56+12+16610G Panel A Panel B MHO Physician present at the facility present at the time of survey visit Duration of Out-of-Office Lanao del Sur 48.7 33.3 5.1 12.8 less tha a day Maguindanao 24.3 13.5 13.5 48.6 1 to 3 months 10% 6% Basilan 8.3 33.3 58.3 Lamitan City 50.0 50.0 more than two weeks but less 16% 56% than a month Sulu 21.1 15.8 52.6 10.5 Tawi-Tawi 14.3 42.9 21.4 21.4 BARMM 28.5 22.8 19.5 29.3 12% 1-5 days one to two weeks 0 10 20 30 40 50 60 70 80 90 100 % No Yes Don’t Know Not Applicable Source: BARMM SARA, 2019 In the mostly non-devolved context, the DOH-ARMM owned the public primary health care facilities and played a particularly significant role in financing health personnel. The DOH-ARMM funded nearly 60 percent of all government health personnel in the region (Figure 7). In contrast to other parts of the country where the LGUs own and operate the RHUs and, accordingly, allocate a portion of their IRA to ensure that the requisite health workforce is in place, very few LGUs in ARMM had augmented the human resource in the RHUs. As seen in Figure 7, only Basilan and Lamitan City, which have a different governance structure with the LGUs managing health service delivery, play a meaningful role in financing the RHU personnel. 23 Section 3. General Service Availability Figure 7. HRH by Source of Secondment Mainland Provinces Lanao del Sur 21.8 67.7 7.7 2.6 Maguindanao 35.5 54.0 4.2 4.0 2.1 Basilan 27.6 44.7 27.6 Island Provinces Lamitan City 3.7 25.9 66.6 3.7 Sulu 22.8 70.3 3.6 3.1 1.2 1.2 Tawi-Tawi 43.9 52.7 1.2 BARMM 29.1 58.9 4.1 6.9 0.8 0 10 20 30 40 50 60 70 80 90 100 % DOH National DOH ARMM Province City/Municipality Others Source: BARMM SARA, 2019 In addition to the core staff hired locally, the national DOH has instituted several programs to supplement the RHU health workforce. Although initially introduced as stopgap measures, these programs have been ongoing for many years. The Doctors to the Barrios (DTTB) program started in the early 1990s in response to a shortage of doctors in remote areas. More recently, the national DOH launched the Nurse Deployment Program (NDP) and the Rural Health Midwives Placement Program (RHMPP). The RHMPP deploys midwives to areas with low utilization of institutional delivery care, immunization, and FP services. The DOH-National Nutrition Council also sponsors barangay nutrition scholars, who are volunteer community workers to assist in implementing nutrition programs in the locality. Figure 7 illustrates the importance of these programs. Indeed, under ARMM, a full 30 percent of government health staff were deployed by the national DOH; in Tawi-Tawi, this figure was as high as 44 percent. While these programs are concentrated at the national level, the DOH-ARMM had also been supporting HRH at the local level. For example, the Midwives in Every Community in ARMM (MECA) Program has been deploying 600 midwives across ARMM in geographically isolated and disadvantaged areas (GIDAs). Different administrative units of the government emphasize different categories of health staff. The national DOH funds more than half (57 percent) of all government-funded general doctors in the region, while the DOH-ARMM was more likely to pay for specialist doctors (75 percent), nurses (60 percent), and midwives (84 percent). 24 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Section 4. General Service Readiness General service readiness is a broad category covering inputs needed to provide basic medical service divided into five domains: basic amenities, basic equipment, standard precautions for infection prevention, diagnostic capacity, and essential medicines (Figure 8). Tracer indicators from each domain are aggregated to create a domain-specific score for each RHU. These scores are then further aggregated at the province level to provide greater insights into variations in the distribution of resources across BARMM. Figure 8. General Service Readiness, by Province 100 % 90 80 70 72.1 67.1 66.0 60 62.4 63.2 60.0 57.7 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM General Service Readiness Basic Amenities Basic Equipment Diagnostic Capacity Essential Medicines Standard Precaution for Infection Prevention Source: BARMM SARA, 2019 Note: The bar indicates the mean percentage of the 54 indicators available at the RHUs within a given province or ARMM-wide. For each province or region, the blue diamonds indicate mean percentage availability of the seven basic amenities, red squares indicate mean percentage availability of the six basic equipment, black checks indicate the mean percentage availability of the nine standard precautions for infection prevention, orange circles indicate the mean percentage availability of the seven diagnostics, and green triangles indicate the mean percentage availability of the 25 essential medicines. Overall Findings Overall, we find significant gaps in general service readiness across BARMM. For each of the five domains, we indicate the mean percentage of tracer indicators available (Figure 8); the bar aggregates over the five domains to present the mean percentage of the full 54 indicators available and the symbols indicate performance for the 25 Section 4. General Service Readiness individual domains. Basic equipment is consistently the highest scoring index, followed by standard precautions and amenities; diagnostics and essential medicines lag behind these domains. While basic equipment is generally available, with an average score of 86.0 percent, just 31.6 percent of essential medicines are available across regions. The aggregated performance illustrates a need for substantial improvement in all provinces of BARMM. Overall, the facilities in BARMM have less than two-thirds (63.2 percent) of the indicators assessed. In contrast to the service-specific readiness assessments examined later in this report, interprovincial variation is somewhat limited for general service readiness. Of the provinces, performance is the highest in Maguindanao, with an overall average score of 67.1 percent, and the lowest in Basilan, where facilities maintained an average of 57.7 percent of the items assessed. Basic Amenities The basic amenities domain assesses the availability of non-medical inputs to care. The domain includes seven tracer indicators: power, improved water, auditory and visual privacy for patient consultations, access to sanitation facilities for patients, communication equipment (telephone or short-wave radio), computer with e-mail/Internet access, and emergency transportation. There is wide variation in the availability of amenities. While sanitation facilities were widely available, nearly two out of three RHUs lack a computer with Internet. The overall score, aggregating the seven indicators across the five provinces, is just 68.9 percent (Figure 9). Figure 9. General Service Readiness: Basic Amenities Basic Amenities 68.9 Access to adequate sanitation 100.0 facilities for clients Improved water source inside or 90.2 within the grounds of the facility Room with auditory and visual 76.4 privacy for patient consultations Power 69.1 Emergency transportation 67.5 Communication equipment 44.7 (phone or SW radio) Facility has access to computer with email /internet access 34.1 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 26 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) The provinces face widespread gaps in the power supply. Lamitan City is the only area to report full access to electricity from at least one source; nearly 18 percent of the RHUs in Lanao del Sur have no access to electricity. The sources of electricity vary. Mainland provinces are more likely to have electricity from a central grid. RHUs in Maguindanao, in particular, are powered by central power supplies. Solar power is also an important source of electricity across BARMM; 42.1 percent of the facilities in Sulu and 38.5 percent of those in Lanao del Sur use solar power as their main source of electricity. Generators also serve an important function across BARMM, particularly in Sulu, where more than one-quarter of the facilities use generators as their main source of electricity. Across the range of sources, only two-thirds of the RHUs report that the electric supply is sufficient to meet all facility needs. About 16 percent of the facilities in Sulu only have electricity to power stand-alone medical devices, such as Expanded Program on Immunization (EPI)29 cold chain, while 20.5 percent of the facilities in Lanao del Sur only have electricity to power lights and communication equipment (Figure 10 and Figure 11). Figure 10. Availability of Electricity at RHUs Mainland Provinces Lanao del Sur 41.0 10.3 30.8 17.9 Maguindanao 32.4 45.9 18.9 2.7 Basilan 33.3 66.7 Island Provinces Lamitan City 100.0 Sulu 78.9 10.5 10.5 Tawi-Tawi 71.4 21.4 7.1 BARMM 48.0 21.1 23.6 7.3 0 10 20 30 40 50 60 70 80 90 100 % Always available (no interruptions) Often available (interruptions of less than 2 hours per day) No electricity Sometimes available (frequent or prolonged interruptions of more 2 hours per day) Source: BARMM SARA, 2019 29 The current National Immunization Program (NIP) used to be called the Expanded Program on Immunization (EPI). 27 Section 4. General Service Readiness Figure 11. Source and Use of Primary Electricity Panel A - Main Source of Electricity by Province Lanao del Sur 35.9 7.7 38.5 17.9 Provinces Mainland Maguindanao 97.3 2.7 Basilan 58.3 16.7 25.0 Island Provinces Lamitan City 100.0 Sulu 31.6 26.3 42.1 Tawi-Tawi 50.0 14.3 28.6 7.1 BARMM 58.5 9.8 24.4 7.3 0 10 20 30 40 50 60 70 80 90 100 % Central supply of electricity (e.g. National or community grid) Solar system Generator (fuel or battery operated generator) No electricity Panel B - Type of Electricity by Province Lanao del Sur 35.9 23.1 20.5 2.6 17.9 Provinces Mainland Maguindanao 91.9 5.4 2.7 Basilan 66.7 33.3 Island Provinces Lamitan City 100.0 Sulu 78.9 5.3 15.8 Tawi-Tawi 71.4 14.3 7.1 7.1 BARMM 67.5 11.4 9.8 4.1 7.3 0 10 20 30 40 50 60 70 80 90 100 % All electrical needs of facility Only stand-alone electric medical devices/appliances (e.g. EPI cold room) Electric lighting, communications, and 1 to 2 electric devices No electricity Electric lightinf (excl flashlights) & communications Source: BARMM SARA, 2019 28 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) About 90 percent of the facilities report access to improved water sources inside or within their grounds. Water is necessary for maintaining hygiene and sanitation at health facilities, as well as for consumption by staff and patients.30 There is relatively limited inter-province variation in the availability of improved water sources. The RHUs in Sulu reported the most significant gap; 15.8 percent of the facilities are without an improved water source (Figure 12). Figure 12. Improved Water Source Inside or Within the Ground of the Facility Mainland Provinces Lanao del Sur 92.3 Maguindanao 89.2 Basilan 91.7 Island Provinces Lamitan City 100.0 Sulu 84.2 Tawi-Tawi 92.9 BARMM 90.2 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Almost one-quarter of the facilities lack audio privacy, visual privacy, or both for patient consultations. A private space for patient consultations is important for ensuring patients are comfortable discussing their medical issues with health care providers and is critical for the confidentiality of the medical encounter. However, nearly one-third of the facilities in Maguindanao and Sulu lack a private space for consultations, and 14.6 percent lack either auditory or visual privacy (Figure 13). 30 Improved water sources include pipes, public taps, standpipes, boreholes, protected wells or springs, or rainwater that is collected within the grounds of the facility. 29 Section 4. General Service Readiness Figure 13. Auditory and Visual Privacy at RHUs Auditory Both Audio and Visual Privacy Visual Privacy Privacy 76% 5% 4% Neither Auditory nor Visual Privacy 15% Source: BARMM SARA, 2019 There are significant gaps in the availability of communication equipment. Computer and internet connectivity are increasingly critical to maintain accurate and up-to-date health information systems. It is also important for referral and helps ensure smooth transfers of emergency patients. As is illustrated by Table 10, access to computers with e-mail remains rare across BARMM. They are available in one-third or fewer facilities in Basilan, Lanao del Sur, and Sulu while Lamitan City and Maguindanao have more than half of the facilities reporting access to them. Access to phones and short-wave radios is also low inBARMM, with the notable exception of Tawi-Tawi, where 92.9 percent of the RHUs have a telephone or short-wave radio, and Lamitan City, where both of the CHOs have communication equipment. Only one-third of the facilities in Tawi-Tawi have access to emergency transportation for transfers. Emergency evacuation can save lives, but many RHUs in BARMM cannot transport patients safely and quickly. Just 67.5 percent of the facilities can offer emergency transport and more than 80 percent RHUs can do so in just two provinces (Maguindanao and Sulu). Table 10 highlights important geographic trends. Basilan, in particular, underperforms relative to other provinces, while Maguindanao and the urban area of Lamitan City perform relatively well. The largest gaps are in access to communication and transportation equipment. 30 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 10. Availability of Basic Amenities Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Power 51.3 78.4 33.3 100.0 89.5 92.9 69.1 Improved water 92.3 89.2 91.7 100.0 84.2 92.9 90.2 source; inside or within the grounds of the facility Room with 79.5 67.6 91.7 50.0 68.4 92.9 76.4 auditory and visual privacy for patient consultations Access to adequate 100.0 100.0 100.0 100.0 100.0 100.0 100.0 sanitation facilities for clients Communication 25.6 59.5 16.7 100.0 31.6 92.9 44.7 equipment (telephone or short-wave radio) Facility has access 25.6 59.5 8.3 50.0 26.3 21.4 34.1 to computer with e-mail/Internet access Emergency 59.0 81.1 58.3 100.0 84.2 35.7 67.5 transportation Basic amenities 61.9 76.4 57.1 85.7 69.2 75.5 68.9 Note: Indicators available at 50 percent of RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Basic Equipment The basic equipment domain includes six tracer indicators: adult and child scales, a thermometer, a stethoscope, a blood pressure (BP) apparatus, and a light source. The importance of this equipment is reflected by their frequent inclusion in the 11 specific service readiness assessments reviewed in this report. Adult scales, thermometers, stethoscopes, and BP apparatus are all nearly universally available. However, across BARMM, child scales were seen at just over half of the RHUs—this number drops to only 28.2 percent of the RHUs in Lanao del Sur and 47.4 percent of those in Sulu. A spotlight light source that can be used for patient exams31 is available in 77.2 percent of the RHUs (Figure 14). 31 The light source could be a flashlight. 31 Section 4. General Service Readiness Figure 14. General Service Readiness: Basic Equipment Basic Equipment 86.0 BP apparatus 100.0 Adult scale 96.7 Stethoscope 94.3 Thermometer 94.3 Light source 77.2 Child scale 53.7 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 While overall performance is relatively high, we find evidence of interprovincial variability in the availability of basic equipment. For example, almost all (92.9 percent) facilities in Tawi-Tawi have child scales, but only one-quarter of those in Lanao del Sur do so. Similarly, almost all RHUs in Tawi-Tawi have a light source to conduct patient exams, while a spotlight source is missing from nearly one-third of the RHUs in Basilan, Sulu, and Lanao del Sur (Table 11). Table 11. Availability of Basic Equipment Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Adult scale 92.3 100.0 100.0 100.0 94.7 100.0 96.7 Child scale 28.2 67.6 50.0 100.0 47.4 92.9 53.7 Thermometer 89.7 97.3 100.0 100.0 89.5 100.0 94.3 Stethoscope 87.2 100.0 100.0 100.0 89.5 100.0 94.3 BP apparatus 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Light source 69.2 86.5 66.7 100.0 68.4 92.9 77.2 Basic equipment 77.8 91.9 86.1 100.0 81.6 97.6 86.0 Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. 32 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Standard Precautions for Infection Prevention The assessment of standard precautions for infection prevention focuses on the safe handling, management, and disposal of infectious waste. Infection prevention includes nine tracer indicators: safe final disposal of sharps, safe final disposal of infectious waste, sharps storage, infectious waste storage, single-use syringes, disinfectant, soap and running water or alcohol-based hand rub, latex gloves, and guidelines on infection prevention. Figure 15. General Service Readiness: Standard Precautions for Infection Prevention Standard precautions for 77.3 infection prevention Appropriate storage of 100.0 sharps waste Soap and water or alcohol-based 98.4 hand rub Single use syringes 96.7 Latex gloves 95.1 Disinfectant 89.4 Safe final disposal of sharps 82.9 Safe final disposal of 68.3 infectious wastes Guidelines for 36.6 standard precautions Appropriate storage of 28.5 infectious waste 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Infection prevention is a relatively high-scoring domain, but nearly three-quarters of RHUs cannot safely store infectious wastes. Aggregate performance averages at approximately 77 percent. Availability of single-use syringes and safe disposal of sharps are both nearly universal, and disinfectant is also widespread. However, storage of infectious waste in a lidded bin with a plastic liner is available at just over one-quarter of the RHUs in BARMM (Figure 15). Guidelines for standard precautions are also widely lacking. They are available at approximately one-third of the facilities in Lanao del Sur, Maguindanao, and Sulu; no facilities in Basilan had them in stock on the day of the survey. 33 Section 4. General Service Readiness The availability of storage for infectious waste varied by province. While nearly two-thirds of Maguindanao’s RHUs can safely store infectious waste, this is true of just 7.1 percent of the facilities in Tawi-Tawi and fewer than 20 percent of the RHUs in Basilan, Lanao del Sur, and Sulu. Similarly, 83.3 percent of the RHUs in Basilan are able to safely dispose of infectious waste, which could include incineration, open burning in a protected area, dump without burning in a protected area, or removal to a protected storage area, while the same is true for just 56.4 percent of the facilities in Lanao del Sur (Table 12). Table 12. Standard Precautions for Infection Prevention Mainland Provinces Island Provinces Indicator Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Safe final disposal 89.7 81.1 83.3 100.0 84.2 64.3 82.9 of sharps Safe final disposal 56.4 67.6 83.3 100.0 78.9 71.4 68.3 of infectious wastes Appropriate storage 100.0 100.0 100.0 100.0 100.0 100.0 100.0 of sharps waste Appropriate storage 15.4 62.2 8.3 50.0 15.8 7.1 28.5 of infectious waste Disinfectant 84.6 91.9 91.7 100.0 84.2 100.0 89.4 Single-use - 94.9 97.3 100.0 100.0 94.7 100.0 96.7 standard disposable or auto-disable syringes Soap and running 94.9 100.0 100.0 100.0 100.0 100.0 98.4 water or alcohol- based hand rub Latex gloves 87.2 97.3 100.0 100.0 100.0 100.0 95.1 Guidelines 35.9 35.1 0.0 50.0 36.8 71.4 36.6 for standard precautions Standard 73.2 81.4 74.1 88.9 77.2 79.4 77.3 precautions for infection prevention Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. 34 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Diagnostic Capacity Tracer indicators on diagnostic capacity investigate the capacity of facilities to conduct eight routine tests covering a range of priority health conditions. These include diagnostic capacity for hemoglobin; blood glucose; urine dipsticks for protein and glucose; urine tests for pregnancy; and malaria, HIV, and syphilis diagnosis. The survey identified that none of the 123 facilities visited provide HIV or syphilis testing, since these are usually carried out in social hygiene clinics. Urine tests for pregnancy and blood glucose testing were found at 88.6 percent and 85.4 percent of the facilities, respectively. Urine dipsticks for protein and glucose were available in 45.5 percent of the facilities, while malaria diagnostic tests were available at 61.0 percent of the facilities (Figure 16). These findings preview relatively strong performance in MCH programs—particularly in comparison to NCD diagnosis and care. Figure 16. General Service Readiness: Diagnostic Capacity Diagnostic Capacity 52.0 Urine test for pregnancy 88.6 Blood glucose 85.4 Hemoglobin 83.7 Malaria diagnostic capacity 61.0 Urine dipstick-protein and glucose 45.5 Syphilis rapid test 0.0 HIV diagnostic capacity 0.0 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 There is significant variation between provinces; with a mean performance score of 57.1 percent, Sulu had the highest overall readiness to provide general diagnostic services. At the lower end of the performance spectrum, facilities in Basilan and Maguindanao had less than half of the diagnostic indicators on the day of the survey. The difference in scores largely reflects the lack of protein and glucose urine dipsticks in the lower performing provinces (Table 13). 35 Section 4. General Service Readiness Table 13. Diagnostic Capacity Mainland Provinces Island Provinces Diagnostic Capacity Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Hemoglobin 76.9 89.2 75.0 50.0 94.7 85.7 83.7 Blood glucose 76.9 91.9 75.0 100.0 94.7 85.7 85.4 Malaria diagnostic 48.7 51.4 50.0 50.0 94.7 85.2 61.0 capacity Urine dipstick- 76.9 32.4 33.3 50.0 21.1 35.7 45.5 protein and glucose HIV diagnostic 0.0 0.0 0.0 0.0 0.0 0.0 0.0 capacity Syphilis rapid test 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Urine test for 89.7 83.8 100.0 100.0 94.7 78.6 88.6 pregnancy Diagnostic Capacity 52.7 49.8 47.6 50.0 57.1 53.1 52.0 Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Essential Medicines The essential medicines domain is the broadest of any assessed in this report and includes critical medicines needed to treat a variety of MCH, NCD, and communicable conditions. Specifically, the domain tracks 25 tracer indicators, including calcium channel blockers, amoxicillin syrup and tablet, ampicillin, aspirin, beclomethasone, beta blockers, carbamazepine, ceftriaxone, diazepam, angiotensin-converting-enzyme (ACE) inhibitors, fluoxetine, gentamicin, glibenclamide, haloperidol, insulin, magnesium sulfate, metformin, omeprazole, oral rehydration solution (ORS), oxytocin, salbutamol, statins, thiazide, and zinc sulfate. The results show gaps in the availability of essential medicines at the RHUs. Only amoxicillin, ORS, and oxytocin were available at more than half of the facilities in each of the five provinces. Beclomethasone, thiazide, ceftriaxone, glibenclamide, and aspirin inhalers were each available in less than 10 percent of the facilities, and gentamicin, ampicillin powder, diazepam, salbutamol, and simvastatin were available at less than 20 percent of the facilities. ORS was the most widely available medicine but was still missing at 11 percent of the facilities, while oxytocin was missing at 15 percent of the facilities. Carbamazepine, fluoxetine, haloperidol, and insulin were not available at any RHU in BARMM (Figure 17). 36 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 17. General Service Readiness: Essential Medicines Essential Medicines 31.6 28.5 Oral rehydration solution 88.6 Oxytocin injection 84.6 Amoxicillin tablet 76.4 Amoxicillin syrup/suspension/dispersible 74.0 Metformin tablet 69.1 Beta blocker 66.7 Zinc sulphate tablets, dispersible tables 56.1 or syrup Magnesium sulphate... 48.8 Enal april tablet or alternative ACE inhibitor 43.9 Calcium channel blocker 39.0 Omeprazole tablet or alternative 33.3 Simvastatin tablet or other statin 19.5 Salbutamol inhaler 18.7 Diazepam injection 16.3 Ampicillin powder 14.6 Gentamicin injection 13.8 Ceftriaxone injection 7.3 Glibenclamide tablet 6.5 Aspirin cap/tab 6.5 Thiazide 4.1 Beclometasone inhaler 1.6 Insulin regular injection 0.0 Haloperidol tablet 0.0 Fluoxetine tablet 0.0 Carbamazepine tablet 0.0 0 10 20 30 40 50 60 70 80 90 100 % The gaps in the availability of essential medicines are widespread, and there is relatively little interprovincial variation in aggregate scores. Lamitan City and Maguindanao both maintained an average of just 36 percent of medicines; Tawi-Tawi was the lowest-scoring province, with just 24 percent. The differences between provinces cannot be isolated to any particular drug(s) and appear to be a result of systemic differences in the supply chains between the provinces (Table 14). 