5th Annual Report on Responsible Parenthood and Reproductive Health Act of 2012 (2018) PDF

RPRH 5th ANNUAL REPORT 2018 RPRH 5th Annual Report CONTENTS Message from the Secretary i Acknowledgments iii Acronyms v Executive Summary...

RPRH 5th ANNUAL REPORT 2018 RPRH 5th Annual Report CONTENTS Message from the Secretary i Acknowledgments iii Acronyms v Executive Summary xi RPRH 5th Annual Report 1 Policy and Governance 1 Executive Level 1 Legislative Level 2 Local Level 3 Challenges and Recommendations 3 2 Budget and Financing 5 National Government Budget 5 Social Health Insurance 6 Financing Support from Other Sources 11 Challenges and Recommendations 12 3 Progress on the Key Result Areas 13 Key Result Area 1: Maternal, Newborn, Child Health and Nutrition 13 Key Interventions 16 Challenges and Recommendations 25 Key Result Area 2: Family Planning 27 Key Interventions 30 Challenges and Recommendations 37 Key Result Area 3: Adolescent Sexual and Reproductive Health 39 Key Interventions 41 Challenges and Recommendations 47 Key Result Area 4: Sexually Transmitted Infections and HIV/AIDS 48 Key Interventions 51 Challenges and Recommendations 53 Key Result Area 5: Elimination of Violence Against Women and 56 Children Key Interventions 59 Challenges and Recommendations 64 RPRH in the Past Five Years 69 Chronology of Major Events 69 Enabling Mechanisms 69 Financing 70 Implementation Outcomes 71 Success Stories 77 References 89 MESSAGE FROM THE SECRETARY The Department of Health (DOH) is pleased to present the 5th Annual RPRH Report on the implementation of Republic Act No. 10354, otherwise known as the Responsible Parenthood and Reproductive Health Act of 2012 (RPRH Law). The details of the 2018 program performance, as well as the challenges on the five elements or key result areas of Reproductive Health (RH), are highlighted in this Report. The Key Result Areas (KRAs) are 1) maternal, neonatal, child health and nutrition; 2) family planning; 3) adolescent sexuality and reproductive health; 4) sexually-transmitted infections and HIV and AIDS; 5) gender-based violence; and other related concerns in reproductive health and rights. It also includes a report on Budget and Financing as well as Policy and Governance across the five KRAs. This Report attests to our achievements as we continue our efforts to fulfill and uphold the reproductive health and rights of the Filipinos, especially the marginalized and the underserved populations. With the successful passage of the Universal Health Care Law and other landmark legislation in 2018, the DOH and partners in the RPRH community, have been positioned more than ever to provide quality care to our mothers and children, and Filipino families as a whole. The journey towards Universal Health Care is challenging, the DOH has instituted the roadmap through the FOURmula One Plus or the F1 Plus strategy as its guiding framework. The F1 Plus shall ensure that health services are inclusive and equitable and anchored on the principles of performance accountability and good governance towards achieving the goals of universal health care. FRANCISCO T. DUQUE III, MD, MSc Secretary of Health i ii ACKNOWLEDGMENTS The 5th Annual RPRH Report was developed through a series of write-shops with the key players and stakeholders involved in the implementation of the RPRH programs. This report was prepared by the Department of Health and the Commission on Population and Development with technical assistance from the United States Agency for International Development (USAID) through the ReachHealth Project implemented by the Research Triangle Institute. DOH and POPCOM wish to thank the following for their valuable inputs in the completion of the report: The members of the technical writing team: Jocelyn Ilagan, Rhodora Tiongson, Joyce Encluna, Jan Llevado, Mary Ann Evangelista, and Donabelle de Guzman; The Central Department of Health / Regional Office contributors: Cherylle Gavino, Zenaida Recidoro, Ken Raymund Borling, Ken Remollo, Dulce Elfa, Onofria De Guzman, Edna Nito, Janice C. Acosta, Evangeline B. Empis, Armi A. Dela Cruz, Estelita V. Ancheta, Jhoanna Gatbonton, Brian Mascarina, John Legisma, Maria June R. Robles, Renilyn Reyes, Jeanette Pauline Cortez, Cheryll Rebollos-Sarmiento, Fairuz D. Dinalo, and Cheryl Mary L. Plaza POPCOM central and regional contributors: Lydio Español, Jr., Aileen T. Serrano, Desiree Conception U. Garganian, Lyka Manglahan, Vicky De La Torre, Cecil A. Basawil, Jesusa R. Lugtu, Roilo Vincent G. Laguna, Angelica Lanbety, Gorge Paminsala, Alvin Santos, Darlynn Remolino, E.B. Sarmiento, Anika Hanna B. Abiog, and Armando G. Orcilla, Jr. Development Partners and CSO Contributors: Noemi Bautista, Jose Roi Avena, Jose Juan A. Dela Rosa, Rosario Benabaye, Joy Salgado, Erick Bernardo. Technical Secretariat/ Support Staff: Ken Raymund Borling, Carla Jean Berte, Karro Kevin B. Cruz, and Jameron Calupitan. The document was prepared under the guidance of DOH Undersecretary Myrna Cabotaje, Undersecretary Juan Antonio Perez III, Esperanza Cabral, Junice Melgar, and Yolanda Oliveros. The team also wishes to thank the officials and staff of the following institutions and civil society organizations that have contributed to the report: Department of Education, Likhaan Center for Women’s Health, Philippine Commission on Women, UNFPA and USAID Implementing Partners. iii iv ACRONYMS 2PNC Two Post-Natal Consultations 4ANC Four Antenatal Care Visits 4Rs Recognition, Recording, Reporting, Referral 4Ps Pantawid Pamilyang Pilipino Program AECID Agencia Espanola de Cooperacion International Para el Desarrollo AHD Adolescent Health and Development AIARHC Albay Inter-Agency Reproductive Health Committee AIDS Acquired Immunodeficiency Syndrome AJA Adolescent Job Aid ALL Acute Lymphocytic Leukemia ANC Antenatal Care Visits AO Administrative Order ARH Adolescent Reproductive Health ARMM Autonomous Region of Muslim Mindanao ART Antiretroviral Therapy ARV Anti-Retroviral ASC Ambulatory Surgical Clinic ASRH Adolescent Sexual and Reproductive Health AYHD Adolescent and Youth Health and Development AYRH Adolescent and Youth Reproductive Health BEmONC Basic Emergency Obstetric and Newborn Care BHS Barangay Health Station BHW Barangay Health Worker BIHC Bureau of International Health Cooperation BNS Barangay Nutrition Scholar BTL Bilateral Tubal Ligation BWC Brokenshire Woman Center C4C Communication for Communicators C4RH Filipino Catholic Voices for Reproductive Health CBT Competency-Based Training CCT Conditional Cash Transfer CD4 Cluster of Differentiations CEmONC Comprehensive Emergency Obstetric and Newborn Care CHO City Health Office CHR Commission on Human Rights CHSI Center for Health Solutions and Innovations CHT Community Health Team CICP Center for Innovation, Change and Productivity CONAP Continuing Appropriations CPR Contraceptive Prevalence Rate CPU Central Processing Unit CRVS Civil Registry and Vital Statistics CS Caesarean Section CSC Civil Service Commission CSE Comprehensive Sexual Education v CSO Civil Society Organization CWC Council for the Welfare of Children DC Department Circular DepEd Department of Education DILG Department of Interior and Local Government JRMMC Jose Reyes Memorial Medical Center DM Department Memorandum DMPA Depot Medroxyprogesterone Acetate DOH Department of Health DOH EB Department of Health Epidemiology Bureau DOH-RO Department of Health – Regional Office DOJ Department of Justice DOLE Department of Labor and Employment DPCB Disease Prevention and Control Bureau DPO Department Personnel Order DSWD Department of Social Welfare and Development DQC Data Quality Check EINC EO Essential Intrapartum and Newborn Care Executive Order EPI Expanded Program on Immunization EPP Estimation and Projection Package ERPAT Empowerment and Reaffirmation of Paternal Abilities EU European Union FBD Facility-based Delivery FCSAI Fundacion Espanol para la Cooperacion FHB Family Health Bureau FDA Food and Drug Administration FDS Family Development Sessions FFSW Freelance Female Sex Worker FSW Female Sex Worker FGD Focus Group Discussion FHRP Family Health and Responsible Parenting FHS Family Health Survey FHSIS Field Health Service and Information System FIC Fully Immunized Child FNRI Food and Nutrition Research Institute FP Family Planning FPCBT Family Planning Competency Based Training FPS Family Planning Survey FWS Female Sex Worker FY Fiscal Year GAA General Appropriations Act GARPR Global AIDS Response Progress Report GAD Gender and Development GBV Gender-based Violence GIDA Geographically Isolated and Disadvantaged Areas GPH Government of the Philippines GPOBA Global Partnership Output-Based Aid GRRB-IRH Gender-Responsive and Rights-Based Integrated Reproductive Health HARP HIV/AIDS and ART Registry HCT HIV Counselling and Testing vi HBV Hepatitis B Virus HCI Health Care Institute HCV Hepatitis C Virus HFEP Health Facilities Enhancement Program Hi-5 High Five Strategy HIV Human Immunodeficiency Virus HIV/AIDS Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome HPV Human Papilloma Virus HSP Health Sector Plan HUP Health Use Plan IACAT Inter-Agency Committee on Anti-trafficking IACVAWC Inter-Agency Council on Violence Against Women and their Children IEC Information, Education, and Communication IHBSS Integrated HIV Behavioral and Serologic Surveillance IMR Infant Mortality Rate ILHZ Inter-Local Health Zones IPCC Interpersonal Counseling and Communication IPT Intimate Partner Transmission IRR Implementing Rules and Regulations IRR DC IRR Drafting Committee IUD Intrauterine Device IYCF Infant and Young Child feeding JICA Japan International Cooperation Agency JMC Joint Memorandum Circular JPMNCHN Joint Programme on