37 Section 4. General Service Readiness Table 14. Availability of Essential Medicines Mainland Provinces Island Provinces Essential Medicines Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Calcium channel 74.4 21.6 0.0 100.0 31.6 21.4 39.0 blockera Amoxicillinb 79.5 91.9 58.3 100.0 63.2 35.7 74.0 Amoxicillin tablet 87.2 75.7 58.3 100.0 78.9 57.1 76.4 Ampicillin powder 7.7 13.5 25.0 50.0 15.8 21.4 14.6 for injection Aspirin cap/tab 7.7 8.1 0.0 0.0 5.3 7.1 6.5 Beclomethasone 0.0 0.0 8.3 0.0 0.0 7.1 1.6 inhaler Beta blocker 79.5 91.9 41.7 50.0 31.6 35.7 66.7 Carbamazepine 0.0 0.0 0.0 0.0 0.0 0.0 0.0 tablet Ceftriaxone 2.6 13.5 0.0 0.0 0.0 21.4 7.3 injection Diazepam injection 10.3 35.1 0.0 50.0 0.0 14.3 16.3 ACE inhibitorc 48.7 59.5 33.3 0.0 36.8 14.3 43.9 Fluoxetine tablet 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Gentamicin 2.6 29.7 0.0 50.0 5.3 21.4 13.8 injection Glibenclamide 2.6 10.8 0.0 0.0 10.5 7.1 6.5 tablet Haloperidol tablet 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Insulin regular 0.0 0.0 0.0 0.0 0.0 0.0 0.0 injection Magnesium sulfate 33.3 59.5 50.0 50.0 57.9 50.0 48.8 injectable Metformin tablet 92.3 78.4 41.7 50.0 26.3 64.3 69.1 Omeprazole tablet 48.7 27.0 0.0 0.0 42.1 28.6 33.3 or alternative Oral rehydration 94.9 91.9 91.7 100.0 84.2 64.3 88.6 solution Oxytocin injection 76.9 86.5 83.3 100.0 94.7 85.7 84.6 Salbutamol inhaler 20.5 24.3 8.3 0.0 21.1 7.1 18.7 Simvastatin tablet 23.1 32.4 16.7 0.0 5.3 0.0 19.5 or other statin Thiazide 7.7 2.7 0.0 0.0 0.0 7.1 4.1 Zinc sulphated 64.1 43.2 66.7 100.0 68.4 35.7 56.1 Essential Medicines 34.6 35.9 23.3 36.0 27.2 24.3 31.6 Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. a. Amlodipine tablet or alternative; b. Syrup, suspension, or dispersible tablet; c. Enalapril tablet or alternative; d. Tablets, dispersible tablets, or syrup. Note: Numbers represent percent. 38 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Essential medicines are generally procured centrally by the national DOH. The DOH regularly provides maintenance medicines such as amlodipine (calcium channel blocker), losartan (an alternative to enalapril or ACE inhibitor), metoprolol (beta blocker), and metformin. With the exception of amlodipine, these medicines were relatively more available than most others in the RHUs.32 Until 2015, the DOH also had a Complete Treatment Pack program which provided to all RHUs nationwide common medicines including aspirin and antibiotics such as amoxicillin. However, the program discontinued in 2015. The regional office currently provides amoxicillin, which may explain its wide availability in most provinces; aspirin could be found in very few RHUs at the time of the survey. Supply chain issues reflect poor coordination within the health sector. The public health system relies heavily on verticalized programs, many of which have internal logistic arrangements to distribute medicines and diagnostics. Through these, commodities may be distributed to the IPHOs or directly to the RHUs. Key informant interviews at the national DOH, DOH-ARMM, and some RHUs reveal several logistics issues in the distribution of the goods from Metro Manila to the RHUs and other facilities nationwide. Supply requests are frequently served with up to a year delay, jeopardizing the forecasting of supplies requirements. The distribution arrangements also change from time to time. There were different accounts on which commodities are delivered only up to the provincial level and which ones are delivered directly to the RHUs, and during which period. Buffer stocks are also delivered to the regional office warehouse, with accounts of near-expiring stocks delivered to the warehouse even if not requested. These also reflect challenges in communications and coordination among the different offices of the DOH-ARMM including the Technical Service Office, the Supplies Office, and the Planning Office. The impact of this was evident in the assessment of immunization readiness which showed poor availability of vaccine supplies. One-third of the facilities did not have measles or pentavalent vaccines in stock, and oral polio vaccine (OPV) was available at fewer than half of the facilities. Vaccines not included on the NIP schedule, such as the human papillomavirus (HPV) and rotavirus vaccines, were barely or not at all available. These gaps are of concern given the alarmingly low vaccination rates in BARMM.. Performance by PhilHealth Accreditation Status PhilHealth PCB accreditation status does not seem to be strong indication of the general service readiness of an RHU in BARMM. As noted earlier in this report, there are relatively few nonaccredited facilities. Both of the CHOs in Lamitan City and all of the RHUs in Lanao del Sur were accredited. Our analyses suggest that general service readiness of PCB-accredited facilities is only slightly higher than that of facilities that are not PCB accredited. In Sulu, the few nonaccredited RHUs had almost the same rating as that of the accredited RHUs. In Basilan, where half of the RHUs are PCB accredited and half are not, the average score of the accredited facilities was higher by 5 percentage points than the non-accredited facilities. Moreover, at just 63.9 percent, the average scores for even the accredited facilities shown significant need of improvement. 32 A random monitoring form inspected showed deliveries of the losartan, metoprolol, and metformin, but not of amlodipine, suggesting a supply gap in the national DOH also. 39 Section 4. General Service Readiness Table 15. General Service Readiness Scores by PCB Accreditation Province PCB Accredited Not PCB Accredited Total Lanao del Sur Score 60.0% n.a. 60.0% n 39 0 39 Maguindanao Score 67.4% 55.4% 67.1% n 36 1 37 Basilan Score 60.3% 55.0% 57.7% n 6 6 12 Lamitan City Score 72.1% n.a. 72.1% n 2 0 2 Sulu Score 62.6% 59.9% 62.4% n 18 1 19 Tawi-Tawi Score 69.3% 57.6% 66.0% n 10 4 14 BARMM Score 63.9% 56.3% 63.2% n 111 12 123 Note: Numbers represent percent. 40 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Section 5. Specific Service Readiness Overview Specific service readiness assessments examine the functional ability of facilities to provide specified priority services. The specific services examined include five MCH services (FP, ANC, BONC, immunization, and childhood illness care); four NCD services (diabetes care, cardiovascular disease, CRD, and cervical cancer care); and two communicable disease services (TB and malaria). For each of 11 services, we provide information on the availability of inputs needed to deliver care, including the availability of trained personnel, service-specific equipment, diagnostics, and medications needed to provide the service. Maternal and Child Health Despite years of policy attention, MCH outcomes in the Philippines continue to lag behind those of regional and economic peers. A 2012 United Nations Children’s Fund (UNICEF) report estimated that 13 Filipino mothers die each day because of complications related to childbirth (UNICEF 2012). The most recent estimate of the maternal mortality rate (MMR)—114 deaths per 100,000 live births in 2015—indicates a lack of significant progress at the national level in the years since.33 While precise information on health outcomes in ARMM is limited (Mujer Quintos 2017), there is evidence that MCH outcomes, including maternal and child mortality, are particularly poor in the region (PSA and ICF International 2014, 2018). Under-5 mortality in ARMM, for example, is nearly 80 percent higher than the national average (Table 16). Table 16. Neonatal, Infant, and Under-5 Mortality Rates, per 1,000 Live Births BARMM National Neonatal Mortality Rate 11 13 Infant Mortality Rate 32 23 Under-5 Mortality Rate 55 31 Source: Australia DFAT and World Bank 2015. Note: Numbers represent percent. National policies aimed at improving MCH outcomes are well aligned with international best practices. A 2008 DOH Administrative Order (A.O.) aims to eliminate traditional birth attendants by authorizing only trained midwives, nurses, and doctors to assist women at delivery.34 LGUs nationwide are expected to ensure that local facilities have the resources needed to deliver effective intrapartum care, while PhilHealth reimbursements are applicable for normal delivery at accredited facilities through the MCP and for newborn services through the complementary Newborn Care Package (NCP).35 33 “World Databank.” World Bank (Online). Available: http://www.worldbank.org/. Accessed: February 25, 2018. 34 A.O. 2008-0029: Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality. 35 Includes physical examination and screening tests, eye prophylaxis, Vitamin K administration, and Bacillus Calmette–Guérin (BCG), and Hepatitis B (HepB) vaccination, as well as breastfeeding advice for the new mother. 41 Section 5. Specific Service Readiness Overview Efforts to ensure safe delivery are reinforced by policies promoting access to ANC and FP services. PhilHealth’s MCP entitles women to a minimum of four ANC visits as part of the complete MCP; in the case that a woman intends to deliver elsewhere, a stand-alone ANC package provides a case-based payment to eligible facilities for each woman attending four or more ANC visits. The Reproductive Health Law of 2013 entitles universal access to contraception to avoid mistimed, unplanned, unwanted, and unsupported pregnancies. While legal and political struggles with pro-life groups around the country delayed full implementation of the law nationwide, the Executive Order (E.O.) 12 s. 201736 ordered the DOH to review and redress gaps in the implementation of the Reproductive Health Laws. PhilHealth benefit packages cover long-lasting and reversible forms of contraception, including intrauterine contraceptive devices (IUCDs) and implants and LGUs are responsible for procuring including oral contraceptives, Depot Medroxyprogesterone Acetate (DMPA), and condoms. Family Planning Contraceptive use is far less common in BARMM than it is in other regions of the Philippines. Nationally, the utilization rate of FP commodities stands at 54.3 percent, which is about twice the utilization rate found in BARMM (26.3 percent) (PSA and ICF International 2018). Figure 18 focuses on modern contraceptive preference structures in BARMM and nationwide, for which the disparities in utilization are similar to those for overall contraception use. Nationally, 40.4 percent of women use modern contraceptives, compared to 18.7 percent of women in BARMM. While hormone pills are the most commonly used contraceptives in both populations, they are far more popular in the national population (57 percent of all contraceptive use) than in BARMM (43 percent of all contraceptive use). By contrast, injectables are relatively more popular in BARMM, where they account for 32 percent of all contraceptive use compared to 15 percent of all contraceptive use nationwide. Within BARMM, provincial-level data suggest that Maguindanao has the highest reported utilization rate (50.3 percent), while Basilan has the lowest (24.1 percent). Notably, contraceptive use in all five of the provinces in BARMM remains well below the national DOH target of 65 percent. 36 E.O. No. 12 s. 2017: Attaining and sustaining ‘Zero Unmet Need for Family Planning’ through the strict implementation of the Responsible Parenthood and Reproductive Health Act, providing funds for that and for other purposes. 42 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 18. Modern Contraceptive Preferences - BARMM and National Preferences 50 % 45 40 0.5 0.1 1.7 35 30 20.9 25 20 0.1 0.2 1.1 15 9.7 5.0 10 0.6 3.5 5.6 5 7.4 1.2 1.5 0 ARMM National Female Sterilization Injectable Condom Male Sterilization Implant Standard Days Method IUD Pills Lactational Amenorrhea Method Source: NDHS 2017. Box 1. Family Planning Service Readiness Indicators The staff and guidelines domain assesses the availability of FP guidelines, checklists, and staff trained in FP. The equipment domain confirms the availability of a BP apparatus. The medicines and commodities domain assess the availability of combined estrogen-progesterone oral contraceptive pills, progestin-only contraceptive pills, injectable contraceptives, and condoms. The overall score aggregates over the 8 tracer indicators. 43 Section 5. Specific Service Readiness Overview In contrast to the utilization status as reported in the NDHS, overall readiness to provide FP services was the highest of the 12 specific services investigated in this report. Facilities in BARMM have on average, 87.3 percent of the FP tracer indicators, and interprovincial variation was relatively narrow. As illustrated in Figure 19, the most significant gaps relate to the staff and guidelines domain. Figure 19. Family Planning Service Readiness 100 % 100.0 90 91.4 88.5 87.3 86.6 84.6 84.4 80 70 60 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Family Planning Service Readiness Staffing and Guidelines Equipment Medicines and Commodities Source: BARMM SARA, 2019 Despite overall high aggregate scores, gaps remain in ensuring training and access to job aids for facility staff (Figure 20). Nearly 30 percent of the facilities did not have any staff trained to provide FP services, one-quarter did not have guidelines related to the provision of FP services, and two-thirds did not have any job aids on hand. The largest gap in job aids was found in Lanao del Sur, where less than half (41.0 percent) of the facilities had FP checklists or job aids. The core medicines and commodities included in the SARA FP service readiness score are widely available, but there are larger gaps in the availability of other forms of FP commodities. Of the tracer commodities (combined estrogen-progesterone oral contraceptive pill, progestin-only contraceptive pill, injectables and condoms), all were available at more than 90 percent of facilities and only the progestin-only contraceptive pills were available at fewer than 95 percent of the RHUs. The four contraceptives investigated as part of the service readiness 44 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 20. FP: Staff and Guidelines Staff and Guidelines 71.8 Guidelines on family planning 78.9 Staff trained in FP 70.9 Family planning checklists and/ 65.9 or job-aids 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 score for FP ensure capacity to provide the basic services but comprise a relatively small proportion of the contraceptives in general use. Survey teams investigated several auxiliary commodities to provide a fuller picture. The teams asked whether supplies were in stock and valid, currently out of stock or expired, or if they are never stocked. As shown in Figure 21, estrogen-progesterone combination injectables are rarely stocked in BARMM, as are female condoms. The long-lasting intrauterine device (IUD) was available at approximately three-quarters of the facilities in BARMM. Notably, nearly 20 percent of the RHUs reported IUD being out of stock. Figure 21. FP: Auxiliary Medicines and Commodities Intrauterine contraceptive 60.2 18.7 21.1 device (IUD) Emergency contraceptive pills 11.4 0.8 87.8 Implants 27.6 15.4 56.9 Female condoms 0.8 99.2 Male condoms 94.3 4.1 1.6 Injectable contraceptives 2.4 8.9 88.6 Progestin-only injectable 87.8 4.1 8.1 contraceptives Combined estogen progesterone 12.2 6.5 81.3 injectable contraceptives Progestin-only 86.2 9.8 4.1 contraceptive pills Combined estogen progesterone 96.7 2.4 0.8 oral contraceptive pills 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or Currently out of stock Never had it Source: BARMM SARA, 2019 Note: For each medicine or commodity, bars shaded in blue represent the proportion of facilities having supplies in stock on the day of the survey. Bars shaded in green represent the proportion of facilities who report having stocked the supply in the past but for whom the supply was either out of stock on not valid on the day of the survey. Bars shaded in rose represent the proportion of facilities that report having never stocked the supply. For example, we see that 60 percent of facilities had intrauterine contraceptive devices (IUCDs) in stock on the day of the survey, 19 percent of facilities were either out of stock or stocked invalid IUCDs, and 21 percent of facilities reportedly never stocked IUCDs. 45 Section 5. Specific Service Readiness Overview There is relatively little variation in readiness to provide FP services across the five provinces. Facilities in the lowest scoring province—Basilan—have an average of 84.4 percent of the inputs investigated, while those in Sulu, the highest scoring province, have 91.4 percent of the tracer indicators (Table 17). Table 17. FP Service Readiness Mainland Provinces Island Provinces Family Planning Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Service Readiness Staff and Guidelines 67.5 74.8 66.7 100.0 77.2 69.0 71.8 Equipment 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Medicines and 93.6 95.9 93.8 100.0 100.0 96.4 95.7 Commodities FP Service 84.6 88.5 84.4 100.0 91.4 86.6 87.3 Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Antenatal Care BARMM has the lowest ANC utilization rate in the country. In 2013, 95.4 percent of pregnant women nationwide received ANC from a skilled provider (PSA and ICF International 2014). In BARMM, however, this figure was just 52.8 percent. There has been little measurable progress since then. According to the most recent figures, 86.5 percent of pregnant women nationwide attended the recommended four visits in 2017; the same is true for less than half—just 47.8 percent—of pregnant women in BARMM (PSA and ICF International 2018). Field Health Service Information System (FHSIS) data suggest significant variation in utilization of ANC among the five provinces of BARMM (Table 18). The mainland provinces of Maguindanao and Lanao del Sur report coverage of 4+ ANC visits nearly on par with the national average. The island provinces, however, indicate overall low coverage and unsteady progress over time. While caution must be used when interpreting routine data, data indicate particularly low utilization in the provinces reporting the highest maternal and infant mortality rates: Basilan and Sulu. Table 18. ANC Utilization Rates - Data Provided by DOH-ARMM ANC 4- Visit 2013 2014 2015 2016 Lanao del Sur 76.9 87.6 88.6 84.7 Maguindanao 61.0 78.0 77.0 70.0 Basilan 25.7 38.2 37.7 34.3 Sulua 35.0 63.0 46.0 42.0 Tawi-Tawi - - - - Note: a. From Summit Presentation. Sulu presented data listed as ANC, 4x not specified. Tawi-Tawi did not include this in its summit presentation. Note: Numbers represent percent. 46 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Box 2. ANC Service Readiness Indicators The staff and guidelines domain assesses the availability of ANC guidelines, checklists, and staff trained in ANC. The equipment domain confirms the availability of a BP apparatus. The diagnostics domains check for hemoglobin and urine dipstick- protein testing capacity. The medicines and commodities domain assess the availability of iron tablets, folic acid tablets (or iron folic tablets), tetanus toxoid, intermittent preventive treatment (IPT) drug (for malaria), and insecticide-treated nets (ITNs). The overall score aggregates over the 11 tracer indicators. Overall, facilities in BARMM have an average of 68.0 percent of the ANC tracer indicators; provincial scores ranged from a low of 58.7 percent in Lanao del Sur to a high of 79.2 percent in Tawi-Tawi (Figure 22). All RHUs have equipment to check BP, which is the sole tracer indicator included in the equipment domain. There is relatively little variation in the availability of staff and guidelines (aggregate score of 62.9 percent), diagnostics (66.0 percent), or medicines and commodities (67.8 percent). Figure 22. ANC Service Readiness 100 % 90 80 77.0 79.2 70 71.0 68.2 60 61.4 68.0 58.7 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Antenatal Care Service Readiness Staffing and Guidelines Equipment Diagnostics Medicines and Commodities Source: BARMM SARA, 2019 47 Section 5. Specific Service Readiness Overview Diagnostic capacity and commodities for ANC are not consistently available across the region. Survey teams looked for the capacity to perform hemoglobin tests and of dipsticks to monitor urine protein; the former was found in most—83.7 percent—of the RHUs, but urine protein testing capacity was missing in more than half the facilities across BARMM. Just 45.5 percent of the RHUs had testing materials on hand on the day of the interview. Among the tracer medicines and commodities, iron and folic acid tablets were universally available (Figure 23). However, there are gaps in the availability of tetanus toxoid (Figure 24). Figure 23. ANC: Medicines and Commodities ANC Medicines and Commodities 66.0 Folic acid tablets 100.0 Iron tablets 100.0 Tetanus toxoid vaccine 71.5 IPT drug 30.9 ITNs 27.6 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 48 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 24. ANC: Medicines and Commodities - Availability of Tetanus Toxoid Vaccine Mainland Provinces Lanao del Sur 46.2 53.8 Maguindanao 86.5 8.1 5.4 Basilan 75.0 25.0 Island Provinces Lamitan City 50.0 50.0 Sulu 84.2 15.8 Tawi-Tawi 85.7 14.3 BARMM 71.5 26.8 2.0 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or Currently out of stock Never had it Source: BARMM SARA, 2019 Note: For each medicine or commodity, bars shaded in blue represent the proportion of facilities having supplies in stock on the day of the survey. Bars shaded in green represent the proportion of facilities who report having stocked the supply in the past but for whom the supply was either out of stock on not valid on the day of the survey. Bars shaded in rose represent the proportion of facilities that report having never stocked the supply. For example, we see that, BARMM-wide, 72 percent of facilities had tetanus toxoid vaccine in stock on the day of the survey, 27 percent of facilities were either out of stock or stocked invalid vaccines, and 2 percent of facilities reportedly never stocked tetanus toxoid vaccine. Inputs to prevent and treat malaria among pregnant women were generally available in areas with ongoing transmission of the parasite but were otherwise not present. In the first quarter of 2016, just 33 cases of malaria were reported in BARMM; 22 of those cases were in Sulu, 9 were in Tawi-Tawi, and the remainder were in Maguindanao. The availability of malaria-specific commodities appears to track with the parasite’s prevalence. About 84 percent of the RHUs in Sulu stock IPTs and 74 percent stock ITNs. To the extent that the allocation of these resources reflects the needs of local populations, domain scores may underestimate actual readiness to deliver care. Overall readiness to deliver ANC services is highest in Tawi-Tawi and lowest in Lanao del Sur. Variations in performance reflect a combination of factors (Table 19). For example, there are substantial interprovincial differences in the availability of trained staff and guidelines. Just 38.5 percent of the facilities in Lanao del Sur had guidelines on ANC, and 56.4 percent had staff trained on ANC. In Basilan and Sulu, less than half of the RHUs have at least one staff member trained on ANC. Meanwhile, higher readiness scores in Tawi-Tawi and Sulu reflect the general availability of commodities related to the prevention and treatment of malaria in these provinces. 49 Section 5. Specific Service Readiness Overview Table 19. ANC Service Readiness Mainland Provinces Island Provinces Indicator Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 46.2 73.9 58.3 100.0 63.2 78.6 62.9 Equipment 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Diagnostics 76.9 60.8 54.2 50.0 57.9 60.7 64.6 Medicines and 50.8 67.6 58.3 50.0 88.4 82.9 66.0 Commodities Antenatal Care 58.7 71.0 61.4 68.2 77.0 79.2 68.0 Service Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Basic Obstetric and Neonatal Care Institutional delivery rates are significantly lower in BARMM than elsewhere in the country. Recently released data from the 2017 NDHS indicate that just 28.4 percent of pregnant women gave birth at a facility, compared to the national average of 77.7 percent (PSA and ICF International 2018). Despite low overall utilization rates, both household and routine data indicate that institutional delivery is increasing in BARMM. Although the overall facility-based delivery rate remains well below the national target of 91 percent, 2017 NDHS data for ARMM indicated that it had nearly doubled since 2013, when just 12.4 percent of women gave birth at health facilities. FHSIS data from ARMM suggest significant progress in all five provinces between 2013 and 2016. Although Sulu had the lowest reported facility-based delivery rate in 2016 at 24.0 percent, this figure represents a remarkable sixfold increase over the 2013 rate (Figure 25). 50 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 25. Facility-Based Delivery 2013–2016 80.1 80 % 74.0 70 67.2 70.1 59.2 64.5 60 54.1 50.1 50 46.7 53.1 39.7 40 43.4 34.6 37.5 29.4 30.3 30 34.0 31.6 26.0 20 23.2 17.2 24.0 17.7 9.7 10 12.2 4.6 0 2013 2014 2015 2016 Basilan Lanao del Sur Maguindanao Sulu Tawi-Tawi Lamitan City BARMM Source: FHSIS Data from DOH-ARMM. Box 3. BONC Service Readiness Indicators The staff and guidelines domain checks for guidelines for essential childbirth care, checklists and/or job aids for essential childbirth care, staff trained in essential childbirth care, and staff trained in newborn resuscitation. The equipment domain asked about the availability of emergency transportation, sterilization equipment, an examination light, a delivery pack, a suction catheter and suction bulb, a manual vacuum extractor, a vacuum aspirator or dilation and curettage kit and speculum, a neonatal bag and mask, a delivery bed, a partograph, gloves, an infant weighing scale, BP apparatus, and soap and running water or alcohol-based hand rub. Under medicines and commodities, survey teams checked for antibiotic eye ointment for the newborn, injectable uteratonic, injectable antibiotic (ampicillin, gentamicin, or metronidazole), magnesium sulfate, skin disinfectant, and intravenous infusion. The overall score averages across the 24 tracer indicators. 