Maternal, Neonatal, Child Health and Nutrition K-12 Kinder to Grade 12 KAP Key Affected Population KP Kalusugan Pangkalahatan KRA Key Results Area KATROPA Kalalakihang Tumutugon sa Responsibilidad at Obligasyon Para sa Kalusugan ng Ina at Pamilya LAM Lactational Amenorrhea Method LAPM Long Acting Permanent Method LARC Long Acting Reversible Contraception LCAT-VAWC Local Committees on Anti-Trafficking and Violence Against Women and Children LCE Local Chief Executive LGBT Lesbian, Gay, Bisexual, Transgender LGBTQI Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex LGU Local Government Unit LPPEAHD Learning Package on Parent Education on Adolescent Health and Development M/TSM Males/Transgenders who have sex with males M&E Monitoring and Evaluation MAH Market Authorization Holder MAPEH Music, Arts, Physical Education and Health MARP Most At-Risk Population vii MBFHI Mother-Baby Friendly Hospital Initiative MCP Modern Contraceptive Prevalence mCPR Modern Contraceptive Prevalence Rate MCW Magna Carta for Women MDs Medical Doctors MDG Millennium Development Goal MEC Medical Eligibility Criteria MFP Modern Family Planning MHO Municipal Health Officer MMR Maternal Mortality Ratio MNCHN Maternal, Newborn, and Child Health and Nutrition MNFP Modern Natural Family Planning MOOE Maintenance and Other Operating Expenses MOU Memorandum of Understanding MOVE Men Opposed to Violence Against Women Everywhere MR Measles-Rubella MR GAD Men's Responsibilities in Gender and Development MRL Muslim Religious Leader MSM Men Having Sex with Men MYCNSIA Maternal and Young Child Nutrition Security Initiative in Asia NAC National Advisory Committee NAPC National Anti-Poverty Commission NASPCP National AIDS/STD Prevention and Control Program NBB No Balance Billing NBI National Bureau of Investigation NCMH National Center for Mental Health NCR National Capital Region NDHS National Demographic and Health Survey NDP Nurse Deployment Program NEDA National Economic and Development Authority NGO Non-Government Organization NHIP National Health Insurance Program NHTS National Household Targeting System NHTS PR National Household Targeting System –Poverty Reduction NIT National Implementation Team NMR Neonatal Mortality Rate NNC National Nutrition Council NNS National Nutrition Survey NOH National Objectives for Health NSD Normal Spontaneous Delivery NSV Non-Scalpel Vasectomy NTHC National TeleHealth Center NVAWDocS National VAW Documentation System OAE Otoacoustic emissions device OB/GYNE Obstetrics and Gynecology ODA Official Development Assistance OFW Overseas Filipino Worker OHAT Outpatient HIV/AIDS Treatment OIS Opportunistic Infections ONAR Office of the National Administrative Register OPCCB Organization, Position, Classification and Compensation Bureau viii OSG Office of the Solicitor General PAFLO Population Awareness and Family Life Orientation PCB Primary Care Benefit PNC Post Natal Care PCW Philippine Commission on Women PE Peer Educators PGH Philippine General Hospital PHA Public Health Assistant PHIC Philippine Health Insurance Corporation PHO Provincial Health Office PIA Philippine Information Agency PICT Provider –Initiated HIV Counseling and Testing PLHIV People Living with HIV PME Planning, Monitoring and Evaluation PMTCT Prevention of Mother to Child Transmission PNGOC Philippine NGO Council on Population, Health and Welfare, Inc. PNSCB Philippine National Statistics Coordination Board PNP Philippine National Police PNP-WCPC Philippine National Police-Women and Child Protection Unit PO People’s Organization POC Point of Care POPCOM Commission on Population and Development PPAs Programs, Projects and Activities PPMP Project Procurement Management Plan PPIUD Postpartum Intrauterine Device PSA Philippine Statistics Authority PSPI Population Services Pilipinas, Inc PREVENTS Primary Care Revitalized and Enhanced Through Skills and Services PTA Parent-Teacher Association PWID People Who Inject Drugs PYD Program for Young Adolescents PYP Program for Young Parents Q&A Question and Answer RA Republic Act RFSW Registered Female Sex Worker RIT Regional Implementation Team RITM Research Institute for Tropical Medicine RH Reproductive Health RHMPP Rural Health Midwives Placement Program RHO Reproductive Health Officer RHU Rural Health Unit RNHeals Registered Nurses for Health Enhancement and Local Service RP-FP Responsible Parenting and Family Planning RPO Regional Population Office RPRH Responsible Parenthood and Reproductive Health RTI Reproductive Tract Infection SACCL STD/AIDS Central Cooperative Laboratory SBA Skilled Birth Attendance SC Supreme Court SDI Subdermal Implant ix SHC Social Hygiene Clinics SK Sangguniang Kabataan SOGIE Sexual Orientation and Gender Identity and Expression SQAO Status Quo Ante Order SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health Rights SSESS STI Sentinel Etiologic