51 Section 5. Specific Service Readiness Overview The RHUs across BARMM have substantial gaps in their readiness to provide BONC services. Among the five provinces, Maguindanao has the highest overall readiness score with nearly three-quarters of the tracer indicators, while facilities in Lanao del Sur have an average of just half of the tracer indicators assessed. While the score was low in all of the domains, staff and guidelines was the lowest scoring domain (Figure 26). Figure 26. BONC Service Readiness 100 % 90 80 83.3 73.8 70 67.1 67.9 65.0 60 61.5 54.6 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Basic Obstetric Care Service Readiness Staffing and Guidelines Equipment Medicines and Commodities Source: BARMM SARA, 2019 Facilities have an average of just under half (47.6 percent) of the staff training and guidelines indicators assessed. As shown in Figure 27, the checklists and/or job aides for essential childbirth care indicator was the most commonly available of the four tracer indicators included in this domain. All RHUs in Lamitan City and 70 percent of those in Maguindanao have staff trained in essential childbirth care in the province. By contrast, in Lanao del Sur only 30 percent of the RHUs have staff trained in childbirth care, and even fewer have staff trained in newborn resuscitation. Most basic equipment was nearly universally available, but there is wide interprovincial variability in access to emergency transportation. BP apparatuses, gloves, and soap and running water, or alcohol hand rub were almost universally available, and delivery beds were available at approximately 90 percent of the RHUs across BARMM 52 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 27. BONC: Staff and Guidelines Staff and Guidelines 47.6 Checklist and/or job-aids for 55.3 essential childbirth care Guidelines for essential 48.8 childbirth care Staff trained in essential 43.9 childbirth care Staff trained in 42.3 newborn resuscitation 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 (Figure 28). Infant scales, sterilization, and examination lights were found at 80 percent or more of the facilities. Vacuum extractors and aspirators were rare but use of this equipment is not recommended in the Philippine setting. Access to emergency transportation highlights the extreme variability: while two-thirds of the facilities overall had emergency transport, this varied from a low of just 35.7 percent of the RHUs in Tawi-Tawi, probably due to its extreme remoteness, to 84.2 percent in Sulu and 100 percent in Lamitan City. Figure 28. BONC: Equipment BONC Equipment 69.3 BP apparatus 100.0 Soap and running water or alcohol-based 98.4 hand rub Gloves 95.1 Delivery bed 90.2 Infant weighing scale 88.6 Examination light 82.9 Sterilization equipment 82.9 Partograph 73.2 Suction apparatus (mucus extractor) 73.2 Emergency transport 67.5 Delivery pack 56.1 Neonatal bag and mask 50.4 Vacuum aspirator or D&C kit 7.3 and speculum Manual vacuum extractor 4.9 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 53 Section 5. Specific Service Readiness Overview Gaps in the essential medicines for BONC services are widespread. Skin disinfectant, intravenous solution, and oxytocin were found in 85 percent or more of the facilities. Magnesium sulfate was available at approximately half of the RHUs across the region but was unevenly distributed across the provinces. Similarly, antibiotic eye ointment was at 58.5 percent of the facilities overall, but just 38.5 percent of those at Lanao del Sur. The largest gap was found in the availability of injectable antibiotics.37 While many drugs were reportedly never stocked at the RHUs, a number of facilities reported temporary stock-outs. For example, nearly 40 percent of the RHUs were out of metronidazole on the day of the survey (Figure 30). Figure 29. BONC: Medicines and Commodities Medicines and 66.7 Commodities Skin disinfectant 93.5 Intravenous solution 87.0 with infusion set Injectable uterotonic 84.6 (oxytocin) Antibiotic eye ointment 58.5 for newborn Magnesium sulphate 48.8 (injectable) Injectable antibiotic 27.6 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 37 Survey teams asked about three injectable antibiotics: ampicillin, gentamicin, and metronidazole. Ampicillin was the most common of the three but was available at fewer than 15 percent of the RHUs. 54 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 30. Stock-outs of BONC Medicines and Commodities Panel A Panel B Oxytocin injection Metrodinazole injection Mainland Provinces Mainland Provinces Lanao del Sur 77 15 8 Lanao del Sur 36 64 Maguindanao 81 16 3 Maguindanao 3 24 73 Basilan 83 8 8 Basilan 50 50 100 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 95 5 Sulu 11 32 58 Tawi-Tawi 79 14 7 Tawi-Tawi 7 50 43 BARMM BARMM 82 13 5 3 36 61 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Panel C Panel D Gentamicin injection Ampicillin powder for injection Mainland Provinces Mainland Provinces Lanao del Sur 3 28 69 Lanao del Sur 8 23 69 Maguindanao 24 24 51 Maguindanao 11 24 65 Basilan 100 Basilan 25 75 100 50 50 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 5 16 79 Sulu 5 16 79 Tawi-Tawi 50 50 Tawi-Tawi 14 43 43 BARMM BARMM 9 24 67 11 22 67 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Panel E Panel F Magnesium sulphate injectable Antiniotic eye ointment for newborn Mainland Provinces Mainland Provinces Lanao del Sur 31 18 51 Lanao del Sur 36 49 15 Maguindanao 57 22 22 Maguindanao 68 30 3 Basilan 50 8 42 Basilan 42 33 25 50 50 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 58 5 37 Sulu 63 32 5 Tawi-Tawi 42 29 29 Tawi-Tawi 71 21 7 BARMM BARMM 46 17 37 55 35 10 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Source: BARMM SARA, 2019 Note: For each medicine or commodity, bars shaded in blue represent the proportion of facilities having supplies in stock on the day of the survey. Bars shaded in green represent the proportion of facilities who report having stocked the supply in the past but for whom the supply was either out of stock on not valid on the day of the survey. Bars shaded in rose represent the proportion of facilities that report having never stocked the supply. For example, we see in Panel A that, BARMM-wide, 82 percent of facilities had oxytocin injections in stock on the day of the survey, 13 percent of facilities were either out of stock or stocked invalid medicines, and 5 percent of facilities reportedly never stocked oxytocin. 55 Section 5. Specific Service Readiness Overview Survey data on auxiliary commodities reinforce the findings that stock-outs and inconsistent supply of BONC consumables are major challenges. Figure 31 provides information for a longer list of auxiliary medicines and commodities. These are important inputs to routine BONC services but are not included in the SARA index. This graphic highlights an important trend: reliable access to these commodities remains an issue. More than a quarter of the facilities were out of stock of cefixime, azithromycin, nifedipine, or methyldopa at the time of the survey. Other commodities such as misoprostol are not yet in wide use anywhere in BARMM. Figure 31. BONC: Auxiliary Medicines and Commodities Methyldopa tablet 22.8 40.7 36.6 Hydralazine injection 17.9 13.8 68.3 Nifedipine cap/tab 16.3 52.0 31.7 Betamethasone or 97.6 2.4 Dexamethasone injectable Benzathine benzypenicillin 2.4 22.8 74.8 powder for injection Cefixime cap/tab 8.9 50.4 40.7 Azithromycin cap/tab 6.5 41.5 52.0 or oral liquid Misoprostol cap/tab 1.6 4.1 94.3 Metronidazole injectable 3.3 35.8 61.0 Gentamicin injectable 8.9 24.4 66.7 Ampicillin powder for injection 11.4 22.0 66.7 Magnesium sulphate injectable 46.3 17.1 36.6 Calcium gluconate injectable 8.9 18.7 72.4 Sodium chloride 13.0 22.8 64.2 injectable solution Oxytocin injectable 82.1 13.0 4.9 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or Currently out of stock Never had it Source: BARMM SARA, 2019 Note: For each medicine or commodity, bars shaded in blue represent the proportion of facilities having supplies in stock on the day of the survey. Bars shaded in green represent the proportion of facilities who report having stocked the supply in the past but for whom the supply was either out of stock on not valid on the day of the survey. Bars shaded in rose represent the proportion of facilities that report having never stocked the supply. For example, we see that 23 percent of facilities had methyldopa tablets in stock on the day of the survey, 41 percent of facilities were either out of stock or stocked invalid medicines, and 37 percent of facilities reportedly never stocked methyldopa. 56 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) The aggregate readiness to provide BONC services is low but highly variable. As seen in Table 20, Maguindanao had the highest aggregate readiness score of the five provinces with an average of nearly three-quarter of the tracer indicators. In contrast, facilities in Lanao del Sur had just over half (54.9 percent) of tracer indicators. The low regional average—65.0 percent—highlights the significant scope for improvement in this area. Table 20. BONC Service Readiness Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 27.6 68.2 41.7 87.5 44.7 51.8 47.6 Equipment 62.8 74.9 65.5 82.1 72.9 69.4 69.3 Medicines and 54.7 74.8 65.3 83.3 68.4 75.0 66.7 Commodities Basic Obstetric Care 54.9 73.8 61.5 83.3 67.1 67.9 65.0 Service Readiness Note: Indicators available at 50 percent of RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Immunization Immunization coverage falls short of targets nationwide, and coverage rates in BARMM have long been particularly low. According to the 2017 NDHS data, coverage of basic vaccines has been declining for the past decades, from 73 percent in 1998 to 70 percent in 2017 nationwide and, alarmingly, from 47 percent to just 18 percent in BARMM in 2017. This trend raises serious concerns both about the systems in place to prevent infectious disease outbreaks and the acceptability of vaccines among local populations (Figure 32). 57 Section 5. Specific Service Readiness Overview Figure 32. Children Ages 12–23 Months with All Basic Vaccines - 1998–2018 Percent of children 12-23 months with all basic vaccines 100 % 90 80 79.5 70 72.8 69.8 69.9 67.8 60 50 46.8 44.0 40 30 30.6 29.4 20 18.0 10 0 1998 2003 2008 2013 2018 BARMM Philippines Source: NDHS - Various Years. Basic vaccines include BCG, measles, DTP3, and polio. Box 4. Immunization Service Readiness Indicators The staff and guidelines domain checks guidelines for child immunization and seven separate trainings: immunization service delivery (Immunization in Practice [IIP] or similar), vaccine management/handling and cold chain, data reporting and monitoring of service delivery, disease surveillance and reporting, injection safety and waste management, reaching every district (RED), and any new vaccine-specific training. The equipment domain checks the availability of a cold box/vaccine carrier with ice packs, a functioning refrigerator with a thermometer and temperature monitoring at an appropriate temperature, sharps/safety box, auto-disposable syringes, immunization cards, and immunization tally sheets. The medicines and commodities domain assesses the availability of National Immunization Program (NIP) vaccines: measles, pentavalent (DPT-Hib-HepB), OPV, and BCG. The overall score aggregates over the 20 tracer indicators. In addition to collecting information on the NIP vaccines, survey teams collect data on four non-NIP vaccines: Inactivated Polio Vaccine (IPV), pneumococcal vaccine, rotavirus, and HPV vaccines. Information on the availability of these vaccines is provided but is not included in the immunization service readiness assessment. 58 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Overall, significant gaps in readiness to provide immunization services in BARMM reflects the low coverage rate. Facilities have an overall average of just more than half (56.6 percent) of the tracer indicators. Among other areas, large gaps relate to medicines and commodities. RHUs stock an average of 58.9 percent of the vaccines included in the assessment. Among the provinces, the largest gaps were found in Lanao del Sur with an average of just 34.0 percent of vaccines (Figure 33). Figure 33. Immunization Service Readiness 100 % 90 92.5 80 70 60 62.6 58.2 55.4 56.6 50 53.6 49.9 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Immunization Service Readiness Staffing and Guidelines Basic Equipment Medicines and Commodities Source: BARMM SARA, 2019 Availability of staff and guidelines to provide immunization services was also low with the RHUs across BARMM receiving an average overall score of 41.5 percent. While guidelines are available at nearly three-quarters of the facilities, the survey identified gaps in immunization-specific training. The most common training covers data reporting and monitoring of services, which is available at 45.5 percent of the facilities; staff in just 31.7 percent of the facilities had received RED training. The equipment domain score is at 70.6 percent overall; the largest gaps are related to the capacity to monitor and log temperature (Figure 34). In Lanao del Sur, facilities have an average of just half of the indicators considered. While syringes are available at all RHUs, the assessment suggests serious issues in following the cold chain protocol: fewer than five percent of the facilities had adequate refrigerator temperatures to stock vaccines on the day of the survey. 59 Section 5. Specific Service Readiness Overview Figure 34. Immunization: Equipment Immunization Equipment 70.6 Auto-disable syringes 100.0 Sharps container/safety box 98.4 Immunization cards 92.7 Cold box/vaccine carrier with 87.8 ice packs Refrigerator (available 69.1 and functional) Immunization tally sheets 67.5 Temperature monitoring 46.3 device refrigerator Adequate refrigerator 3.3 temperature 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Routine vaccines are more available than non-routine vaccines, but gaps remain. Of the eight vaccines assessed, four are included in the national routine immunization schedule of the NIP: BCG, DPT-Hib-HepB (pentavalent),38 OPV, and measles. As shown in Figure 35 and Figure 36, these vaccines are, on the whole, more widely available than the non-NIP vaccines. Two-thirds of the facilities had measles or pentavalent vaccines in stock on the day of the survey, and just 40 percent of the facilities had a valid dose of OPV. As for non-NIP vaccines, rotavirus was not available anywhere and HPV was available at less than 5 percent of the facilities. No single vaccine was found at even half of the RHUs visited in that province. 38 According to the 2017 Demographic and Health Survey (DHS), both DPT-Hib-HepB and DPT-Hib-IPV are commonly referred to as ‘pentavalent’ vaccine. In public sector facilities, the form of pentavalent given is DPT-Hib-HepB whereas private sector facilities commonly give pentavalent as DPT-Hib-IPV. To assist in identifying the pentavalent formulation used when vaccination information was collected by mother’s recall, a question on whether the last dose of pentavalent vaccine was received from a public or private facility was used in the NDHS as a proxy to determine its composition. 60 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 35. Stock-outs of NIP Vaccines NIP vaccines Panel A Panel B BCG vaccine and diluent DPT-Hib+HepB vaccine Mainland Provinces Mainland Provinces Lanao del Sur 36 18 46 Lanao del Sur 44 10 46 Maguindanao 78 22 Maguindanao 78 22 Basilan 42 17 42 Basilan 50 8 42 100 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 74 21 5 Sulu 84 11 5 Tawi-Tawi 86 14 Tawi-Tawi 86 14 BARMM BARMM 62 17 21 67 12 21 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Panel C Panel D Oral polio vaccine Measles vaccine Mainland Provinces Mainland Provinces Lanao del Sur 8 46 46 Lanao del Sur 49 5 46 Maguindanao 70 27 3 Maguindanao 81 19 Basilan 25 33 42 Basilan 50 8 42 100 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 32 63 5 Sulu 84 11 5 Tawi-Tawi 64 21 14 Tawi-Tawi 71 14 14 BARMM BARMM 40 38 22 67 11 21 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Source: BARMM SARA, 2019 Note: For each medicine or commodity, bars shaded in blue represent the proportion of facilities having supplies in stock on the day of the survey. Bars shaded in green represent the proportion of facilities who report having stocked the supply in the past but for whom the supply was either out of stock on not valid on the day of the survey. Bars shaded in rose represent the proportion of facilities that report having never stocked the supply. For example, we see in Panel A that, BARMM-wide, 62 percent of facilities had BCG in stock on the day of the survey, 17 percent of facilities were either out of stock or stocked invalid vaccine, and 21 percent of facilities reportedly never stocked BCG. 61 Section 5. Specific Service Readiness Overview Figure 36. Stock-outs of Non-NIP Vaccines Non-NIP vaccines Panel A Panel B Pneumococcal vaccine Rotavirus vaccine Mainland Provinces Mainland Provinces Lanao del Sur 38 15 46 Lanao del Sur 31 69 Maguindanao 54 46 Maguindanao 86 14 Basilan 33 17 50 Basilan 8 92 50 50 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 68 26 5 Sulu 79 21 Tawi-Tawi 36 50 14 Tawi-Tawi 57 43 BARMM BARMM 47 31 22 55 45 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Panel C Panel D IPV (Inactivated Poliovirus Vaccine) HPV (Human Papillomavirus) Mainland Provinces Mainland Provinces Lanao del Sur 10 15 74 Lanao del Sur 46 54 Maguindanao 19 78 3 Maguindanao 8 89 3 Basilan 33 17 50 Basilan 100 50 50 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 47 47 5 Sulu 5 74 21 Tawi-Tawi 36 50 14 Tawi-Tawi 7 7 86 BARMM BARMM 24 44 32 4 54 42 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Source: BARMM SARA, 2019 Note: For each medicine or commodity, bars shaded in blue represent the proportion of facilities having supplies in stock on the day of the survey. Bars shaded in green represent the proportion of facilities who report having stocked the supply in the past but for whom the supply was either out of stock on not valid on the day of the survey. Bars shaded in rose represent the proportion of facilities that report having never stocked the supply. For example, we see in Panel A that, BARMM-wide, 47 percent of facilities had pneumococcal vaccine in stock on the day of the survey, 17 percent of facilities were either out of stock or stocked invalid vaccine, and 21 percent of facilities reportedly never stocked pneumococcal vaccine. The gaps in immunization capacity are systematic and widespread in BARMM. The largest supply chain gaps were in Lanao del Sur and Basilan; aggregate medicines and commodities scores were less than 50 percent for both of these provinces. Gaps in the availability of equipment were largest in Lanao del Sur, while gaps in staff and guidelines were most pronounced in the island provinces of Sulu and Tawi-Tawi (Table 21). These are all reflected in the low immunization coverage of the region in particular and calls for urgent attention to address the issue. 62 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 21. Immunization Service Readiness Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 49.7 38.9 47.9 87.5 30.9 27.7 41.5 Equipment 58.0 79.1 69.8 93.8 80.3 67.9 70.6 Medicines and 34.0 77.0 41.7 100.0 68.4 76.8 58.9 Commodities Overall 49.9 62.6 55.4 92.5 58.2 53.6 56.6 Immunization Readiness Note: Indicators available at 50 percent of RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Child Health Malnutrition rates are very high in the Philippines. In 2015, one-third of children under the age of five were stunted (FNRI-DOST 2016). While undernutrition is a serious concern across the country, it highlights a particular challenge in BARMM. For all three indicators, BARMM exceeds the national averages. For example, in 2015, 45 percent of children in BARMM were stunted, compared to 33 percent of children overall and 25 percent of children in BARMM were underweight compared to 22 percent of children overall. Moreover, these trends are not appreciably improving over time. Indeed, there are signs that the proportion of undernourished children has grown in recent years. Data from the National Nutrition Survey (NNS) suggest that undernutrition rates increased noticeably between 2013 and 2015 in Basilan, Maguindanao, and Sulu; stunting increased in Basilan, Lanao del Sur, and Maguindanao, and wasting increased in Sulu and Tawi-Tawi (FINRI-DOST 2015, 2016). While there were some apparent successes over the same time period (for example, wasting appears to have declined noticeably in Maguindanao), such improvements are neither widespread nor systematic (Figure 37). 63 Section 5. Specific Service Readiness Overview Figure 37. Malnutrition in ARMM - Stunting, Underweight, and Wasting - 2013–2015 Panel A Panel B Stunting: 2013-2015 Underweight, 2013-2015 50 50 49.0 48.1 45 45.6 45.2 45 43.3 40 42.0 39.8 40.9 41.2 40 38.8 35 35.1 35 33.9 33.4 30 30.3 30 Percent Percent 27.9 27.2 25 25 25.2 25.8 26.6 26.5 24.9 22.4 22.5 20 20 21.1 20.9 20.0 21.5 15 15 10 10 11.9 5 5 0 0 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi BARMM Philippines Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi BARMM Philippines Stunting NNS 2013 Stunting NNS 2015 Underweight NNS 2013 Underweight NNS 2015 Panel C Wasting: 2013-2015 25 20 15 Percent 14.2 14.2 11.7 10 9.5 8.5 8.8 8.2 8.0 7.0 7.1 5 5.5 5.9 5.3 4.4 0 Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi BARMM Philippines Wasting NNS 2013 Wasting NNS 2015 Source: FNRI-DOST 2015, 2016. Note: For each graph, bars shaded in rose represent prevalence in 2013; bars shadzed in blue represent prevalence in 2015. 64 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Box 5. Child Health Service Readiness Indicators The staff and guidelines domain includes the availability of guidelines for integrated management of childhood illness (IMCI), guidelines for growth monitoring, staff trained on IMCI, and staff trained on growth monitoring. For the equipment domain, we confirm the availability of a child and infant weighing scale, length and height measuring equipment, a thermometer, a stethoscope, and a growth chart. The diagnostics domain assesses at the availability of hemoglobin tests, general microscopy capacity to test stools for parasites, and malaria diagnostic capacity, including rapid diagnostic kits, malaria smear tests, and Wright-Giemsa stain kits. The medicines and commodities domain checks for ORS, amoxicillin, co-trimoxazole, paracetamol, Vitamin A capsules, mebendazole or albendazole, and zinc sulfate. We identify gaps in the overall readiness to provide child health services in BARMM. Among the provinces, facilities in Tawi-Tawi had the lowest average score, with 59.8 percent of the tracer indicators included (Figure 38). Sulu has the highest overall readiness to deliver services, with an average score of 75.9 percent of the indicators. Overall, the RHUs in BARMM have approximately 70 percent of the indicators considered. Figure 38. Child Health Service Readiness 100 % 90 80 75.0 75.9 70 68.4 69.7 66.3 60 59.8 57.9 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Child Health Service Readiness Staffing and Guidelines Equipment Diagnostics Medicines and Commodities Source: BARMM SARA, 2019 65 Section 5. Specific Service Readiness Overview There are large and widespread gaps in the availability of trained staff and guidelines for child health services, with an average score of just 39.2 percent for this domain. Guidelines and training related to IMCI were less common than those related to growth monitoring. In Tawi-Tawi, just 14.3 percent of staff are trained in IMCI. No staff in Lamitan City are trained in either IMCI or growth monitoring. Facilities across BARMM have the equipment needed to address child growth monitoring and basic health needs. Child and infant scales, length/height measuring equipment, thermometers, and stethoscope are all widely available, possibly due to provision by developing partners (Figure 39). Overall, facilities have an average of 93.3 percent of the equipment considered. Only growth charts were missing on a regular basis. Figure 39. Child Health: Equipment Child Health Equipment 93.0 Length/height 100.0 measuring equipment Child and infant weighing scale 98.4 Stethoscope 94.3 Thermometer 94.3 Growth chart 78.0 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 With an overall score of just 50.9 percent, there are also gaps in the availability of diagnostic capacity of child health services. There is high variability in the availability of individual tests. Just 10.6 percent of the RHUs in BARMM can test for parasites in the stool while 83.7 percent overall could conduct hemoglobin testing. The domain includes the capacity to diagnose malaria, but malaria transmission is currently limited in BARMM and is found predominately in Sulu and Tawi-Tawi, with a few cases in Maguindanao. The low overall incidence of malaria likely affects the low diagnostic capacity in this area. 66 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 40. Child Health: Diagnostics Child Health Diagnostics 50.9 Haemoglobin (Hb) 83.7 Malaria diagnostic capacity 58.5 Test parasite in stool 10.6 (general microscopy 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Medicines are mostly provided centrally from national DOH for child health and are generally available. Deworming medicine mebendazole and/or albendazole were found at 94.3 percent of the facilities, Oral Rehydration Solution (ORS) for diarrhea is available at 88.6 percent of the facilities, and paracetamol and Vitamin A are available at more than 80 percent of the facilities. Zinc sulfate, the most frequently missing of the medicine indicators, was available at 56.1 percent of the facilities overall (Figure 41). Figure 41. Child Health: Medicines and Commodities Child Health Medicines and 78.5 Commodities Me/albendazole 94.3 Paracetamol 88.6 ORS 88.6 Vitamin A 83.7 Amoxicillin 74.0 Co-trimoxazole 64.2 Zinc sulphate 56.1 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 67 Section 5. Specific Service Readiness Overview When comparing across the provinces, survey data suggest that the medicines largest gaps are found in Tawi-Tawi: while 74.0 percent of the facilities overall had amoxicillin, just 35.7 percent of those in Tawi-Tawi had the drug. Similarly, just 21.4 percent of the facilities in Tawi-Tawi stock co-trimoxazole compared to 64.2 percent overall (Figure 42). The reason for this large variability is unclear, but one possibility could be logistics issues of delivering these commodities due to the province’s extreme remoteness. Notably, the availability of commodities and drugs for child health does not consistently translate into better outcomes in this area, particularly as seen in the uniformly high rate of stunting across the region (Figure 37, Figure 42). Poor health outcomes reflect a number of issues. For example, nutrition outcomes require the staff knowledge, the diagnostics, and the medicines required to detect and treat malnutrition on time. Figure 42. Limited Availability of Child Health Medicines in Tawi-Tawi 100 % 94.3 90 92.9 88.6 88.6 80 83.7 78.5 70 74.0 64.3 64.2 60 56.1 50 46.9 40 42.9 35.7 35.7 35.7 30 20 21.4 10 0 Oral Amoxicillin Co-trimoxazole Paracetamol Vitamin A Me-/albendazole Zinc sulphate Medicines and rehydration (dispersable syrup/ syrup/ capsules cap/tab tablets or syrup Commodities solution packet tablet suspension suspension Tawi-Tawi BARMM Source: BARMM SARA, 2019 There is overall readiness to deliver child health services in BARMM. In contrast to other services discussed in this report, Table 22 shows that the two CHOs in Lamitan City had the lowest availability of guidelines and consumables and the RHUs in Tawi-Tawi reported more severe gaps in medicines and commodities. With the exception of growth charts, tracer equipment was widely available, as was hemoglobin testing capacity. 68 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 22. Child Health Service Readiness Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 26.9 48.6 41.7 12.5 52.6 32.1 39.2 Equipment 84.6 97.8 95.0 100.0 93.7 100.0 93.0 Diagnostics 44.4 48.6 50.0 33.3 64.9 59.5 50.9 Medicines and 85.0 84.9 72.6 64.3 81.2 46.9 78.5 Commodities Child Health 66.3 75.0 68.4 57.9 75.9 59.8 69.7 Services Readiness Note: Indicators available at 50 percent of RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Noncommunicable Disease NCDs are a major cause of morbidity and mortality in the Philippines. CVD is the number one cause of premature death, accounting for a third of mortality in the country. Cancers, diabetes, and CRDs, together, account for another one-fifth of mortality. While clinical data suggest that the burden of NCDs in BARMM is significant, there is currently little information to directly compare disease prevalence across or within regions. Building this capacity by ensuring subnational data on NCD prevalence and risk factors is among the goals outlined in the multisectoral strategic plan for NCDs. In the interim, facility-level data provided by regional and provincial health authorities suggest that NCDs account for five of the top ten causes of mortality in Basilan and Sulu, four of the top ten causes of mortality in Lanao del Sur, and three of the top ten causes of mortality in Tawi-Tawi. 39 Addressing NCDs is emphasized as a health sector priority, and the national DOH has developed evidence-based treatment guidelines to standardize management of disease. The government is transitioning to a multisectoral approach for prevention and control of NCDs while emphasizing a systems strengthening and integration approach (Ulep, Aldeon, and dela Cruz 2013). These recent efforts aim to reinforce more established programs to improve access to and quality of NCD care. In 2012, the DOH issued the Philippine Package of Essential Noncommunicable Interventions (PhilPEN) to institutionalize the management of NCDs following the WHO Program for Essential NCD Care (PEN) protocol.40 ARMM, however, was trained on the protocol only in 2015, after which the DOH-ARMM adopted this as ARMM-PEN. Until 2015, the national DOH also supplied complete treatment packs (ComPacks) to all RHUs, as part of its formal commitment to the institutionalization of PhilPEN services for hypertension and diabetes at primary health care facilities.41 39 Information provided by the DOH-ARMM during the Summit Presentations with the five regions. 40 A.O. 2012-0029: Implementing Guidelines on the Institutionalization of Philippine Package of Essential NCD Interventions (PhilPEN) on the Integrated Management of Hypertension and Diabetes for Primary Health Care Facilities. 41 Before PhilPEN training in 2015, the statins in ComPacks were not prescribed to patients and there was reportedly oversupply of these medicines in the RHUs. After the training, however, the statins were now part of the protocol but the medicines supplies from the DOH from 2015 no longer included these; hence, the RHUs either had to procure statins or prescribed them for the patients to buy. 69 Section 5. Specific Service Readiness Overview PhilHealth also developed a benefit package to support these initiatives in 2013 and integrated PhilPEN guidelines into the PCB (Philippine Health Insurance Corporation 2013). These guidelines prioritized a shift away from tertiary care, reemphasizing the importance of primary care in the management of chronic NCD conditions. PCB-accredited RHUs are required to maintain annual health profiles for their catchment areas. Jointly, these efforts are expected to provide increased access to essential care for NCDs. Cardiovascular Disease CVD accounts for one-third of total deaths and for more than half of all NCD-related deaths in the country (WHO 2018). While mortality data at the province level are not complete, information from the DOH-ARMM indicates that disease patterns in the region are similar to those found elsewhere in the country, with CVD reported as the number one cause of mortality in each of the five provinces. Box 6. CVD Service Readiness Indicators The staff and guidelines domain checks the availability of guidelines and staff trained on diagnosis and care for cardiovascular conditions. The equipment domain assesses the presence of a stethoscope, BP apparatus, an adult scale, and oxygen. The medicine and commodities domain assesses the presence of ACE inhibitors, hydrochlorothiazide, or other thiazide diuretic tablets, beta blockers, calcium channel blockers, aspirin, and metformin. Despite the heavy disease burden, facilities have an average of 56.0 percent of the CVD tracer indicators across regions. Among the provinces, the three island provinces scored the lowest, with the RHUs in Basilan reporting an average of just 45.8 percent of the indicators included, followed by Sulu and Tawi-Tawi. While equipment scores are fairly high, and many RHUs do have staff trained in CVD diagnosis and treatment, there are large gaps in the availability of diagnostic capacity and medicines. 70 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 43. CVD Service Readiness 100 % 90 80 70 60 60.7 62.4 58.3 56.0 50 46.5 47.6 45.8 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Mainland Island Provinces Cardiovascular Disease Service Readiness Staffing and Guidelines Equipment Medicines and Commodities Source: BARMM SARA, 2019 Trained staff are more commonly available than are clinical guidelines on the appropriate management of CVD. Over half (56.1 percent) of the facilities have at least one staff member trained to provide CVD care, possibly due to both national DOH and PhilHealth’s effort to increase PhilPEN training nation.42 By contrast, fewer than 10 percent of the facilities in Lanao del Sur or Basilan have guidelines. The very low availability of guidelines pulls the staff and guidelines domain score for the BARMM region down to 37.4 percent (Figure 44). Figure 44. CVD: Staff and Guidelines Staff and Guidelines 37.4 Staff trained in diagnosis and management of chronic 56.1 cardiovascular conditions Guidelines for diagnosis and treatment of chronic 18.7 cardiovascular conditions 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 42 A.O. 0020.s.2013: Adoption of the Philippine Package of Essential Non-Communicable Disease (NCD) Interventions (PhilPEN) In the Implementation of PhilHealth’s Primary Care Benefit Package. 2013. 71 Section 5. Specific Service Readiness Overview Equipment needed to provide CVD care is generally available. However, large gaps were seen in the availability of medicines. Stethoscopes, scales, and BP apparatuses are all widely available. Only oxygen was found at less than 90 percent of the facilities (Figure 45). Medicines and commodities include ACE inhibitors, hydrochlorothiazide/ thiazide diuretic tablets, beta blockers, calcium channel blockers, aspirin tablets, and metformin tablets. Of these, only metformin was available at a majority of the facilities in all provinces. Aspirin was available at between 5 percent and 10 percent of the facilities, depending on province, and thiazide diuretics were even less common. As mentioned earlier, the wide availability of metformin can be explained by the fact that this medicine continues to be provided by the national DOH, while aspirin was among the medicines in the DOH Complete Treatment Pack that was discontinued in 2015. Thiazide is not provided by the DOH and again explains its low availability. The RHUs across BARMM had an average of 38.2 percent of the tracer medicines on the day of the survey (Figure 46). Figure 45. CVD: Equipment CVD Equipment 92.1 BP apparatus 100.0 Adult scale 96.7 Stethoscope 94.3 Oxygen 77.2 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Figure 46. CVD: Medicines and Commodities Medicines and commodities 38.2 Metformin cap/tabs 69.1 Beta blocker 66.7 ACE inhibitor 43.9 Calcium channel blockers 39.0 Aspirin cap/tabs 6.5 Hydrochlorothiazide tablet or 4.1 other thiazide diuretic tablet 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 72 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Overall, there is high variation in the readiness to deliver CVD care across the five provinces in BARMM. CVD service readiness scores ranged from a low of 45.8 percent in Basilan to a high of 62.4 percent in Maguindanao (Table 23). Variations in overall scores were largely driven by performance in the staff and guidelines and the medicines and commodities domains. Medicines were generally more available in the mainland provinces of Maguindanao and Lanao del Sur. Beta blockers, for example, were found at 91.9 percent of the RHUs in Maguindanao, compared to less than one-third of those in Sulu. Metformin was at 92.3 percent of the RHUs in Lanao del Sur, compared to half of the facilities in Basilan and approximately one-quarter of the RHUs in Sulu. These differences contributed to the wide variations seen in overall CVD service readiness across the region. Table 23. CVD Service Readiness Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 34.6 50.0 25.0 50.0 31.6 28.6 37.4 Equipment 87.2 96.6 95.8 100.0 90.8 91.1 92.1 Medicines and 51.7 43.7 19.4 33.3 21.9 25.0 38.2 Commodities Cardiovascular 60.7 62.4 45.8 58.3 46.5 47.6 56.0 Disease Service Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Diabetes The prevalence of diabetes mellitus (diabetes) is growing rapidly in the Philippines (Tan 2015). The International Diabetes Federation (IDF) estimates that there are more than 3.7 million adults living with diabetes in the country and the WHO estimates that diabetes accounted for 6 percent of all-cause mortality in the Philippines in 2014 (IDF 2018).43 Efforts to address the growing burden of disease take a two-pronged approach, emphasizing healthy lifestyles to lower the susceptibility of the population to diabetes and equipping health facilities across the country with the tools needed to provide high-quality care. PhilHealth covers the cost of diabetes-related hospital admissions and for outpatient care for qualified members. The government has worked to make diabetes medicines widely available and affordable in the country. 43 “WHO | Diabetes Country Profiles: The Philippines.” WHO 2016 (Online). Available: http://www.who.int/diabetes/country-profiles/phl_en.pdf. Accessed: August 9, 2018. 73 Section 5. Specific Service Readiness Overview Box 7. Diabetes Service Readiness Indicators Diabetes Service Readiness The staff and guidelines domain asks about the availability of guidelines and staff trained on diabetes diagnosis and care. The equipment domain asks about a BP apparatus, an adult scale, and a measuring tape. The diagnostics domain asks about blood glucose tests and urine dipsticks for both protein and ketones. The medicines domain assesses the presence of metformin, glibenclamide, insulin, injectable glucose, and gliclazide/glipizide. Across region, the RHUs have an average of just under half (48.9 percent) of tracer indicators to provide diabetes services. While equipment were generally available, widespread gaps were found in the availability of staff and guidelines, diagnostics, and medicines and commodities. Aggregate scores ranged from an average of 41.0 percent in Basilan and equally low in Sulu, to 53.3 percent in Lanao del Sur (Figure 47). Figure 47. Diabetes Service Readiness 100 % 90 80 70 60 50 53.3 51.4 50.0 48.9 46.7 40 41.0 41.7 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Mainland Island Provinces Diabetes Service Readiness Staffing and Guidelines Equipment Diagnostics Medicines and Commodities Source: BARMM SARA, 2019 74 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Guidelines on diabetes diagnosis and management are available at just 17.1 percent of the RHUs in BARMM. In Basilan and Lamitan City, no facilities had these guidelines on the day of the survey, and just 7.7 percent of those in Lanao del Sur had guidelines on hand. Trained staff are somewhat more available, with about 60 percent of the facilities overall reporting that at least one member of the staff had been trained on diabetes diagnosis and management (Figure 48).44 Among the five provinces, overall aggregate scores for the staff and guidelines domain ranged from a low of 28.6 in Tawi-Tawi to a high of 50.0 percent in Maguindanao. Variations in the availability of trained staff may be explained due to the ongoing rollout of training that has yet to be completed. Figure 48. Diabetes: Staff and Guidelines Staff and Guidelines 38.2 Staff trained in diabetes 59.3 diagnosis and treatment Guidelines for diabetes diagnosis 17.1 and treatment 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Diabetes-related equipment is nearly universally available. Each of the three tracer indicators—BP apparatus, adult scale, and a measuring tape—appear multiple times in this report as they are used for several services. All regions have a total score for the domain of greater than 95 percent. Figure 49. Diabetes: Equipment Diabetes Equipment 98.9 Measuring tape 100.0 (height board/stadiometre) BP apparatus 100.0 Adult scale 96.7 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 44 An additional training, on the management of diabetes using insulin, was conducted in late 2017—shortly after data collection for this work was completed. 75 Section 5. Specific Service Readiness Overview Facilities across BARMM had an average of just over half (58.3 percent) of the diagnostic capacity indicators assessed. Blood glucose tests were most common, made available at 85.4 percent of the facilities, while urine dipsticks for ketones and protein were both seen at slightly less than half of the facilities (Figure 50). Figure 50. Diabetes: Diagnostics Diagnostics 58.3 Blood glucose 85.4 Urine dipstick-protein 45.5 Urine dipstick-ketones 43.9 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Facilities have, on average, less than 20 percent of the tracer medicines and commodities for diabetes. Metformin, the most widely available of the medicines, was available at two-thirds of the facilities overall but ranged widely across the region. For example, it was found at 92.3 percent of the facilities in Lanao del Sur, compared to only 26.3 percent of the facilities in Sulu. Glibenclamide and gliclazide/glipizide tablets were rarely available. Insulin was not available at any RHU45 and glucose was seen at just one of the 123 RHUs visited (Figure 51). Differences in the availability of metformin notwithstanding, the overall medicine domain scores were uniformly low across the five provinces and ranged from a low of just 9.5 percent in Sulu to 21.6 percent in Maguindanao. It may be noted that metformin is among the medicines provided by the national DOH, while gliclazide was among the medicines in the DOH Complete Treatment Pack discontinued in 2015. Figure 51. Diabetes: Medicines and Commodities Medicines and Commodities 17.6 Metformin cap/tab 69.1 Gliclazide tablet or 11.4 glipizide tablet Glibenclamide cap/tab 6.5 Glucose 50% injectable 0.8 Insulin regular injectable 0.0 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 45 As previously noted, training on management of diabetes using insulin was conducted in late 2017, after data collection for this work was completed. 76 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Overall scores ranged from a low of 41.0 percent in Basilan to a high of 53.3 percent in Lanao del Sur. Equipment availability was high throughout the region, while the availability of medicines and commodities was generally very low. The largest variations in performance were observed in the availability of staff and guidelines and in diagnostics. Variations in the availability of diagnostics were driven, in large part, by the greater availability of ketone and protein dipsticks observed at the RHUs in Lanao del Sur, relative to those elsewhere (Table 24). Table 24. Diabetes Service Readiness Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 34.6 51.4 20.8 50.0 31.6 35.7 38.2 Equipment 97.4 100.0 100.0 100.0 98.2 100.0 98.9 Diagnostics 75.2 52.3 47.2 66.7 45.6 52.4 58.3 Medicines and 21.0 21.6 10.0 10.0 9.5 15.7 17.6 Commodities Diabetes Service 53.3 51.4 41.0 50.0 41.7 46.7 48.9 Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Chronic Respiratory Disease CRDs accounted for nearly 5 percent of all deaths in the country in 2017,46 placing them among the top 10 most important causes of mortality in the Philippines. This group of conditions includes asthma, chronic obstructive pulmonary disease (COPD), and other conditions affecting the airways and lungs. The majority of CRD-linked deaths (65 percent) are due to COPD. Asthma is also an important cause of mortality, constituting approximately one-third of the CRD-linked deaths.47 It is thought to affect approximately 30 percent of Filipinos, has been recognized as a major driver of health care costs in the country, and is the top cause of PhilHealth reimbursements (Philippine Health Insurance Corporation 2016). High rates of CRD in the Philippines are associated with the prevalence of smoking and indoor cooking fires. The national policy adopts a multipronged approach and includes efforts to prevent CRD through smoking cessation and other anti-tobacco programs, while PhilHealth offers access to primary and inpatient care to those diagnosed with disease. Clinical guidelines for the implementation of PCB indicates that the RHUs should be prepared to provide nebulization services and to provide beta2 agonists, inhaled corticosteroids and oral corticosteroids. 46 Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from http://vizhub.healthdata.org/gbd-compare. (Accessed May 2019) 47 Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from http://vizhub.healthdata.org/gbd-compare. (Accessed May 2019) 77 Section 5. Specific Service Readiness Overview Box 8. CRD Service Readiness Indicators The staff and guidelines domain assesses the availability of guidelines and staff trained on diagnosis and care for CRD. The equipment domain confirms the availability of a stethoscope, a peak flow meter, spacers for inhalers, and oxygen. The medicine and commodities domain assesses the presence of salbutamol, beclomethasone, prednisolone, hydrocortisone, and epinephrine. The RHUs in BARMM have an average of just 26.2 percent of the CRD tracer indicators assessed. Only in Maguindanao did the RHUs have, on average, more than one in four of the tracer indicators assessed. The RHUs in Basilan had the lowest aggregate score. Serious gaps were identified in each of the three domains, with the largest pertaining to medicines and commodities domain (Figure 52). Figure 52. CRD Service Readiness 100 % 90 80 70 60 50 40 32.7 30 23.8 22.7 23.4 24.0 20 21.2 26.2 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Mainland Island Provinces Chronic Respiratory Disease Service Readiness Staffing and Guidelines Equipment Medicines and Commodities Source: BARMM SARA, 2019 78 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) One-third of the facilities have staff trained in the diagnosis and management of CRD and just under 15 percent have guidelines for the diagnosis and management of CRD available at the facility (Figure 53). ARMM-wide, facilities have a domain score of 23.6 percent and province scores ranged from a low 4.2 percent in Basilan to 40.5 percent in Maguindanao. While trained staff were sporadically available throughout, guidelines were nonexistent in both Lanao del Sur and Basilan. Figure 53. CRD: Staff and Guidelines Staff and Guidelines 23.6 Staff trained in diagnosis and 33.3 management of CRD Guidelines for diagnosis and 13.8 management of CRD 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 Facilities had, on average, half of the recommended equipment for CRD, which includes a stethoscope, peak flow meters, spacers for inhalers, and oxygen. Only stethoscopes and oxygen were generally available, having been seen at 94.3 percent and 77.2 percent of the RHUs, respectively (Figure 54). Spacers for inhalers were rarely available, and peak flow meters were lacking altogether with the exception of just two facilities in Sulu. Figure 54. CRD: Equipment CRD Equipment 44.3 Stethoscope 94.3 Oxygen 77.2 Spacers for inhalers 4.1 Peak flow meter 1.6 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 79 Section 5. Specific Service Readiness Overview BARMM-wide, just 12.7 percent of all the tracer commodities for CRD was seen, ranging from a low of 8.3 percent in Basilan to a high of just 17.3 percent in Maguindanao; the two CHOs in Lamitan City did not have any of the five tracer indicators assessed: salbutamol inhalers, beclomethasone inhalers, prednisolone caps/tabs, hydrocortisone injections, and epinephrine injections. Epinephrine was the most frequently available medicine but was still found in less than a third of the facilities (Figure 55). Beclomethasone was completely lacking in Lanao del Sur, Maguindanao, Sulu, and Lamitan City, and hydrocortisone injections were missing in all RHUs in Basilan, Sulu, and Lamitan City. While some facilities never stock these items, the lack of commodities was frequently attributed to stock-outs or expiry of existing stocks (Figure 56). Figure 55. CRD: Medicines and Commodities Medicines and commodities 12.7 Epinephrine injectable 29.3 Salbutamol inhaler 18.7 Prednisolone cap/tabs 8.1 Hydrocortisone injection 5.7 Beclomethasone inhaler 1.6 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 80 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 56. Stock-out of CRD Medicines and Commodities Panel A Panel B Salbutamol Inhaler Beclomethasone Inhaler Mainland Provinces Mainland Provinces Lanao del Sur 21 72 8 Lanao del Sur 31 69 Maguindanao 24 65 11 Maguindanao 43 57 Basilan 8 83 8 Basilan 8 33 58 50 50 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 21 74 5 Sulu 63 37 Tawi-Tawi 7 86 7 Tawi-Tawi 7 64 29 BARMM BARMM 19 72 9 2 43 55 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Panel C Panel D Prednilsolone cap/tabs Hydrocortisone Injection Mainland Provinces Mainland Provinces Lanao del Sur 10 31 59 Lanao del Sur 10 13 77 Maguindanao 5 27 68 Maguindanao 3 16 81 Basilan 17 33 50 Basilan 100 50 50 100 Island Provinces Lamitan City Island Provinces Lamitan City Sulu 5 37 58 Sulu 11 89 Tawi-Tawi 7 50 43 Tawi-Tawi 14 36 50 BARMM BARMM 8 33 59 6 15 80 0 10 20 30 40 50 60 70 80 90 100 % 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it Available today Non valid or currently out of stock Never had it Panel E Epinephrine Injectable Mainland Provinces Lanao del Sur 23 28 49 Maguindanao 54 41 5 Basilan 8 17 75 50 50 Island Provinces Lamitan City Source: BARMM SARA, 2019 Note: For each medicine or commodity, bars shaded in blue represent the proportion Sulu 16 21 63 of facilities having supplies in stock on the day of the survey. Bars shaded in green represent the proportion of facilities who report having stocked the supply in the past but for whom the supply was either out of stock on not valid on the day of the survey. Tawi-Tawi 21 43 36 Bars shaded in rose represent the proportion of facilities that report having never stocked the supply. For example, we see in Panel A that, BARMM-wide, 19 percent of facilities had salbutamol inhalers in stock on the day of the survey, 72 percent of BARMM 29 32 39 facilities were either out of stock or stocked invalid inhalers, and 9 percent of facilities reportedly never stocked salbutamol. 0 10 20 30 40 50 60 70 80 90 100 % Available today Non valid or currently out of stock Never had it 81 Section 5. Specific Service Readiness Overview The RHUs in all provinces reported major gaps in their ability to provide CRD services. Table 25 shows that overall scores ranged from a low of 21.2 percent in Basilan to a high of 32.7 percent in Maguindanao. The two CHOs in Lamitan City did not significantly outperform the RHUs visited elsewhere. While equipment availability was high throughout the region, the availability of medicines and commodities was uniformly very low. Maguindanao had higher availability of trained staff and guidelines, while this was particularly low in Basilan and Tawi-Tawi. Table 25. CRD Service Readiness Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 19.2 40.5 4.2 25.0 18.4 14.3 23.6 Equipment 39.7 48.0 45.8 50.0 44.7 44.6 44.3 Medicines and 12.8 17.3 8.3 0.0 8.4 11.4 12.7 Commodities CRD Service 23.8 32.7 21.2 22.7 23.4 24.0 26.2 Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Cervical Cancer Screening Cervical cancer is the second most common cancer among women and is responsible for 7 percent of all deaths due to malignancy in the Philippines. In an effort to prevent HPV infection among the coming generation, the national DOH recommended that HPV vaccine be made available at no-cost for girls. At the same time, the government seeks to expand access to early diagnosis and prompt treatment for women who have pre-cancerous or cancerous lesions. Routine screening was included in the 2012 PCB package, although few facilities were then equipped to provide the services. More recently, regional centers to train providers to conduct cervical cancer screening have opened, and the government is in the process of nationwide rollout of trainings to support access to cervical cancer screening for women across the country. Box 9. Cervical Cancer Screening Service Readiness Indicators The staff and guidelines domain assesses whether guidelines are in place and whether any staff are trained for cervical cancer prevention and control. The equipment domain assesses the availability of a speculum. The diagnostics domain assesses the availability of acetic acid. 82 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Survey data indicate that few RHUs are able to diagnose cervical cancer. With the exception of Maguindanao, where efforts to expand access to cervical cancer screening services are more apparent, the RHUs in the provinces have, on average, fewer than 25 percent of the indicators assessed. Cervical cancer screening services were nonexistent at the RHUs in Basilan (Figure 57). Figure 57. Cervical Cancer Screening Service Readiness 100 % 90 80 70 60 65.5 50 40 30 25.0 28.9 20 22.4 10 0.0 7.9 3.6 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Cervical Cancer Screening Service Readiness Staffing and Guidelines Equipment Medicines and Commodities Source: BARMM SARA, 2019 The average score for the staff and training domain is just 25.2 percent. As of the time of the survey, guidelines for cervical cancer prevention and control were only in place at a small number of facilities on the mainland provinces—approximately one-third of the facilities in Maguindanao and a scattering of facilities in Lanao del Sur. Trained staff are also concentrated at facilities on the mainland: 85.6 percent of staff in Maguindanao have trained staff available, as do 38.5 percent of the facilities in Lanao del Sur. By contrast, no facilities in Tawi-Tawi or Basilan had any staff trained in cervical cancer prevention and control, and only two of Sulu’s 19 RHUs had any staff with relevant training. Overall domain scores range from 0 in Tawi-Tawi and Basilan to 58.1 percent in Maguindanao. 83 Section 5. Specific Service Readiness Overview Figure 58. Cervical Cancer Screening: Staff and Guidelines, Equipment, and Medicines and Commodities Cervical Cancer Screening 28.9 Service Readiness Speculum 40.7 Staff trained in cervical cancer 40.7 prevention and control Acetic Acid 24.4 Guidelines for cervical cancer 9.8 prevention and control 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 The equipment and commodities required for diagnosis of cervical cancer are also rare. Speculums are available at fewer than half the facilities (Figure 58). This ranges from none in Basilan and 7.1 percent in Tawi-Tawi to 83.8 percent in Maguindanao. Acetic acid is somewhat more common but is still available in just 24.4 percent of the RHUs, ARMM-wide. While 62 percent of the facilities in Maguindanao had acetic acid, it was not available in any of the RHUs in either Basilan or Sulu. Across each of the three cervical cancer screening domains assessed, Maguindanao had the highest aggregate score. This reflects the investments made to roll out training and ensure access to the basic inputs needed for diagnostic services (Table 26). By contrast, the RHUs in the island provinces do not offer cervical cancer screening services yet. Table 26. Cervical Cancer Screening Service Readiness Mainland Provinces Island Provinces Indicator Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 20.5 58.1 0.0 25.0 5.3 0.0 25.2 Equipment 33.3 83.8 0.0 50.0 21.1 7.1 40.7 Medicines and 15.4 62.2 0.0 0.0 0.0 7.1 24.4 Commodities Cervical Cancer 22.4 65.5 0.0 25.0 7.9 3.6 28.9 Screening Service Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. 84 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Communicable Disease Effective management of communicable diseases has long been an important priority of the Philippines government. To this end, PhilHealth has introduced a series of primary care packages including the Outpatient Malaria Package and the Outpatient Anti-Tuberculosis Treatment through DOTS Package.48 These benefits cover diagnostic and therapeutic care associated with the disease and are available to all PhilHealth members. Malaria services are expected to be available at the RHUs accredited to deliver the Outpatient Malaria Package. TB services are mainly provided by PhilHealth-accredited RHUs, although PhilHealth has certified other stand-alone centers to extend the reach of this care. Tuberculosis The prevalence of TB is very high in the Philippines. While the confidence intervals of the 2013 and 2016 National Tuberculosis Prevalence Surveys (NTPS) overlap, other sources suggest a steady increase in TB over the last 10 years, from an estimated incidence of 520 per 100,000 in 2007 to 554 per 100,000 in 2016.49 In 2016, there were approximately 345,000 notified cases nationwide.50 The WHO estimates approximately 58 percent of TB-infected individuals were identified and received treatment, suggesting a sizable treatment gap in the country. Among those treated in 2015, the treatment success rate is estimated at 91 percent.51 Box 10. Tuberculosis Service Readiness Indicators The staff and guidelines domain includes eight tracer indicators, including four sets of guidelines related to the diagnosis and treatment of TB, the management of HIV and TB co-infection, the treatment and referral of multi-drug-resistant (MDR) TB, and TB infection control. The domain also assesses whether the facility has staff trained the same four areas: the diagnosis and treatment of TB, the management of HIV and TB co-infection, the treatment and referral of MDR TB, and TB infection control. The diagnosis domain asks about the availability of TB microscopy, HIV diagnostic capacity, and a system of HIV diagnosis among TB patients. The medicines and commodities domain ask about the availability of up to two first-line TB medications. 48 In addition to the communicable disease discussed here, there is also and Outpatient HIV-AIDS Package and the PhilHealth Sustainable Development Goal (SDG) packages also include benefits for Voluntary Surgical Contraceptive Procedures (for example, tubal ligation or vasectomy) and Animal Bite Treatment Package. Notably, PhilHealth also covers hospital and specialist care related to these conditions; however, a consideration of those hospital services is out of scope of this report. 49 “World Databank.” World Bank (Online). Available: http://www.worldbank.org/. Accessed: February 25, 2018. 50 “WHO | Tuberculosis country profiles: Philippines.” WHO (Online). Available: http://www.who.int/tb/country/data/profiles/en/. Accessed: March 22, 2018. 51 “WHO | Tuberculosis country profiles: Philippines.” WHO (Online). Available: http://www.who.int/tb/country/data/profiles/en/. Accessed: March 22, 2018. 85 Section 5. Specific Service Readiness Overview We find mixed evidence regarding the readiness to provide TB services at the RHUs across BARMM. As shown in Figure 59, the facilities visited have an average of 56.2 percent of the indicators considered. Among the provinces, Lanao del Sur has the lowest overall score, the RHUs there reported an average of 42.1 percent of the indicators assessed. Maguindanao is the high performer among the provinces, with an average of 73 percent of indicators at the facilities; the two CHOs in Lamitan City have an overall aggregate score of 70.8. Figure 59. TB Service Readiness 100 % 90 80 70 70.8 70.5 60 61.0 56.3 56.2 50 49.4 40 42.1 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Mainland Island Provinces Overall Tuberculosis Screening Service Readiness Staffing and Guidelines Equipment Medicines and Commodities Source: BARMM SARA, 2019 While most RHUs have staff trained to manage TB, the RHUs are less prepared to manage HIV-TB co-infection. Just one-third of the facilities have relevant guidelines, compared to 78.9 percent of the RHUs having guidelines for TB in general. Training follows a similar trend, 77.2 percent of the RHUs have at least one staff member trained in general diagnosis and treatment of TB, but just less than 50 percent have staff trained on TB-HIV co-infection (Figure 60). Staff and guidelines domain scores range from a low of 39.4 percent in Lanao del Sur to 83.1 percent in Maguindanao. 86 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 60. TB: Staff and Guidelines Staff and Guidelines 61.0 Guidelines for diagnosis for 78.9 diagnosis and treatment of TB Staff trained in TB diagnosis 77.2 and treatment Staff trained in 72.4 TB Infection Control Guidelines for TB infection 66.7 control Staff trained in client MDR-TB 65.9 treatment or identification of need for referral Guidelines related to MDR-TB 48.0 treatment (for identification of need for referral) Staff trained in 45.5 management of HIV & TB co-infection Guidelines for management of 33.3 HIV & TB co-infection 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 The diagnostics domain looks at availability of TB microscopy, HIV diagnostic capacity, and system for diagnosis of HIV among TB clients. While most RHUs offer TB microscopy, there is no expectation for the RHUs to provide HIV diagnostics; these services fall under the responsibility of social hygiene clinics. However, a small number of RHUs (5.7 percent) have a specific system (including a referral system) in place to diagnose HIV among TB-infected patients (Figure 61). Diagnostics domain scores range from a low of 24.6 percent in Sulu to a high of just 38.9 percent in Basilan. Figure 61. TB: Diagnostics Diagnostics 29.3 TB microscopy 82.1 System for diagnosis of HIV 5.7 among TB clients HIV diagnostic capacity 0.0 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 87 Section 5. Specific Service Readiness Overview TB medicines and commodities are widely available at the RHUs in BARMM. Survey teams assessed the availability of up to two first-line drugs. Only facilities in Tawi-Tawi reported any gaps: 92.8 percent reported having at least one first-line drugs. All facilities in Lanao del Sur, Maguindanao, Basilan, and Sulu reported having at least two first-line drugs (Figure 62). Figure 62. TB: Medicines and Commodities 100 % 100.0 100.0 100.0 100.0 100.0 99.2 90 92.9 80 70 60 50 40 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Mainland Island Provinces Source: BARMM SARA, 2019 There is relatively little variation in the readiness to provide TB services at the RHUs across the ARMM provinces. TB medicines and commodities were nearly universal reflecting the priority of the government and its centralized distribution system, while building diagnostic capacity was more dependent locally reflecting the overall low performance in contrast to the wide availability of medicines. The differential availability in guidelines and trained staff account for the largest differences in aggregate readiness between low-scoring Lanao del Sur and high-scoring Maguindanao (Table 27). 88 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 27. TB Service Readiness Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 39.4 83.1 57.3 81.3 69.7 50.9 61.0 Diagnostics 29.9 27.0 38.9 33.3 24.6 31.0 29.3 Medicines and 100.0 100.0 100.0 100.0 100.0 92.9 99.2 Commodities Overall TB Service 42.1 70.5 56.3 70.8 61.0 49.4 56.2 Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. Malaria Malaria incidence is declining rapidly in BARMM. While the provinces of BARMM were among the most malaria-endemic of the country as recently as 2012, cases of reported malaria have dropped decisively in recent years. There were just 5 reported cases of malaria in 2017 and there have not been any known mortalities linked to malaria since 2015.52 According to FHSIS data, only Sulu, Tawi-Tawi, and Maguindanao reported any malaria cases in 2016. Box 11. Malaria Service Readiness Indicators The staff and guidelines domain checks availability of guidelines on diagnosis and treatment of malaria and guidelines for IPT, as well as whether the facility has staff trained in diagnosis and treatment of malaria and staff trained in IPT. The diagnostics domain checks the facility’s malaria diagnostic capacity, and the medicines and commodities domain checks the availability of first-line antimalarials, paracetamol, and IPT. Readiness to provide malaria services reflects the disease prevalence. Aggregate scores for malaria service readiness are highest in Sulu (reporting an average of 71.7 percent of indicators) and Tawi-Tawi (51.8 percent of indicators), the two provinces where malaria cases were reported. As has been the case throughout, staff and guidelines was the lowest performing domain, while diagnostic capacity was very high in these two provinces (Figure 63). 52 This paragraph relies on information from the 2017 DOH-ARMM Accomplishment Report 89 Section 5. Specific Service Readiness Overview Figure 63. Malaria Service Readiness 100 % 90 80 70 71.7 60 50 51.8 40 41.4 37.5 40.5 30 27.2 30.2 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Malaria Service Readiness Staffing and Guidelines Equipment Medicines and Commodities Source: BARMM SARA, 2019 Availability of guidelines and trained staff was low overall, with Sulu and Tawi-Tawi reporting an average overall score of 59.2 and 41.1, respectively. While training on IPT was relatively rare throughout, almost 94.7 percent of the RHUs in Sulu had at least one staff member training on the diagnosis and treatment of malaria, as did 71.4 percent of the RHUs in Tawi-Tawi. Guidelines were similarly concentrated in Sulu and Tawi-Tawi. Figure 64. Malaria: Staff and Guidelines Staff and Guidelines 32.9 Staff trained in malaria diagnosis 46.3 and treatment Staff trained in IPT 31.7 Guidelines for IPT 28.5 Guidelines for diagnosis 25.2 and treatment of malaria 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 90 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Similarly, malaria diagnostic capacity was widely available at the RHUs in Sulu and Tawi-Tawi, with 94.7 percent and 92.9 percent of the facilities in Sulu and Tawi-Tawi, respectively, having diagnostic services (Figure 65). Figure 65. Malaria: Diagnostics 100 % 94.7 90 92.9 80 70 60 58.3 58.5 50 50.0 46.2 40 40.5 30 20 10 0 Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Mainland Island Provinces Source: BARMM SARA, 2019 First-line antimalarial drugs are available at just over half the facilities in Sulu and Tawi-Tawi, where they are found at 57.9 and 57.1 percent of the RHUs, respectively. IPT to prevent malaria in pregnant women is widely lacking in BARMM even in these two provinces. While the pain killer paracetamol is widely available, it is stocked for a wide variety of conditions and likely does not reflect a specific intention to provide malaria care. (Figure 66). Figure 66. Malaria: Medicines and Commodities Medicines and Commodities 46.9 Paracetamol cap/tab 88.6 IPT drug 30.9 First-line antimalarial 21.1 in stock 0 10 20 30 40 50 60 70 80 90 100 % Source: BARMM SARA, 2019 91 Section 5. Specific Service Readiness Overview Variation in the readiness to diagnose and treat malaria tracks with the incidence of the disease; hence, aggregate scores are highest in Sulu, Tawi-Tawi, and Maguindanao. Sulu has the highest ongoing transmission of malaria and also has the highest readiness score (Table 28). Almost 95 percent of the RHUs in Sulu had at least one staff member trained on the diagnosis and treatment of malaria and 71.4 percent of the RHUs in Tawi-Tawi, while trained staff were rare elsewhere. Guidelines were similarly concentrated in Sulu and Tawi-Tawi. While approximately two-thirds of the RHUs in BARMM can diagnose malaria, diagnostic capacity was nearly universal at the RHUs in Sulu and Tawi-Tawi. First-line antimalarial drugs are most common in Sulu and Tawi-Tawi. Table 28. Malaria Service Readiness Mainland Provinces Island Provinces Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Staff and Guidelines 17.3 35.8 25.0 25.0 59.2 41.1 32.9 Diagnostics 46.2 40.5 58.3 50.0 94.7 92.9 58.5 Medicines and 34.2 46.8 27.8 50.0 80.7 52.4 46.9 Commodities Malaria Service 27.2 40.5 30.2 37.5 71.7 51.8 41.4 Readiness Note: Indicators available at 50 percent of the RHUs or greater in an area are in green. Indicators available at 49.9 percent or fewer RHUs in an area are in red. Note: Numbers represent percent. 92 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Section 6. Trends in Specific Service Readiness The data introduced so far suggest a number of trends in service readiness in BARMM. Table 29 provides an overview of readiness to provide MCH, NCD, and communicable services. Cells are color coded to indicate domain-specific and overall readiness scores for each province. Cells shaded in green have aggregate service readiness scores of 50 percent or higher, while those shaded in rose have scores of 49.9 percent or lower. Table 29. Specific Service Readiness: Overall Performance Mainland Provinces Island Provinces Domain Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM FP 84.6 88.5 84.4 100.0 91.4 86.6 87.3 ANC 58.7 71.0 61.4 68.2 77.0 79.2 68.0 BONC 54.9 73.8 61.5 83.3 67.1 67.9 65.0 Immunization 49.9 62.6 55.4 92.5 58.2 53.6 56.6 Child Health 66.3 75.0 68.4 57.9 75.9 59.8 69.7 CVD 60.7 62.4 45.8 58.3 46.5 47.6 56.0 Diabetes 53.3 51.4 41.0 50.0 41.7 46.7 48.9 CRD 23.8 32.7 21.2 22.7 23.4 24.0 26.2 Cervical Cancer 22.4 65.5 0.0 25.0 7.9 3.6 28.9 Malaria 27.2 40.5 30.2 37.5 71.7 51.8 41.4 TB 42.1 70.5 56.3 70.8 61.0 49.4 56.2 Note: Aggregate scores of 50 percent or higher are in green. Aggregate scores of 49.9 percent or lower are in red. Note: Numbers represent percent. The five provinces in BARMM have generally higher readiness to provide MCH services, while overall capacity to provide NCD or communicable disease-related services is low or variable. Aggregate specific-service readiness scores were the highest for the FP services, followed by child health, ANC, BONC, and immunization services (in that order). NCD services lag significantly. Communicable diseases service performance is highly variable, pointing to variations in both the priority status of the condition and in the geographic distribution of the conditions. TB is a high-priority condition and stands out for the very high availability of medicines and commodities aimed at treating the disease. Malaria services are limited overall, but readiness tracks the geographic patterns in disease prevalence. 93 Section 6. Trends in Specific Service Readiness Data suggest that the RHUs in Lanao del Sur tend to have more significant gaps in MCH service readiness than do facilities elsewhere in the region. Of the five provinces, Lanao del Sur had the lowest service-specific readiness score for ANC, BONC, and immunization and nearly ties Basilan’s low score for FP; among the five provinces, Tawi-Tawi had the lowest child health service readiness score. At the other end of the spectrum, Sulu had the highest overall readiness to provide FP services, and Tawi-Tawi led the group in readiness to provide ANC services, while Maguindanao led the provinces in readiness to provide BONC and immunization services. Lamitan City’s two CHOs generally outperformed the RHUs found in the five provinces. The main drivers for the variation in performance vary by category. While there were consistently large differences in the average availability of trained staff and service-specific guidelines, there were also large differences in the availability of medicines needed to provide ANC and child health services, as well as in the equipment needed for immunization. Table 30–Table 33 provide additional details into this variation. The broad-ranging gaps in the availability of trained staff and service-specific guidelines (Table 30) reflect the government’s high-priority programs and suggest that with the right attention, these areas can be significantly improved. MCH and TB programs have been the most effective at implementing trainings and distributing guidelines and job aids, and the results reflect the rollout of training and advocacy for specific services. However, work is ongoing. For example, for cervical cancer screening using acetic acid, only Maguindanao has been trained so far. This is reflected in the scores for cervical cancer screening readiness. Similarly, training on management of diabetes using insulin was conducted only in late 2017, shortly after the survey work was completed. Hence, it is expected that the RHUs’ capacity to provide insulin services will improve soon after. Table 30. Specific Service Readiness: Guidelines and Staffing Mainland Provinces Island Provinces Indicator Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM FP Services 67.5 74.8 66.7 100.0 77.2 69.0 71.8 ANC Services 46.2 73.9 58.3 100.0 63.2 78.6 62.9 BONC Services 27.6 68.2 41.7 87.5 44.7 51.8 47.6 Immunization 49.7 38.9 47.9 87.5 30.9 27.7 41.5 Child Health 26.9 48.6 41.7 12.5 52.6 32.1 39.2 CVD Services 34.6 50.0 25.0 50.0 31.6 28.6 37.4 Diabetes 34.6 51.4 20.8 50.0 31.6 35.7 38.2 CRD Services 19.2 40.5 4.2 25.0 18.4 14.3 23.6 Cervical Cancer 20.5 58.1 0.0 25.0 5.3 0.0 25.2 Malaria 17.3 35.8 25.0 25.0 59.2 41.1 32.9 TB 39.4 83.1 57.3 81.3 69.7 50.9 61.0 Note: Aggregate scores of 50 percent or higher are in green. Aggregate scores of 49.9 percent or lower are in red. Note: Numbers represent percent. 94 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) The equipment domain is consistently among the highest scoring domains. The relatively strong overall performance of the equipment domain likely reflects a combination of the long-lasting nature of these investments and broad applicability of a small number of items (for example, BP apparatus) (Table 31). Table 31. Specific Service Readiness: Equipment Mainland Provinces Island Provinces Service Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM FP Services 100.0 100.0 100.0 100.0 100.0 100.0 100.0 ANC Services 100.0 100.0 100.0 100.0 100.0 100.0 100.0 BONC Services 62.8 74.9 65.5 82.1 72.9 69.4 69.3 Immunization 58.0 79.1 69.8 93.8 80.3 67.9 70.6 Child Health 84.6 97.8 95.0 100.0 93.7 100.0 93.0 CVD Services 87.2 96.6 95.8 100.0 90.8 91.1 92.1 Diabetes 97.4 100.0 100.0 100.0 98.2 100.0 98.9 CRD Services 39.7 48.0 45.8 50.0 44.7 44.6 44.3 Cervical Cancer 33.3 83.8 0.0 50.0 21.1 7.1 40.7 Note: Aggregate scores of 50 percent or higher are in green. Aggregate scores of 49.9 percent or lower are in red. Note: Numbers represent percent. There are gaps in diagnostic capacity at the RHUs across BARMM. While overall diagnostic capacity is low at the RHUs in BARMM, it is particularly problematic for the diagnosis of TB (available at just 29.3 percent of the RHUs) and cervical cancer (24.4 percent of the RHUs) (Table 32). Table 32. Specific Service Readiness: Diagnostic Capacity Mainland Provinces Island Provinces Domain Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM ANC Services 76.9 60.8 54.2 50.0 57.9 60.7 64.6 Child Health 44.4 48.6 50.0 33.3 64.9 59.5 50.9 Diabetes 75.2 52.3 47.2 66.7 45.6 52.4 58.3 Cervical Cancer 15.4 62.2 0.0 0.0 0.0 7.1 24.4 Malaria 46.2 40.5 58.3 50.0 94.7 92.9 58.5 TB 29.9 27.0 38.9 33.3 24.6 31.0 29.3 Note: Aggregate scores of 50 percent or higher are in green. Aggregate scores of 49.9 percent or lower are in red. Note: Numbers represent percent. 95 Section 6. Trends in Specific Service Readiness Gaps in the availability of essential medicines are the largest for NCD treatment and, equally alarmingly, large for vaccines. With the important exception of vaccines, availability of medicines and commodities for MCH services is relatively high (Table 33). This finding complements the general service readiness overview provided in Section 4 of this report, where the analysis suggested significant gaps in drugs required for the management of hypertension and other chronic conditions. Table 33. Specific Service Readiness: Essential Medicines Mainland Provinces Island Provinces Indicator Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM FP Services 93.6 95.9 93.8 100.0 100.0 96.4 95.7 ANC Services 50.8 67.6 58.3 50.0 88.4 82.9 66.0 BONC Services 54.7 74.8 65.3 83.3 68.4 75.0 66.7 Immunization 34.0 77.0 41.7 100.0 68.4 76.8 58.9 Child Services 85.0 84.9 72.6 64.3 81.2 46.9 78.5 CVD Services 51.7 43.7 19.4 33.3 21.9 25.0 38.2 Diabetes 21.0 21.6 10.0 10.0 9.5 15.7 17.6 Chronic Respiratory 12.8 17.3 8.3 0.0 8.4 11.4 12.7 Malaria 34.2 46.8 27.8 50.0 80.7 52.4 46.9 TB 100.0 100.0 100.0 100.0 100.0 92.9 99.2 Note: Aggregate scores of 50 percent or higher are in green. Aggregate scores of 49.9 percent or lower are in red. Note: Numbers represent percent. As mentioned earlier, the national DOH provides several commodities in the RHUs. Key informant interviews at the national DOH, DOH-ARMM, and some RHUs revealed several logistics issues in the distribution of the goods from Metro Manila to the RHUs and other facilities nationwide. In spite of these irregular arrangements, however, this survey’s results show that some medicines, in particular FP commodities, find their way to the RHUs. The maintenance medicines are also relatively available in the RHUs, although not as widely available as the FP commodities, which may suggest that there is a need to more accurately forecast the volume of supplies required. Vaccines, on the other hand, need special handling and many RHUs do not have enough cold storage space. Vaccines are therefore stored in the provincial hospitals or the RHUs in provincial centers. Other RHUs will have to pick up their supplies when needed, and this poses a problem for far-flung RHUs, and communications access compounds this setback. 96 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Section 7. BARMM in the National Context We conclude this work by placing the survey findings within the national context. To do so, we use data from a 2014 survey covering 14 of the country’s 17 regions.53 The 2014 survey was designed to be representative at the national and regional levels, and data were collected at one RHU in each of 240 LGUs across 14 regions.54 Because this survey was designed to inform the implementation of the government’s PCB, it was limited to PCB- accredited facilities and did not collect the complete set of indicators included in this survey. For this comparison, data from BARMM were reanalyzed to exclude the tracer indicators that were not available in the national survey. Results for the five domains of general service readiness and for eight specific services are provided below. BONC and malaria service readiness were not assessed in 2014, and there was insufficient indicator overlap to compare TB service readiness across the two rounds. A comparison of the two surveys suggests that the RHUs in BARMM are significantly under resourced when compared to those in other regions of the Philippines. Table 34 provides an overview of general service readiness using a condensed set of tracer indicators.55 Only in infection prevention does BARMM perform above the national average. Moreover, RHUs in BARMM have the lowest overall availability of basic equipment, diagnostics, and medicines of any of the 15 regions visited across the two rounds of data collection. The RHUs in BARMM were able to provide fewer than half (46 percent) of the diagnostic tests assessed, compared to 67 percent elsewhere in the country. Similarly, while the 2014 survey of 14 regions found that the RHUs had, on average, 87 percent of the tracer essential medicines, the RHUs in BARMM had just 46 percent of these same medicines in 2017. 53 The three regions that were excluded from the national survey include the NCR, which constitutes Metro Manila and was considered to be nonrepresentative of the rest of the country; Region 8, which had been severely affected by Typhoon Haiyan shortly before data collection; and BARMM, which was excluded due to structural differences in the health sector organization that has been described elsewhere in this report. 54 In each province, eight LGUs were randomly selected. 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. 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. 55 The following changes were made to align the analyses: basic infrastructure was adapted to exclude communication equipment (telephone or short-wave radio); basic equipment excludes a light source; infection prevention excludes infectious waste storage, disinfectant, and guidelines on infection prevention; diagnostic capacity excludes urine tests for pregnancy; essential medicines excludes ampicillin, aspirin, carbamazepine, ceftriaxone, fluoxetine, gentamicin, haloperidol, insulin, omeprazole, and statins. 97 Section 7. ARMM in the National Context Table 34. General Service Readiness: Comparison to the National Context - 2014 Data and a Condensed Set of Tracer Indicators General Service Readiness Region Basic Infrastructure b Basic Equipmentc Infection Preventiond Diagnostic Capacitye Essential Medicinesf 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 Philippinesa 78 98 87 67 87 ARMM 73 88 90 46 46 Note: a. Excluding the NCR and Region 8. Data collected in 2014. b. Basic infrastructure includes power, improved water, auditory and visual privacy for patient consultations, access to sanitation facilities for patients, computer with e-mail/Internet access, and emergency transportation. c. Basic equipment includes adult scale, child scale. thermometer, stethoscope, and BP apparatus. d. Infection prevention includes six tracer indicators: safe final disposal of sharps, safe final disposal of infectious waste, sharps storage, single-use syringes, soap and running water or alcohol-based hand rub, and latex gloves. e. Tracer indicators on diagnostic capacity include tests for hemoglobin and blood glucose; urine dipsticks for protein and glucose; and urine tests for malaria, HIV, and syphilis diagnosis. f. Essential medicines include calcium channel blockers, amoxicillin syrup and tablet, beclomethasone (inhaled corticosteroids), beta blockers, diazepam, ACE inhibitors, glibenclamide (sulfunylureas), magnesium sulfate, metformin, ORS, oxytocin, salbutamol (beta 2 agonist), thiazide (diuretic), and zinc sulfate. Note: Numbers represent percent. BARMM has the lowest aggregate readiness scores for seven of the eight specific services that could be compared. The availability of FP commodities is similar in BARMM to those found at the RHUs elsewhere. While the overall availability of inputs to provide ANC service is low in BARMM, results are similar to those found in other regions, including CAR and Region 9. By contrast, BARMM has the lowest aggregate score by a very wide margin for the remaining services. For immunization services, there is a 14-point gap between BARMM and Region 1, the region with the lowest readiness score in 2014. There is a 12-point gap between BARMM and Region 7 for cervical cancer screening readiness, a 13-point gap between BARMM and CAR for CVD service readiness, and a 19-point gap between BARMM and CAR for diabetes service readiness. For CRD, there is a large 33-point gap between BARMM and Caraga. These findings highlight significant differences in the overall availability of basic inputs to deliver primary health services in BARMM relative to other parts of the country. 98 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 35. Specific Service Readiness in the National Context - 2014 Data and a Condensed Set of Tracer Indicators Specific Service Readiness Region FP b ANC c Immunizationd Child Healthe CVDf,g DMh CRDi,j CCSk CAR 93 80 77 87 76 77 67 64 Region 1 93 89 70 88 88 88 74 48 Region 2 90 88 78 93 87 90 76 61 Region 3 95 95 83 89 90 98 69 85 Region 4A 99 85 81 86 88 93 72 75 Region 4B 98 82 81 79 87 87 71 48 Region 5 100 93 74 90 79 97 68 70 Region 6 93 86 83 83 86 89 71 60 Region 7 92 87 73 80 85 94 76 47 Region 9 99 81 77 87 86 80 66 53 Region 10 99 97 84 95 89 96 70 74 Region 11 100 95 80 98 86 91 66 66 Region 12 96 96 82 98 82 90 65 53 Caraga 99 92 85 93 88 94 62 63 Philippinesa 96 89 79 89 86 91 70 61 ARMM 98 80 56 76 63 58 29 35 Note: a. Excluding the NCR and Region 8. Data collected in 2014. b. FP is altered from the main analysis to exclude guidelines on family planning, checklists and/or job aids, and staff trained on FP and progesterin-only contraceptive pills. c. ANC is altered from the main analysis to exclude ANC guidelines, ANC check lists and job aids, IPT, and ITNs. d. Immunization is altered from the main analysis to exclude all guidelines and training indicators, cold box/vaccine carrier with ice packs, auto-disposable syringes, temperature monitoring, adequate temperature, immunization cards, immunization tally sheets, IPV, and HPV. e. Child health is altered from the main analysis to exclude all guidelines and training indicators, length board, growth chart, and vitamin A. f. CVD is altered from the main analysis to exclude guidelines for diagnosis and treatment of chronic cardiovascular conditions, oxygen, and aspirin. g. The 2014 survey included the availability of lipid profile reagents as a diagnostic, which was not collected in the 2016 survey. h. Diabetes is altered from the main analysis to exclude guidelines for diabetes diagnosis and treatment, measuring tape, insulin, and glucose. i. CRD is altered from the main analysis to exclude guidelines and staff trained for diagnosis and management of CRD, spacers for inhalers, oxygen, and prednisolone. j. The 2014 survey includes an additional medicine indicator for beta blocker, which was not collected in the 2016 survey. k. CCS is altered from the main analysis to exclude guidelines for cervical cancer prevention and control. Note: Numbers represent percent. 99 Section 8. Conclusions, Limitations and Areas for Further Work Section 8. Conclusions, Limitations and Areas for Further Work Conclusions This report is the first to provide a systematic assessment of readiness to deliver primary health care services in BARMM. Data were collected prior to transition from ARMM to BARMM, from nearly all RHUs in the five provinces in the region. Population-based surveys have documented significant demographic and epidemiological challenges in the area. While the causes of poor health outcomes in BARMM are complex and multidimensional, the results of this survey highlight the critical importance of equipping the region’s public primary health sector to deliver essential preventive and curative services. The survey identified important gaps in access to care across BARMM; the availability of primary care infrastructure and health personnel fall well below the national targets. The number of all cadres needs to be increased, especially in rural and remote areas. The number of government doctors would need to nearly triple to reach the national target. However, any program to increase the number of workers needs to be carefully planned and managed to avoid challenges down the road. The current reliance on centrally supported deployment programs, while an important stop-gap measure, risks the long-term sustainability of HRH in the region. Better distribution of existing health staff could be achieved through incentive mechanisms to promote deployment in underserved areas. A complete HRH needs assessment would provide a definitive picture of existing gaps and facilitate negotiations with the LGUs regarding budgetary support for expansions of the health workforce. Widespread gaps in consumables undermine the ability to deliver health services. Of the 75 medicines and commodities assessed, just 11 were available in at least half of the RHUs in each of the five provinces. There are similar gaps in diagnostic capacity across every service for which it was examined. Addressing the critical shortcomings in the logistics and supply chain is an urgent priority. In particular, mechanisms must be developed to ensure timely delivery of medicines and supplies to the RHUs across the region. Potential interventions may involve designating personnel to establish standardized logistics systems and parallel efforts to adequately monitor the logistics systems. Reorganization of the health sector under the MOH-BARMM would provide opportunities to build a better system to address these issues. Ensuring basic amenities are available such as power, emergency transportation, and communication channels is critical for health service delivery at the frontline level. Approximately 15 percent of the RHUs in Sulu, for example, lack access to running water while nearly 20 percent of the RHUs in Lanao del Sur have no source of electricity. Fewer than half of the RHUs in BARMM have access to communication equipment, such as telephones or short-wave radios, and even fewer have computers with Internet access. Emergency transportation, too, is lacking. Across BARMM, one in three facilities lacks transportation to evacuate patients; in Tawi-Tawi, this number jumps to two out of every three RHUs. Given the remoteness of some of the provinces, creative ways to improve emergency transportation and ensure access to permanent 100 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) power supply should be sought in close collaboration with the regional authorities. Moreover, increased access to tax revenues and increased fiscal autonomy would allow for the BARMM government to take charge of improvements in these areas. PhilHealth has a major role to play in improving services in BARMM. The agency should strengthen accreditation systems for the RHUs in BARMM. Findings suggest that most public facilities have been accredited in advance of meeting the formal infrastructural requirements, likely as part of an aim to rapidly expand PhilHealth’s provider network and, thus, access to care. While this is an important initiative, it risks the creation of an empty entitlement, where patients are granted nominal coverage for services that local facilities cannot provide. It is, therefore, critical that PhilHealth uses its leverage as a funder to encourage facilities to rapidly move to meet actual accreditation requirements. Significant delays in the release of PhilHealth capitation payments also need to be addressed. Predictability in the timing of these payments can greatly aid in the planning and sustainability of operations and will increase the incentive for facilities to meet accreditation standards. In the context of the recent UHC Law, PhilHealth’s mandate becomes increasingly important as an eventual single purchaser of health services. The LGUs should be encouraged to play a larger role in health service delivery. This was suggested earlier, with reference to efforts to develop the local workforce, but extends generally to the strengthening of local publicly funded health services. The national government provides IRA transfers to the LGUs to support social services, including health care. While the LGUs are authorized to determine the specific allocation of these transfers, few of those in the region have chosen to fund health care services in recent years. Coordination between health officers and the LGU through a functional local health board can help raise the local profile of the health sector and clarify the specific support that the LGUs might provide. Potential support includes distribution of commodities, non-personnel operating expenses, infrastructure or equipment investments, or expansion and capacity building of local HRH. Accountability mechanisms should be introduced to ensure that all parties meet their respective financial obligations to the health sector. The use of real-time information systems using modern technology would greatly aid in monitoring and decision making for service delivery. The national DOH and PhilHealth are working to roll out electronic medical records, but currently, the availability of this system is limited to a small part of the five provinces. As evidenced from this assessment, availability of Internet connection and other basic communication channels remains a constraint, particularly in the island provinces. Again, the LGUs could support these efforts. Finally, while the availability of inputs is a critical component of health care, the overall quality of care depends on many additional factors, including provider knowledge and communication skills. Supply-side readiness is just one spoke in the wheel of what determines health outcomes. While this is partially captured in the patient satisfaction survey conducted as part of this study (Annex 4), efforts to gain a more comprehensive understanding of quality of care of health services in the region would benefit from a more detailed assessment. More generally, there are currently no routine mechanisms to assess the quality of care in BARMM, and these should be instituted as part of the regular supervision process by regional authorities. 101 Section 8. Conclusions, Limitations and Areas for Further Work The findings of this report suggest that investments in supply-side readiness are essential if the Philippines is to address poor health outcomes. The BOL and formation of BARMM have major implications for the health sector. With the expected reorganization of both the management and financing of the health sector, the region has an opportunity to significantly improve services. The study presented here provides an important baseline of the health sector capacity to deliver key services which will help the MOH-BARMM make informed decisions even as the region gains the autonomy in planning and allocating resources. Limitations and Areas for Further Work This paper highlights significant and systemic gaps in readiness to provide basic health services at the RHUs across BARMM. A key objective of this report is to stimulate policy dialogue on ways to enhance health service delivery at the primary care facilities in the region. However, there are limitations to this work. One important example relates to our efforts to situate these findings within the broader health services delivery system in the country, presented in Section 7.56 In particular, this effort is limited by the different sampling frames used by the two surveys. The current survey sought to gain a complete picture of BARMM’s public primary care system, and teams visited nearly all facilities in the surveyed area. For the national survey, by contrast, data were collected with the intention of understanding the capacity to deliver on PhilHealth entitlements across the country. Random selection occurred at the municipality level, stratified by region and province. To be eligible for inclusion in the survey, the RHUs had to be PCB accredited at the time of the survey. Thus, the RHUs surveyed are likely to represent the best RHU in each municipality and do not illustrate, for example, the variation of performance that may be present in a given region – either within or between provinces. A related issue stems from the decision to focus on the public sector. The private sector plays a critical role in service delivery at the local level. However, a full assessment of the private sector was beyond the scope of this study. Despite these limitations, the data presented here provide a comprehensive and actionable assessment of significant health sector challenges in BARMM. A related limitation links to the efforts to situate performance within the functions of the public health system. There is particular relevance for linking the issues identified here with bottlenecks in the health financing system. While this study was meant to inform an ongoing health financing systems assessment, data from the broader study were not yet available at the time of this report. Security concerns made many areas relatively inaccessible and limited the ability for the team to develop a deeper examination of results, particularly those related to bottlenecks in the supply chain and financing. However, efforts to link these issues to supply-side readiness merit further examination. Finally, it is important to comment upon the strategy employed to assess readiness. This report builds upon the WHO’s SARA framework to assess facility readiness to deliver general and specified health services. However, in so doing, the report does not provide an exhaustive list of the services and indicators that might have been investigated, had it been designed locally to focus on key government priorities. Nonetheless, the data that are available are broad and provide insights into service readiness of the region. Using these data, we are able to draw important and relevant conclusions. 56 Data collected in 2014 from 14 regions, excluding BARMM, the NCR, and Region 8, which had recently been hit by the powerful Typhoon Haiyan. Data analysis was designed to be representative at the national and regional levels. Approximately half of the provinces are represented. 102 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Future studies can help address the limitations mentioned above. A similar examination of service readiness among private sector providers would greatly expand our understanding of the services available to individuals living in BARMM. In parallel, efforts to improve health outcomes in BARMM would benefit from a fuller examination of the key determinants—including the demand-side determinants—of the maternal health, NCD, and communicable disease outcomes considered here. An examination of the quality of care, using information on the performance of health care workers, would be particularly valuable. 103 Annex 1: List of facilities visited Annex 1: List of facilities visited Lanao del Sur Maguindanao Basilan Sulu Tawi-Tawi Baying Datu Abdullah Sangki Al-Barka Pandami Tapul Binindayan Datu Anggal Midtimbang Hadji Mohammad Ajul Tongkil (Baguingingi) (BHS)-Banaran Tunggosong Buadipuso Buntong Datu Blah Sinsuat Hadji Muhtamad Hadji Panglima Tahil Bongao Bumbaran Datu Hoffer Ampatuan Maluso Indanan Lawm Tabawan Main Butig Datu Piang Matarling B Jolo Mapun Main Madalum Datu Salibo Akbar Lugus Panglima Sugala Madamba Datu Saudi Ampatuan Atong Atong Maimbung Simunul Maguing Guindulungan East Lamitan Panamao Languyan Pualas Mamasapano Tuburan Pangutaran Tandubas Bacolod Kalawi Matuber Health Center West Lamitan Siasi Sapa-Sapa Main Balabagan Mother Kabuntalan Sumisip Kalingalan Caluang Sibutu Main Balindong Barira Tabuan Lasa Luuk Sitangkai Bubong Buluan Tipo-Tipo Omar South Ubian Main Calanogas Datu Odin Sinsuat Ungkaya Pukan Panglima Estino Tandubanak Ditsaan Ramain Datu Unsay Parang Turtle Island Ganasi Gen. S. K. Pendatun Pata Kapatagan Matanog Patikul Kapay Pandag Talipao, Bilaan Lumba Bayabao Parang Lumbaca Unayan Sultan Kudarat Lumbatan Sultan Mastura Lumbayanaque Upi (North) Malabang Northern Kabuntalan Marantao Ampatuan Marogong Buldon Masiu Datu Montawal Mulondo Datu Paglas Pagayawan Mangudadatu Piagapo Pagalungan Picong Paglat Poona Bayabao Rajah Buayan Saguiran Sharief Saydona Mustapha Sultan Domalondong Shariff Aguak Tagoloan South Upi Tamparan Sultan Sa Barongis Tubaran Talayan Tugaya Talitay Taraka 104 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Annex 2: Additional Details on Service Readiness – by Domain Table 36. General Service Readiness: Overview Mainland Provinces Island Provinces Indicator Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Basic Amenities 61.9 76.4 57.1 85.7 69.2 75.5 68.9 Basic Equipment 77.8 91.9 86.1 100.0 81.6 97.6 86.0 Standard Precaution 73.2 81.4 74.1 88.9 77.2 79.4 77.3 for Infection Prevention Diagnostic Capacity 52.7 49.8 47.6 50.0 57.1 53.1 52.0 Essential Medicine 34.6 35.9 23.3 36.0 27.2 24.3 31.6 Service Readiness 60.7 67.1 57.7 72.1 62.4 66.0 63.2 Note: Numbers represent percent. Table 37. Service Specific Staff and Guidelines Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM FP Services Guidelines on family 84.6 75.7 83.3 100.0 78.9 64.3 78.9 planning Family planning checklists 41.0 75.7 66.7 100.0 84.2 78.6 65.9 and/or job-aids Staff trained in FP 76.9 73.0 50.0 100.0 68.4 64.3 70.7 ANC Services Guidelines in ANC 38.5 78.4 50.0 100.0 57.9 85.7 61.0 ANC checklists 43.6 75.7 83.3 100.0 84.2 85.7 69.1 and/or job-aids Staff trained in ANC 56.4 67.6 41.7 100.0 47.4 64.3 58.5 Note: Numbers represent percent. 105 Annex 2: Additional Details on Service Readiness – by Domain Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM BONC Services Guidelines for essential 23.1 64.9 41.7 50.0 57.9 71.4 48.8 childbirth care Checklist and/or 30.8 70.3 58.3 100.0 57.9 71.4 55.3 job-aids for essential childbirth care Staff trained in essential 30.8 70.3 25.0 100.0 31.6 35.7 43.9 childbirth care Staff trained in newborn 25.6 67.6 41.7 100.0 31.6 28.6 42.3 resuscitation Immunization Guidelines for child 59.0 89.2 75.0 100.0 73.7 71.4 74.0 immunization Staff trained in child 48.7 32.4 58.3 100.0 15.8 21.4 37.4 immunization - Immunization service delivery (immunization in practice (IIP) or any similar) Staff trained in child 48.7 29.7 33.3 100.0 15.8 21.4 34.1 immunization - Vaccine management/handling and cold chain Staff trained in child 61.5 40.5 41.7 50.0 31.6 35.7 45.5 immunization - Data reporting and monitoring of service delivery Staff trained in child 46.2 32.4 33.3 100.0 31.6 21.4 36.6 immunization - Disease surveillance and reporting Staff trained in child 43.6 32.4 50.0 100.0 26.3 21.4 36.6 immunization - Injection safety and waste management Staff trained in child 41.0 24.3 41.7 100.0 26.3 14.3 31.7 immunization - RED (Reaching Every District) Staff trained in child 48.7 29.7 50.0 50.0 26.3 14.3 35.8 immunization - Training on new vaccine prior to introduction 106 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Child Health Guidelines for IMCI 20.5 51.4 50.0 0.0 47.4 42.9 39.0 Guidelines for growth 25.6 56.8 75.0 50.0 63.2 42.9 48.0 monitoring Staff trained in IMCI+ 30.8 27.0 16.7 0.0 21.1 14.3 24.4 Staff trained in growth 30.8 59.5 25.0 0.0 78.9 28.6 45.5 monitoring+ Malaria Guidelines for diagnosis 12.8 16.2 16.7 0.0 63.2 42.9 25.2 and treatment of malaria Guidelines for IPT 2.6 45.9 25.0 0.0 52.6 28.6 28.5 Staff trained in malaria 30.8 35.1 25.0 50.0 94.7 71.4 46.3 diagnosis and treatment Staff trained in IPT 23.1 45.9 33.3 50.0 26.3 21.4 31.7 Tuberculosis Guidelines for diagnosis 64.1 89.2 91.7 100.0 89.5 64.3 78.9 and treatment of TB Guidelines for 2.6 78.4 16.7 50.0 31.6 14.3 33.3 management of HIV & TB co-infection Guidelines related to 17.9 83.8 33.3 50.0 73.7 14.3 48.0 MDR-TB treatment (for identification of need for referral) Guidelines for TB 30.8 86.5 75.0 100.0 78.9 85.7 66.7 infection control Staff trained in TB 66.7 86.5 75.0 100.0 84.2 71.4 77.2 diagnosis and treatment Staff trained in 25.6 73.0 50.0 50.0 36.8 35.7 45.5 management of HIV & TB co-infection Staff trained in client 48.7 83.8 58.3 100.0 78.9 50.0 65.9 MDR-TB treatment or identification of need for referral Staff trained in TB 59.0 83.8 58.3 100.0 84.2 71.4 72.4 Infection Control Diabetes Guidelines for diabetes 7.7 32.4 0.0 0.0 10.5 28.6 17.1 diagnosis and treatment Staff trained in diabetes 61.5 70.3 41.7 100.0 52.6 42.9 59.3 diagnosis and treatment 107 Annex 2: Additional Details on Service Readiness – by Domain Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Cardiovascular Disease Guidelines for diagnosis 5.1 37.8 8.3 0.0 15.8 21.4 18.7 and treatment of chronic cardiovascular conditions Staff trained in diagnosis 64.1 62.2 41.7 100.0 47.4 35.7 56.1 and management of chronic cardiovascular conditions Chronic Respiratory Guidelines for diagnosis 0.0 37.8 0.0 0.0 5.3 14.3 13.8 and management of CRD Staff trained in diagnosis 38.5 43.2 8.3 50.0 31.6 14.3 33.3 and management of CRD Cervical Cancer Guidelines for cervical 2.6 29.7 0.0 0.0 0.0 0.0 9.8 cancer prevention and control Staff trained in cervical 38.5 86.5 0.0 50.0 10.5 0.0 40.7 cancer prevention and control STAFF AND GUIDELINES 36.9 57.7 41.7 64.2 48.3 40.9 46.3 Table 38. Service Specific Equipment Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Adequate refrigerator 0.0 2.7 8.3 50.0 5.3 0.0 3.3 temperature Adult scale 92.3 100.0 100.0 100.0 94.7 100.0 96.7 Auto-disable syringes 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Blood pressure apparatus 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Child and Infant 97.4 97.3 100.0 100.0 100.0 100.0 98.4 weighing scale Child scale 28.2 67.6 50.0 100.0 47.4 92.9 53.7 Cold box/vaccine carrier 74.4 97.3 75.0 100.0 94.7 100.0 87.8 with ice packs Delivery bed 84.6 94.6 91.7 100.0 84.2 100.0 90.2 Delivery pack 38.5 86.5 75.0 50.0 42.1 28.6 56.1 Emergency transport 59.0 81.1 58.3 100.0 84.2 35.7 67.5 108 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Examination light 74.4 86.5 83.3 100.0 84.2 92.9 82.9 Gloves 87.2 97.3 100.0 100.0 100.0 100.0 95.1 Growth chart 48.7 94.6 75.0 100.0 89.5 100.0 78.0 Immunization cards 89.7 97.3 91.7 100.0 100.0 78.6 92.7 Immunization tally sheets 59.0 83.8 66.7 100.0 63.2 50.0 67.5 Infant weighing scale 82.1 89.2 91.7 100.0 94.7 92.9 88.6 Length/height measuring 100.0 100.0 100.0 100.0 100.0 100.0 100.0 equipment Light source 69.2 86.5 66.7 100.0 68.4 92.9 77.2 Manual vacuum extractor 10.3 0.0 8.3 0.0 0.0 7.1 4.9 Neonatal bag and mask 35.9 62.2 41.7 100.0 63.2 42.9 50.4 Oxygen 69.2 86.5 83.3 100.0 78.9 64.3 77.2 Partograph 71.8 78.4 50.0 100.0 68.4 85.7 73.2 Peak flow meter 0.0 0.0 0.0 0.0 10.5 0.0 1.6 Refrigerator (available 28.2 94.6 58.3 100.0 94.7 85.7 69.1 and functional) Sharps container/ 94.9 100.0 100.0 100.0 100.0 100.0 98.4 safety box Soap and running water or 97.4 97.3 100.0 100.0 100.0 100.0 98.4 alcohol based hand rub Spacers for inhalers 2.6 5.4 0.0 0.0 0.0 14.3 4.1 Speculum 33.3 83.8 0.0 50.0 21.1 7.1 40.7 Sterilization equipment 66.7 94.6 66.7 100.0 100.0 85.7 82.9 Stethoscope 87.2 100.0 100.0 100.0 89.5 100.0 94.3 Suction apparatus 71.8 78.4 41.7 100.0 73.7 85.7 73.2 (mucus extractor) Temperature monitoring 17.9 56.8 58.3 100.0 84.2 28.6 46.3 device in refrigerator Thermometer 89.7 97.3 100.0 100.0 89.5 100.0 94.3 Vacuum aspirator or D&C 2.6 0.0 8.3 0.0 26.3 14.3 7.3 kit and speculum EQUIPMENT 63.4 76.5 68.6 83.8 66.9 70.2 69.2 Note: Numbers represent percent. 109 Annex 2: Additional Details on Service Readiness – by Domain Table 39. Service Specific Diagnostics Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Acetic Acid 15.4 62.2 0.0 0.0 0.0 7.1 24.4 Blood glucose 76.9 91.9 75.0 100.0 94.7 85.7 85.4 Haemoglobin 76.9 89.2 75.0 50.0 94.7 85.7 83.7 HIV diagnostic capacity 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Malaria diagnostic 46.2 40.5 58.3 50.0 94.7 92.9 58.5 capacity Syphilis rapid test 0.0 0.0 0.0 0.0 0.0 0.0 0.0 System for diagnosis of 2.6 2.7 33.3 0.0 0.0 7.1 5.7 HIV among TB clients TB microscopy 87.2 78.4 83.3 100.0 73.7 85.7 82.1 Test parasite in stool 10.3 16.2 16.7 0.0 5.3 0.0 10.6 (general microscopy) Urine dipstick-ketones 71.8 32.4 33.3 50.0 21.1 35.7 43.9 Urine dipstick-protein/ 76.9 32.4 33.3 50.0 21.1 35.7 45.5 glucose Urine test for pregnancy 89.7 83.8 100.0 100.0 94.7 78.6 88.6 DIAGNOSTIC CAPACITY 46.2 44.1 42.4 41.7 41.7 42.9 44.0 Note: Numbers represent percent. Table 40. Service Specific Medicines and Commodities Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM ACE inhibitor 48.7 59.5 33.3 0.0 36.8 14.3 43.9 Amlodipine tablet or 74.4 21.6 0.0 100.0 31.6 21.4 39.0 alternative calcium channel blocker Amoxicillin syrup/ 79.5 91.9 58.3 100.0 63.2 35.7 74.0 suspension or dispersible tablet Amoxicillin tablet 87.2 75.7 58.3 100.0 78.9 57.1 76.4 Ampicillin powder 7.7 13.5 25.0 50.0 15.8 21.4 14.6 for injection Antibiotic eye ointment 38.5 75.7 41.7 100.0 63.2 71.4 58.5 for newborn Aspirin cap/tab 7.7 8.1 0.0 0.0 5.3 7.1 6.5 BCG vaccine 35.9 78.4 41.7 100.0 73.7 85.7 61.8 Note: Numbers represent percent. 110 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Beclometasone inhaler 0.0 0.0 8.3 0.0 0.0 7.1 1.6 Beta blocker 79.5 91.9 41.7 50.0 31.6 35.7 66.7 Calcium channel blockers 74.4 21.6 0.0 100.0 31.6 21.4 39.0 Carbamazepine tablet 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Ceftriaxone injection 2.6 13.5 0.0 0.0 0.0 21.4 7.3 Co-trimoxazole 74.4 81.1 41.7 0.0 63.2 21.4 64.2 syrup/suspension Combined estrogen 100.0 97.3 100.0 100.0 100.0 92.9 98.4 progesterone oral contraceptive pills Condoms 97.4 97.3 83.3 100.0 100.0 100.0 96.7 Diazepam injection 10.3 35.1 0.0 50.0 0.0 14.3 16.3 DPT-Hib+HepB vaccine 43.6 78.4 50.0 100.0 84.2 85.7 66.7 Epinephrine injectable 23.1 54.1 8.3 0.0 15.8 21.4 29.3 First-line antimalarial 0.0 16.2 0.0 50.0 57.9 57.1 21.1 in stock First-line TB medications 100.0 100.0 100.0 100.0 100.0 92.9 99.2 Fluoxetine tablet 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Folic acid tablets 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Gentamicin injection 2.6 29.7 0.0 50.0 5.3 21.4 13.8 Glibenclamide cap/tab 2.6 10.8 0.0 0.0 10.5 7.1 6.5 Haloperidol tablet 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Hydrocortisone injection 10.3 2.7 0.0 0.0 0.0 14.3 5.7 Injectable antibiotics 12.8 35.1 25.0 50.0 26.3 50.0 27.6 Injectable contraceptives 97.4 100.0 100.0 100.0 100.0 92.9 98.4 Insulin regular injection 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Intravenous solution with 79.5 94.6 91.7 100.0 78.9 92.9 87.0 infusion set IPT drug 7.7 37.8 16.7 0.0 89.5 85.7 39.0 Iron tablets 100.0 100.0 100.0 100.0 100.0 100.0 100.0 ITN 0.0 21.6 16.7 0.0 73.7 71.4 27.6 Magnesium sulphate 33.3 59.5 50.0 50.0 57.9 50.0 48.8 Me-/albendazole cap/tab 94.9 97.3 91.7 0.0 100.0 92.9 94.3 Measles vaccine 48.7 81.1 50.0 100.0 84.2 71.4 67.5 111 Annex 2: Additional Details on Service Readiness – by Domain Mainland Provinces Island Provinces Indicators Lanao del Sur Maguindanao Basilan Lamitan City Sulu Tawi-Tawi BARMM Metformin cap/tab 92.3 78.4 41.7 50.0 26.3 64.3 69.1 Omeprazole tablet or 48.7 27.0 0.0 0.0 42.1 28.6 33.3 alternative such as pantoprazole, rabeprazole Oral polio vaccine 7.7 70.3 25.0 100.0 31.6 64.3 39.8 Oral rehydration salts 94.9 91.9 91.7 100.0 84.2 64.3 88.6 Oxytocin 76.9 86.5 83.3 100.0 94.7 85.7 84.6 Paracetamol cap/tab 94.9 94.6 83.3 100.0 100.0 42.9 88.6 Prednisolone cap/tabs 10.3 5.4 16.7 0.0 5.3 7.1 8.1 Progestin-only 79.5 89.2 91.7 100.0 100.0 100.0 89.4 contraceptive pills Salbutamol inhaler 20.5 24.3 8.3 0.0 21.1 7.1 18.7 Simvastatin tablet or 23.1 32.4 16.7 0.0 5.3 0.0 19.5 other statin e.g. atorvastatin,pravastatin, fluvastatin Skin disinfectant 87.2 94.6 91.7 100.0 100.0 100.0 93.5 Tetanus toxoid vaccine 46.2 86.5 75.0 50.0 84.2 85.7 71.5 Thiazide (e.g. 7.7 2.7 0.0 0.0 0.0 7.1 4.1 hydrochlorothiazide) Vitamin A capsules 92.3 94.6 75.0 50.0 89.5 35.7 83.7 Zinc sulphate 64.1 43.2 66.7 100.0 68.4 35.7 56.1 MEDICINES AND 46.5 51.1 42.9 49.5 52.7 46.8 48.8 COMMODITIES Note: Numbers represent percent. 112 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Annex 3: Provincial Overview Lanao del Sur Figure 67. Facilities visited in Lanao del Sur • Population of approximately 933,000. RHU location by municipal population density - Lanao del Sur • 39 RHUs • 22 rural • 17 urban • Average catchment population: 26,800 • 1 doctor for every 24,890people • 1 nurse for every 4,605 people • 1 midwife for every 4,690 people Table 41. Top causes of morbidity and mortality in Lanao del Sur Rank Morbidity Mortality 1 Influenza/ URTI Cerebrovascular Accident/Stroke 2 Essential Hypertension Diseases of the Heart 3 Skin Diseases Pneumonia 4 Diarrhea/Acute Gastroenteritis Cancer (All Forms) 5 Pneumonia Hypovolemic Shock/ Massive Blood Loss due to Gunshot Wound 6 Diabetes Mellitus Diabetes Mellitus 7 Urinary Tract Infection Accident (All Forms) 8 Gastritis/Hyperacidity Kidney Failure 9 Bronchial Asthma Diarrhea with severe dehydration 10 Rheumatoid Arthritis Source: DOH-ARMM 113 Annex 3: Provincial Overview Figure 68. Proportion of the 172 total tracer indicators found at RHUs in Lanao del Sur Percentage of Tracer Indicators at RHUs Lanao del Sur 20 Of the 172 total tracer indicators: min, max and mean percentage available. 15 15 Lanao del Sur • Min: 20.3 • Mean: 44.6 Frequency • Max: 65.1 10 9 6 5 4 3 2 0 0 10 20 30 40 50 60 70 80 90 100 Percent Table 41 provides information from the DOH-ARMM on the top causes of morbidity and mortality in Lanao del Sur. The data highlight the importance of the specific services selected to the health needs of Lanao del Sur. The top two causes of mortality are linked to CVD; diabetes is also among the top ten causes of both morbidity and mortality. Asthma and diarrhea, important elements of CRD and child health services, are also important causes of morbidity. Injury is a major issue in Lanao del Sur – data was collected during the time of the Marawi Crisis, and gunshot injuries is a top cause of mortality. Table 42 indicates the availability of tracer indicators needed to manage the 11 specific services at the top- and bottom-scored RHUs in Lanao del Sur. Highlights include: • Which CVD is a major driver of mortality in Lanao del Sur, local RHUs are ill-equipped to identify and manage disease. The best-resourced RHU in Lanao del Sur stocked three-quarters of the CVD tracer indicators. The least-resourced RHU stocked just one in three indicators. • Diabetes: The best-resourced RHU stocked 69.2 percent of diabetes tracer indicators, while the least- stocked RHU stocked just over one in three indicators assessed. A majority (77 percent) of RHUs stock urine protein tests, but important medicines and commodities are not generally available. While metformin was widely available – all but three facilities had the medicine on the day of the survey – insulin was not available at any RHUs in Lanao del Sur, nor was gliclazide. • Asthma is the 9th cause of reported morbidity, but just 8 of the facilities had salbutamol and none had beclomethasone during the visits by enumerators. In Lanao del Sur, the best-resourced RHU stocked less than half of the CRD tracer indicators, the least-resourced RHU had none of the tracer indicators on hand. 114 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 42. Availability of tracer indicators at the high and low performing RHUs, Lanao del Sur Lanao del Sur Highest Lowest FP 100.0 50.0 ANC 90.9 27.3 BONC 75.9 3.4 Immunization 77.8 14.8 Child Health 89.5 26.3 CVD 75.0 33.3 Diabetes 69.2 38.5 CRD 45.5 0.0 Cervical Cancer 75.0 0.0 TB 75.0 8.3 Malaria 75.0 0.0 Note: Numbers represent percent. Maguindanao Figure 69. Facilities visited in Maguindanao • Population of approximately 1,275,000 RHU location by municipal population density - Maguindanao • 37 RHUs • 20 rural • 17 urban • Average catchment population: 31,730 • 1 doctor for every 46,960 people • 1 nurse for every 6,150 people • 1 midwife for every 3,700 people 115 Annex 3: Provincial Overview Table 43. Top causes of morbidity and mortality in Maguindanao Rank Morbidity Mortality 1 Acute Respiratory Infection Cardiovascular Diseases/ HPN 2 Systemic Viral Infection Cerebrovascular Accident 3 Skin Diseases Gunshot wounds 4 Cardiovascular Disease Pneumonia 5 Diarrhea Cancer, all sites 6 Urinary Tract Infection Kidney Failure 7 Gastritis Vehicular Accidents 8 Accidents/Traumatic Injuries Diabetes Mellitus 9 Musculo-skeletal Disorder Asthma 10 Anemia TB, all forms Source: DOH-ARMM Figure 70. Proportion of the 172 total tracer indicators found at RHUs in Maguindanao Percentage of Tracer Indicators at RHUs Maguindanao 15 Of the 172 total tracer indicators: min, max and mean percentage available. 11 Maguindanao • Min: 38.4 10 • Mean: 56.3 Frequency 8 • Max: 73.8 6 5 5 4 3 0 0 10 20 30 40 50 60 70 80 90 100 Percent 116 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 43 provides information from the DOH-ARMM on the top causes of morbidity and mortality in Maguindanao. The top two causes of mortality are again linked to CVD; diabetes, asthma, and tuberculosis are also among the top ten causes of mortality. Acute respiratory infections and diarrhea, important elements of child health services, are important causes of morbidity. Table 44 indicates the availability of tracer indicators needed to manage the 11 specific services at the top- and bottom-scored RHUs in Maguindanao. Highlights include: • CVD: While facilities in Maguindanao had highest average readiness to provide CVD services in BARMM, gaps were identified. The best-resourced RHU stocked 83.3 percent of CVD tracer indicators, while the least-stocked RHU stocked just less than half that. Facilities have an average of 7.5 of the 12 items assessed – while all facilities have basic equipment including stethoscopes, blood pressure apparatus, and adult scales, other supplies were rare. Just three facilities, for example, stocked aspirin on the date of the survey and just one facility stocked hydrochlorothiazide. • Tuberculosis: Maguindanao has, on average, higher readiness to deal with TB than do the other BARMM provinces. The best-resourced RHU stocked 83.3 percent of TB tracer indicators, while the least-stocked RHU stocked fewer than one in five of the indicators assessed. While TB microscopy is commonly available (found out 78 percent of Maguindanao’s RHUs), HIV-diagnostic capacity was wholly unavailable. Like nearly all RHUs in BARMM, facilities in Maguindanao routinely stock both first- and second-line drugs. Table 44. Availability of tracer indicators at the high and low performing RHUs, Maguindanao Maguindanao Highest Lowest FP 100.0 62.5 ANC 90.9 54.5 BONC 89.7 24.1 Immunization 85.2 22.2 Child Health 94.7 52.6 CVD 83.3 41.7 Diabetes 84.6 38.5 CRD 72.7 18.2 Cervical Cancer 100.0 0.0 TB 83.3 16.7 Malaria 87.5 12.5 Note: Numbers represent percent. 117 Annex 3: Provincial Overview Basilan and Lamitan City Basilan: Lamitan City: • Population of approximately 271,000 people. • 12 RHUs • Population: 74,782 • Average catchment population: 22,65057,58 • 2 CHOs • 1 doctor for every 33,970 people • Average catchment population: 37,391 • 1 nurse for every 2,360 people • 1 doctor for every 18,700 people • 1 midwife for every 2,380 people • 1 nurse for every 4,400 people • 1 midwife for every 37,390 people Figure 71. Facilities visited in Basilan and Lamitan City RHU location by municipal population density - Basilan Table 45. Top causes of morbidity and mortality in Basilan AND Lamitan City; Information provided by the DOH-ARMM Rank Morbidity Mortality 1 Hypertension Myocardial infarction 2 Pneumonia Unknown 3 Upper Respiratory Tract Infection (URTI) Cerebrovascular accident (stroke) 4 Skin diseases Gunshot wound 5 Cough and colds Cardiopulmonary arrest 6 Influenza Cardiac arrest 7 Diarrhea Senility 8 Age Acute Gastroenteritis with Severe Dehydration 9 Bronchitis Asthma 10 Fever Pulmonary tuberculosis Source: DOH-ARMM 57 DOH goal of having one facility for every 20,000 people 58 Note that it would appear that facilities may have overlapping population coverage hence may be double-counting some of the population, since 250,000 people divided by 15 facilities would indicate smaller catchment populations. 118 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Figure 72. Proportion of the 172 total tracer indicators found at RHUs in Basilan, including Lamitan City Percentage of Tracer Indicators at RHUs Basilan, including Lamitan City 5 Of the 172 total tracer indicators: 4 4 min, max and mean percentage available. 4 Basilan, including Lamitan City • Min: 29.7 • Mean: 46.6 3 Frequency • Max: 61.6 Basilan only: 2 2 • Min: 29.7 2 • Mean: 44.6 • Max: 58.1 1 1 Lamitan City only: 1 • Min: 56.4 • Mean: 59.0 • Max: 61.6 0 10 20 30 40 50 60 70 80 90 100 Percent Table 45 provides information from the DOH-ARMM on the top causes of morbidity and mortality in Basilan, including Lamitan City. The data indicate that the illnesses selected for review are important. Cardiovascular disease is the top cause of both morbidity and mortality in the province. Asthma – a common manifestation of CRD – and tuberculosis are also important causes of mortality, while common childhood illnesses, including influenza and diarrhea, are important causes of morbidity in the province. Despite the importance of NCDs in Basilan, few facilities are prepared to address them. Table 46 indicates the availability of tracer indicators needed to manage the 11 specific services at the top- and bottom-scored RHUs in Basilan and Lamitan City. Highlights include: • CVD: CVD is the leading cause of both morbidity and mortality. While all facilities reported the ability to diagnose CVD, only 7 of the 15 facilities had staff trained on the diagnosis and care of cardiovascular disease, and life-saving drugs were frequently missing. Only 4 of 15 RHUs had ACE inhibitors on hand, 6 had beta blockers, and just 2 had calcium channel blockers. No RHU in Basilan had either hydrochlorothiazide or aspirin on stock. The best-resourced RHU in Basilan stocked two-thirds of the CVD tracer indicators. The least-resourced RHU stocked half that. • Asthma is the 9th leading cause of mortality in the province, just one RHU (Akbar RHU) had salbutamol and/ or beclomethasone in stock. In Basilan, the best-resourced facility stocked just over one-third of the CRD tracer indicators. 119 Annex 3: Provincial Overview Table 46. Availability of tracer indicators at the high and low performing RHUs, Basilan and Lamitan City Basilan Lamitan City Highest Lowest Highest Lowest FP 100.0 50.0 100.0 100.0 ANC 81.8 45.5 72.7 63.6 BONC 82.8 17.2 79.3 75.9 Immunization 77.8 22.2 85.2 77.8 Child Health 84.2 37.0 63.2 37.0 CVD 66.7 33.3 58.3 58.3 Diabetes 53.8 30.8 53.8 46.2 CRD 36.4 9.1 27.3 18.2 Cervical Cancer 0.0 0.0 50.0 0.0 TB 83.3 25.0 75.0 66.7 Malaria 62.5 12.5 37.5 37.5 Note: Numbers represent percent. Sulu Figure 73. Facilities visited in Sulu • Population of approximately 825,000 RHU location by municipal population density - Sulu • 19 RHUs • 12 rural • 7 urban • Average catchment population: 43,410 • 1 doctor for every 58,910 people • 1 nurse for every 6,600 people • 1 midwife for every 5,425 people • Sulu reports the lowest health service density of the five provinces 120 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 47. Top causes of morbidity and mortality in Sulu Rank Morbidity Mortality 1 Acute respiratory infection Cerebrovascular accident 2 Acute gastroenteritis Pneumonia 3 Hypertension Acute gastroenteritis 4 Gastritis Gunshot wound 5 Pneumonia Hypertension 6 Skin diseases Myocardial infarction 7 Urinary tract infection Pulmonary tuberculosis 8 Musculoskelatal complaints Vehicular accident 9 Nutritional anemia Bronchial asthma 10 Flu-like disease Diabetes mellitus Source: DOH-ARMM Figure 74. Proportion of the 172 total tracer indicators found at RHUs in Sulu Percentage of Tracer Indicators at RHUs Sulu 10 Of the 172 total tracer indicators: min, max and mean percentage available. 8 Sulu • Min: 27.3 6 • Mean: 51.3 6 Frequency • Max: 62.2 5 5 4 2 2 1 0 0 10 20 30 40 50 60 70 80 90 100 Percent 121 Annex 3: Provincial Overview Table 47 provides information from the DOH-ARMM on the top causes of morbidity and mortality in Sulu. The top cause of mortality is again linked to CVD. Diabetes, asthma, and tuberculosis are also again among the top ten causes of mortality. Acute respiratory infections and diarrhea, important elements of child health services, are important causes of morbidity. Table 48 indicates the availability of tracer indicators needed to manage the 11 specific services at the top- and bottom-scored RHUs in Sulu. Highlights include: • CVD: While CVD is involved in the three of the top 10 causes of mortality – cerebrovascular accidents, hypertension, and myocardial infarction, serious gaps remain in the readiness to provide CVD care in Sulu. The best-resourced RHU in Sulu stocked two in three CVD tracer indicators, while the least-stocked RHU stocked fewer than one in five of the indicators assessed. Just over one-quarter (26 percent) of facilities stock metformin, 36 percent stock ACE inhibitors, and just 32 percent stock beta blockers. While aspirin is important for reducing mortality associated with myocardial infarction, just 5 percent of facilities had aspirin in stock on the day of the survey. • TB: Twelve of the 16 facilities (75 percent) are DOTS accredited, but the survey identified important ongoing gaps. The best-resourced RHU stocked 83.3 percent of TB tracer indicators, while the least-stocked RHU stocked 41.7 percent. As elsewhere in BARMM, first and second line medicines were available at all RHUs in Sulu. While HIV diagnostic services were not available for TB patients visiting RHUs in Sulu, just under 75 percent of facilities offer TB microscopy. Table 48. Availability of tracer indicators at the high and low performing RHUs, Sulu Sulu Highest Lowest FP 100.0 75.0 ANC 100.0 45.5 BONC 86.2 20.7 Immunization 77.8 14.8 Child Health 94.7 42.1 CVD 66.7 16.7 Diabetes 61.5 15.4 CRD 45.5 0.0 Cervical Cancer 50.0 0.0 TB 83.3 41.7 Malaria 87.5 25.0 Note: Numbers represent percent. 122 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Tawi-Tawi Figure 75. Facilities visited in Tawi-Tawi • Population of approximately 325,000 RHU location by municipal population density - Tawi-Tawi • 14 RHUs • 9 rural • 5 urban • Average catchment population: 27,900 • 1 doctor for every 32,560 people • 1 nurse for every 4,765 people • 1 midwife for every 3,200 people Table 49. Top causes of morbidity and mortality in Tawi-Tawi Rank Morbidity Mortality 1 Upper respiratory tract infection Cardiovascular 2 Pneumonia Senility 3 Bronchitis Fetal Deaths 4 Hypertension Pneumonia 5 Urinary tract infection Cancer 6 Acute gastroenteritis Violence 7 Allergic dermatitis Diarrhea 8 Acute gastritis Pulmonary Tuberculosis 9 Soft tissue infection Diabetes Mellitus 10 Pulmonary tuberculosis Neonatal Deaths Source: DOH-ARMM 123 Annex 3: Provincial Overview Figure 76. Proportion of the 172 total tracer indicators found at RHUs in Tawi-Tawi Percentage of Tracer Indicators at RHUs Tawi-Tawi 5 Of the 172 total tracer indicators: 4 min, max and mean percentage available. 4 Tawi-Tawi • Min: 26.2 3 • Mean: 46.5 3 Frequency • Max: 61.6 2 2 2 2 1 1 0 0 10 20 30 40 50 60 70 80 90 100 Percent Table 49 provides information from the DOH-ARMM on the top causes of morbidity and mortality in Tawi-Tawi. Cardiovascular events are the top reported cause of mortality in Tawi-Tawi; tuberculosis and diabetes are also found in the top ten causes of mortality while the large number of fetal and neonatal deaths point to the critical importance of high quality MCH care. Table 50 indicates the availability of tracer indicators needed to manage the 11 specific services at the top- and bottom-scored RHUs in Tawi-Tawi. Highlights include: • CVD: The best-resourced RHU stocked 66.7 percent of TB tracer indicators, while the least-stocked RHU stocked just one-quarter of the CVD tracer indicators. Metformin was the most commonly available CVD drug, but was missing from 36 percent of facilities in the province. Thiazide diuretics and aspirin were both hardly available, found at just 1 facility each. • MCH: Facilities in Tawi-Tawi also reported serious gaps in maternal health inputs. For example, the best- resourced RHU stocked 79.3 percent of BONC tracer indicators, while the least-stocked RHU stocked fewer than half of the tracer inputs. Just 79 percent of facilities had oxytocin on the day of the survey (compared to 87 percent in BARMM overall, and 100 percent of facilities in Basilan). Just half of the facilities had magnesium chloride. Despite these gaps, we note that, of the five provinces, Tawi-Tawi has the highest overall readiness for ANC care, and was second (after Maguindanao) for BONC care. • TB: The best-resourced RHU in Tawi-Tawi stocked two-thirds of TB tracer indicators, while the least-stocked RHU stocked fewer than one in ten of the tracer indicators. Although first-line TB drugs were widely available, Tawi-Tawi was the only province to report any stock-outs of these drugs. Surveyors asked about Isoniazid, Pyrazinamide, Rifampicin and Ethambutol. Two facilities did not have at least one drug, and one facility had a single drug, but did not have a second. Like elsewhere, most facilities had guidelines and staff trained in the diagnosis and treatment of TB, but were ill-equipped to manage TB-HIV co-infection. 124 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Table 50. Availability of tracer indicators at the high and low performing RHUs, Tawi-Tawi Tawi-Tawi Highest Lowest FP 100.0 75.0 ANC 100.0 45.5 BONC 79.3 44.8 Immunization 77.8 18.5 Child Health 78.9 42.1 CVD 66.7 25.0 Diabetes 69.2 23.1 CRD 54.5 9.1 Cervical Cancer 50.0 0.0 TB 66.7 8.3 Malaria 87.5 0.0 Note: Numbers represent percent. 125 Annex 4: Patient Exit Interviews Patient Exit Interviews Summary At each of the 123 RHUs visited, survey teams conducted 20 exit interviews in order to better understand the patient experience. During these interviews, patients reported relatively high satisfaction with care across ARMM and give particularly high marks to the providers for their clinical communication skills. Patients attending the clinics also report few financial or access barriers to care. However, patients did raise concerns related to the capacity of health care professional to provide adequate care and to give them accurate diagnoses. Of the seven dimensions of quality assessed, the technical quality domain, which examines the quality of clinical care, is the lowest performing. A full 55 percent of the patients interviewed report that they sometimes wonder whether the doctor had given a correct diagnosis and one-third of patients did not agree that the clinic had all of the supplied necessary to provide patient care. The findings of these surveys are discussed in greater detail below. Overview of the survey instrument Survey teams administered Rand’s Patient Satisfaction Questionnaire Short Form (PSQ-18) questionnaire. The PSQ-18 is a patient satisfaction framework that was originally developed for use in the United States and has since been used in a range of contexts, including India [1] Iran [2], and Thailand [3], among others. It is a short, 18-question survey that can generally be administered in less than 5 minutes [4]. Designed with brevity in mind, the survey is an adaptation of a longer questionnaire of approximately 50 questions. Both the original and the short version of the questionnaire are designed to assess satisfaction with seven dimensions of care: general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor, and accessibility and convenience. The specific questions used are indicated in Table 35, below. Table 51. The PSQ-18 General Satisfaction The medical care I have been receiving is just about perfect. I am dissatisfied with some things about the medical care I receive. Technical Quality I think the doctor’s office has everything needed to provide complete medical care. Sometimes doctors make me wonder if the diagnosis is correct. When I go for medical care, they are careful to check everything when examining and treating me. I have some doubts about the ability of the doctors who treat me. Interpersonal Manner Doctors act too businesslike and impersonal toward me. My doctors treat me in a very friendly and courteous manner. 126 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Communication Doctors are good about explaining the reason for medical tests. Doctors sometimes ignore what I tell them. Financial Aspects I feel confident that I can get the medical care I need without being set back financially. I have to pay more of my medical care than I can afford. Time spent with the doctor Those who provide my medical care sometimes hurry too much when they treat me. Doctors usually spend plenty of time with me Accessibility and Convenience I have easy access to the medical specialists that I need. Where I get medical care, people have to wait too long for emergency treatment. I find it hard to get an appointment for medical care right away. I am able to get medical care whenever I need it. Methods Respondents were asked to use a 5-point scale to indicate their level of agreement with each of 18 statements. With “1” indicating strong agreement and “5” indicating strong disagreement. For analysis, data was recoded such that higher numbers always indicates greater satisfaction. To achieve this, questions framing positive experiences were reverse coded. We aggregated data to create facility and provincial scores. In the discussion that follows, we present mean scores by province. A score of “5” indicates that all respondents in a given province have expressed the highest level of satisfaction, while a score of “1” indicates that all respondents in a given province have expressed the highest level of dissatisfaction with a given issue. Data overview Respondent profile In all, 2,440 exit interviews were conducted across the five provinces. RHUs were concentrated in the more populous provinces of Maguindanao and Lanao del Sur, and approximately one-third of the interviews took place in these mainland provinces. Three-quarters of survey respondents were female. This reflects, in part, the large number of female caretakers accompanying young children for health care; 28 percent of respondents were caretakers, mostly parents of young children, while 72 percent were patients themselves. One-fifth of patients are under the age of 5, and 43 percent are women of reproductive age (women between ages 18 and 44). Approximately 5 percent of patients are 65 or older. Respondents were, on average, less well-educated than the general population of ARMM. Between one-quarter and one-third of respondents do not have any education. By contrast, the 2017 NDHS found that only 14.6 percent of female respondents in ARMM reported having no education [5]. Maguindanao has the highest proportion of patients with no schooling. 127 Annex 4: Patient Exit Interviews Service Details Patients attend clinics for a range of services; just under two-thirds of patients were attending general outpatient services. Fourteen percent of respondents were at the facility for ANC care. The proportion of patients seeking ANC was highest in Sulu, where nearly a quarter (23.2 percent) of respondents were attending ANC visits. Family planning visits accounted for 2.8 percent of visits. While immunization accounted for just 15.2 percent of the overall sample, it accounted for 75 percent of all care sought by children under the age of 5. A small number of patients were at the clinic for PhilHealth’s PCB enlistment and profiling. Most patients were seen by mid-level staff. Few patients were seen by doctors; most patients saw a nurse (23 percent) or a midwife (28 percent). Just 4 percent of patients saw a doctor on the date of the interview. Thirty percent of patients saw a nurse in Lanao del Sur, and 36 percent of patients in Tawi-Tawi saw a midwife. Results Figure 77. Patient experience using the 7 satisfaction domains of the PSQ-18 General Satisfaction The medical care I have been receiving is just about perfect. 28.3 57.7 9.8 3.9 0.2 I am dissatisfied with some things about the medical care I receive. 2.5 10.7 6.6 59.2 21.0 Technical Quality I think the doctor’s office has everything needed to provide 22.2 44.3 22.5 9.7 1.4 complete medical care. Sometimes doctors make me wonder if the diagnosis is correct. 7.0 29.0 9.0 45.0 10.0 When I go for medical care, they are careful to check everything when 44.1 50.0 3.1 2.5 0.3 examining and treating me. I have some doubts about the ability 2.1 8.8 5.8 56.6 26.7 of the doctors who treat me. Interpersonal Manner Doctors act too businesslike and impersonal toward me. 15.3 21.8 6.5 33.8 22.5 2.4 0.8 My doctors treat me in a very friendly and courteous manner. 53.5 43.1 0.2 Communication Doctors are good about explaining the reason for medical tests. 48.7 49.3 2 1.7 0.2 Doctors sometimes ignore what I tell them. 1.8 6.4 3.0 58.5 30.3 0 10 20 30 40 50 60 70 80 90 100 % Strongly Agree Agree Uncertain Disagree Strongly Disagree 128 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Financial Aspects I feel confident that I can get the medical care I need without being set 39.3 45.5 6.5 6.4 2.3 back financially. I have to pay more of my medical care than I can afford. 1.9 5.5 6.2 23 48.3 41 38.1 37 Time spent with the doctor 18 14 68 Those who provide my medical care sometimes hurry too much when they 2.0 10.0 6.0 59.0 23.0 treat me. Doctors usually spend plenty of time with me. 30.2 98 51.6 10.2 7.6 2 0.4 Accessibility and Convenience 2 23 75 I have easy access to the medical 9 18.0 50 60.2 41 11.1 8.5 2.1 specialists that I need. Where I get medical care, people have to wait too long for 2.97 13.5 9.8 41 48.4 52 25.5 emergency treatment. I find it hard to get an appointment 1.8 10.0 10.1 60.5 17.7 for medical care right away. I am able to get medical care whenever I need it. 3 39.8 36 51.3 61 4.8 3.7 0.4 0 9 10 20 24 30 40 50 60 67 70 80 90 100 % Strongly Agree Agree Uncertain Disagree Strongly Disagree To assess General Satisfaction, patients were asked whether they agree with two statements: (1) The medical care I have been receiving is just about perfect; and (2) I am dissatisfied with some things about the medical care I receive. Nearly 85 percent of patients agreed that the care was just about perfect, however 13 percent of patients agreed with the statement “I am dissatisfied with some things about the medical care received.” Patients in Basilan and Tawi-Tawi were the least likely to agree that the care received had been “just about perfect.” To assess aggregate performance, we averaged the two questions over each of the 20 patients interviewed to create individual facility scores. Results are presented in Table 52, below. Overall, patients express moderately high levels of general satisfaction. Table 52. General Satisfaction Score Province Provincial Mean Lowest Scoring Facility Highest Scoring Facility Lanao del sur 3.99 3.47 4.57 Maguindanao 4.00 3.62 4.38 Basilan 3.74 3.17 4.35 Sulu 4.20 3.97 4.68 Tawi-Tawi 3.81 3.45 4.03 BARMM 3.98 3.17 4.68 Note: Numbers represent percent. 129 Annex 4: Patient Exit Interviews Patients expressed concerns about multiple dimensions of the technical care quality received, and overall satisfaction with technical quality was the lowest of the seven quality domains assessed. This was assessed using four statements: (1) I think the doctor’s office has everything needed to provide complete medical care; (2) Sometimes doctors make me wonder if the diagnosis is correct; (3) When I go to the doctor, they are careful to examine everything; and (4) I have some doubts about doctor’s ability of the doctors who treat me. Overall, 36.2 percent of patients expressed either moderate or high levels of doubt about diagnoses, and approximately 20 percent of patients in Sulu and Lanao del Sur expressed some doubt in the ability of their doctors to treat them. Patients also voiced widespread dissatisfaction with facility infrastructure. Fewer than a quarter of patients strongly agreed that facilities have everything needed to provide complete medical care; patients in Basilan were the most likely to disagree with the statement. Patients in Basilan were also the least likely to agree that practitioners provide careful exams. After aggregating across the 4 indicators of technical quality across all patients in all facilities, the regional average score is 3.83. This is significantly lower than the overall general satisfaction score of 4.68 presented above and suggests considerable room for improvement (Table 53). Table 53. Satisfaction with Technical Quality Province Provincial Mean Lowest Scoring Facility Highest Scoring Facility Lanao del sur 3.78 3.10 4.26 Maguindanao 3.79 3.36 4.14 Basilan 3.83 3.38 4.40 Sulu 3.99 3.51 4.38 Tawi-Tawi 3.83 3.46 4.05 BARMM 3.83 3.10 4.40 Note: Numbers represent percent. Interpersonal skills are critical to set a patient at ease; they are important for effective communication and can impact on patient’s decisions to comply with treatment advice or return to the clinic. Respondents had mixed responses to the dimensions considered for the interpersonal manner index, which included the statements: (1) Doctors act too businesslike and impersonal toward me; and (2) My doctors treat me in a very friendly and courteous manner. While the vast majority of patients in all five regions report that clinicians are very friendly and courteous, many report that clinicians are overly business-like. Indeed, one-quarter of the patients who strongly agreed that the doctor was very friendly and courteous also strongly agreed that the doctor was overly impersonal. The regional average score is 3.88, which is relatively low among the seven satisfaction domains assessed (Table 54). Table 54. Satisfaction with Interpersonal Manner Province Provincial Mean Lowest Scoring Facility Highest Scoring Facility Lanao del sur 4.30 3.08 4.97 Maguindanao 3.24 3.00 3.76 Basilan 3.64 3.10 4.25 Sulu 4.35 3.72 4.90 Tawi-Tawi 3.92 3.17 4.05 BARMM 3.88 3.00 4.97 Note: Numbers represent percent. 130 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Effective communication is critical to obtaining and relaying information to patients. To assess satisfaction with communication, patients were asked whether they agree with two statements: (1) Doctors are good about explaining the reason for medical tests; and (2) Doctors sometimes ignore what I tell them. On the whole, patients report relatively high levels of satisfaction with these dimensions of clinical communication. The regional average of 4.28 suggests consistently high performance across RHUs (Table 55). Fewer than 10 percent of patients interviewed report that doctors sometimes ignore what they are told. Table 55. Satisfaction with Communication Province Provincial Mean Lowest Scoring Facility Highest Scoring Facility Lanao del sur 4.41 3.60 4.78 Maguindanao 4.19 3.72 4.47 Basilan 4.19 3.65 4.57 Sulu 4.41 4.00 4.90 Tawi-Tawi 4.03 3.80 4.25 BARMM 4.28 3.60 4.90 Note: Numbers represent percent. Reducing financial barriers to care seeking is among the top priorities of the Philippine health sector. To assess satisfaction with the financial aspects of care seeking, patients were asked whether they agree with two statements: (1) I feel confident that I can get the medical care I need without being set back financially; and (2) I have to pay more of my medical care than I can afford manner. Overall, approximately 10 percent of patients expressed some concern with this domain. Patients in Basilan were the most likely to express concern. Approximately 8.6 percent of patients reported that they have to pay more than they can afford for care and just 20.7 percent of patients in Basilan expressed strong confidence that they could access needed medical care without facing financial setbacks. After aggregating the 2 indicators across all patients in all facilities, the national average score is 4.14. Results from each of the five provinces are presented in Table 56, below. Table 56. Satisfaction with Financial Aspects Province Provincial Mean Lowest Scoring Facility Highest Scoring Facility Lanao del sur 4.32 3.72 4.80 Maguindanao 4.11 3.47 4.60 Basilan 3.90 3.30 4.30 Sulu 4.21 3.42 4.90 Tawi-Tawi 3.88 3.60 4.15 BARMM 4.14 3.30 4.90 Note: Numbers represent percent. 131 Annex 4: Patient Exit Interviews To assess satisfaction with the time spent with the doctor, patients were asked whether they agree with two statements: (1) Those who provide my medical care sometimes hurry too much when they treat me; and (2) Doctors usually spend plenty of time with me. Overall, patients were less satisfied with the time spent with doctors than with other domains of care. More than 10 percent felt rushed in their sessions. After aggregating across the 2 indicators across all patients in all facilities, the national average score is 3.97. Results are presented in Table 57, below. Patients in Basilan were, on average, least likely to report that the consultation was unrushed that doctors spend sufficient time with patients, although health workforce statistics presented earlier suggest that Basilan has the highest density of health manpower of the five provinces. Table 57. Satisfaction with time spent with doctors Province Provincial Mean Lowest Scoring Facility Highest Scoring Facility Lanao del sur 4.01 3.15 4.60 Maguindanao 3.86 3.03 4.32 Basilan 3.69 3.05 4.00 Sulu 4.34 3.90 4.95 Tawi-Tawi 3.93 3.60 4.05 BARMM 3.97 3.03 4.95 Note: Numbers represent percent. Non-financial barriers to care, such as long waiting times and difficulties in scheduling appointments, can significantly reduce access to care even when efforts have been made to eliminate financial barriers. To assess satisfaction with the accessibility and convenience of health service, patients were asked whether they agree with four statements: (1) I have easy access to the medical specialists that I need; (2) Where I get medical care, people have to wait too long for emergency treatment; (3) I find it hard to get an appointment for medical care right away; and (4) I am able to get medical care whenever I need it. Patients report that services are relatively accessible. After aggregating across the 4 indicators across all patients in all facilities, the national average score is 3.93. Patients in Sulu were most likely to report that specialist and emergency care are easily accessible (Table 58). Table 58. Satisfaction with Access and Convenience Province Provincial Mean Lowest Scoring Facility Highest Scoring Facility Lanao del sur 3.99 3.25 4.54 Maguindanao 3.92 3.35 4.39 Basilan 3.64 3.12 4.03 Sulu 4.11 3.35 4.64 Tawi-Tawi 3.86 3.54 4 BARMM 3.93 3.12 4.64 Note: Numbers represent percent. 132 Preparing for the transition: Supply-Side Readiness of Primary Health Care in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) Bibliography Aung, M.N., et al., Satisfaction of HIV patients with task-shifted primary care service versus routine hospital service in northern Thailand. Journal of infection in developing countries, 2015. 9(12): p. 1360-1366. Australia Department of Foreign Affairs and Trade (DFAT) and World Bank. 2015. “Making Education Spending Count for the Children of Autonomous Muslim Region of Mindanao: Public Expenditure and Institutional Review for ARMM Basic Education.” World Bank, Washington, D.C. Capuno, J. J. 2017. “An Analysis of the Incidence and Human Costs of Violent Conflicts in the Autonomous Region in Muslim Mindanao.” The Asia Foundation, Bangkok, Thailand. Working Paper. Chander, V., et al., Scoring the medical outcomes among HIV / AIDS patients attending antiretroviral therapy center at Zonal Hospital, Hamirpur, using Patient Satisfaction Questionnaire (PSQ-18). Indian Journal of Sexually Transmitted Diseases, 2011. 32(1): p. 19-22. Dayrit, M. M., L. P. Lagrada, O. F. Picazo, M. C. Pons, and M. C. Villaverde. 2018. “The Philippines Health System Review.” World Health Organization, Regional Office for South-East Asia, New Delhi. 8 (2). Global Burden of Disease Health Financing Collaborator Network. 2017. “Evolution and Patterns of Global Health Financing 1995–2014: Development Assistance for Health, and Government, Prepaid Private, and Out-of-pocket Health Spending in 184 Countries.” The Lancet 389 (10083): pp. 1981–2004. Department of Health. (2018). “National Objectives for Health Philippines 2017-2022”. Manila, Philippines. Department of Health. ———. 2015. “Philippine Health System at a Glance.” ———. 2016. “All for Health towards Health for All: Philippine Health Agenda 2016–2022. Healthy Philippines 2022.” Food and Nutrition Research Institute – Department of Science and Technology (FINRI-DOST). 2016. Philippine Nutrition Facts and Figures 2015: Anthropometric Survey. FNRI Bldg., DOST Compound, Gen. Santos Avenue, Bicutan, Taguig City, Metro Manila, Philippines. ———. 2015. Philippine Nutrition Facts and Figures 2013: 8th National Nutrition Survey Overview. FNRI Bldg., DOST Compound, Bicutan, Taguig City, Metro Manila, Philippines. International Diabetes Federation (IDF). 2018. “IDF Country Profiles: The Philippines.” INCITEGov (International Center for Innovation, Transformation and Excellence in Governance). 2007. “Towards Strengthening the Fiscal Capabilities of ARMM.” Local Government Support Program in ARMM (LGSPA), INCITEGov, Pasig City. INCITEGov Policy Paper. 133 Bibliography Marshall, G.N. and R.D. Hays. The Patient Satisfaction Questionnaire Short Form (PSQ-18). 1994. Mujer Quintos, M. A. 2017. “Regional Differences in Maternal Mortality in the Philippines.” Asia Pac. J. Educ. Arts Sci. 4 (1). NSO (National Statistics Office). 2012. “2010 Census of Population and Housing.” ———NSO, DOH (Department of Health Philippines) and MI (Macro International Inc.). 1999. “Philippines National Demographics and Health Survey 1998.” NSO and MI, Manila. Philippine Health Insurance Corporation. 2016. “PhilHealth Circular 2016-0004.” Policy Statements 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. ———. 2013. “PhilHealth Circular 0020-2013.” 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. Philippine Statistics Authority (PSA) [Philippines], a.I.I., Philippines National Demographics and Health Survey, Key Indicators Report. 2018: Manila, Philippines, and Rockville, Maryland, USA: PSA and ICF International. PSA (Philippine Statistics Authority) and ICF International. 2014. Philippines 2013 National Demographic and Health Survey Final Report. Manila, Philippines, and Rockville, Maryland, USA: PSA and ICF International. ———. 2018. Philippines National Demographics and Health Survey, Key Indicators Report. Manila, Philippines, and Rockville, Maryland, USA: PSA and ICF International. Poverty and Human Development Statistics Division of the Philippine Statistics Authority (PSA). 2016. “2015 Full Year Official Poverty Statistics of the Philippines.” Quezon City, the Philippines. Available at https://psa.gov.ph/poverty-press-releases/ data/2015%20Full%20Year%20Poverty%20Statistics. Tan, G. H. 2015. “Diabetes Care in the Philippines.” Ann. Glob. Health 81 (6): pp. 863–869. Ulep, V. G., M. Aldeon, and N. A. dela Cruz. 2013 “Multisector Strategy in Addressing Non-communicable Diseases in the Philippines.” UNICEF (United Nations Children’s Fund). 2012. “Philippines: Maternal and Newborn Health Country Profiles.” WHO (World Health Organization). 2011. “The Philippines Health System Review.” Manila, Philippines: WHO, Western Pacific Region. Ziaei, H., et al., Determinants of patient satisfaction with ophthalmic services. BMC Research Notes, 2011. 4: p. 7. ———. 2018. “Provisional UHC and SDG Country Profile 2018 Philippines.” Regional Office of the Western Pacific, WHO. WPR/2018/DHS/019. ———. 2018. “WHO | NCD Country Profiles: The Philippines.” 134 The World Bank PHILIPPINES 26th Floor, One Global Place, 5th Avenue corner 25th Street, Bonifacio Global City Taguig, Metro Manila 1634 Telephone +63 2 465 2500 Fax +63 2 465 2505 Website www.worldbank.org/en/country/philippines