Surveillance System STI Sexually Transmitted Infection SWRA Sexually Active Women of Reproductive Age TB Tuberculosis TD Tetanus-Diphtheria TFI Tarbilang Foundation Inc. THKs Teen Health Kiosks TOT Training of Trainers TRO Temporary Restraining Order U4U Youth for Youth Activity UHC Universal Health Care UMFP Unmet Need for Modern Family Planning UNAIDS Joint United Nations Programme on HIV/AIDS UNESCO United Nations Education, Scientific and Cultural Organization UNICEF United Nations International Children’s Fund UNFPA United Nations Population Fund UP University of the Philippines USAID United States Agency for International Development USG United States Government VAW Violence Against Women VAWC Violence Against Women and Children VAWCRS Violence Against Women and Children Registry System VIA Visual Inspection with Acetic Acid WB World Bank WCPC Women and Child Protection Center WCPMIS Women and Child Protection Management Information System WCPU Women and Child Protection Units WFS Women Friendly Space WHO World Health Organization WINS Water, Sanitation, & Hygiene in Schools WMCHDDs Women and Men’s Health and Children’s Health Development Division WRA Women of Reproductive Age YAFSS Young Adult Fertility and Sexuality Survey YDS Youth Development Session ZFF Zuellig Family Foundation ZOTO Zone One Tondo Organization x RPRH 5th Annual Report EXECUTIVE SUMMARY Policy and Governance The unequivocal support of the Duterte Administration to reproductive health enabled the swifter implementation of the RPRH law. This support was shown by: Including the strengthening of the implementation of the Responsible Parenthood and Reproductive Law in this administration’s 10-Point Socio-Economic Agenda; Strengthening of the integration of population and development through Executive Order No. 71 changing the name Commission on Population (POPCOM) into the Commission of Population and Development (CPD); and Reverting POPCOM’s attachment from the Department of Health (DOH) to the National Economic and Development Authority (NEDA) for policy and program coordination. The DOH also issued Administrative Order 2018-0014, “Strategic Framework and Implementing Guidelines for FOURmula One Plus for Health (F1+).” It aligned health initiatives into four (4) strategic pillars: Financing, Regulation, Service Delivery, and Governance. It also added a cross cutting initiative for Performance Accountability. The National Objectives for Health 2017-2022, a roadmap for the F1+ towards the achievement of Universal Health Care, was formulated and issued. It specifies the objectives, strategies and targets of DOH F1+ for Health. Important laws relevant to the RPRH implementation were also passed during the 17th Congress. These are: The “Universal Health Care Act.” This law reorganizes the way health services and commodities (including reproductive health) are financed, procured, delivered, and accessed; The “Kalusugan at Nutrisyon ng Mag-Nanay Act” which scales up the national and local health nutrition programs for pregnant and lactating women, adolescent girls, infants, and young children in the first 1,000 days The “Philippine HIV and AIDS Policy Act” which strengthens the country’s policy on HIV/AIDS prevention, treatment, care, and support. It also lowered the minimum age requirement (from 18 to 15 years old) for the availment of HIV testing and counseling without parental or guardian’s consent; and The “105-Day Expanded Maternity Leave Law” which increases the maternity leave period to 105 days for all female workers; with an option to extend for an additional 30 days without pay; and an additional 15 days for solo mothers. The DOH has also issued several policies that specifically enables the implementation of the RPRH law, but challenges remain. The passage of measures that will help eliminate violence against women and children still needs to be lobbied. As in the previous years, there is still a lack of overall strategic direction for the implementation of RPRH. Specific activities and the corresponding agencies and units that should be held accountable for the fulfillment of the RPRH goals and objectives should be clearly stated in its proposed Strategic Plan. In terms of monitoring and evaluation, it is imperative to review all the indicators used to get a clearer status of implementation at the local level. This way, implementation issues can be xi determined, and the national policies and specific supporting interventions could be accurately provided. Budget and Financing The indicative national government budget for RPRH increased by 10% from Php37.4 billion in 2017 to Php41.88 billion in 2018, based on adjusted allotments of concerned government agencies. The DOH remains to be the main source of funds with its total budget allocation of PhP41.35 billion in 2018, comprising 39% of RPRH’s total budget in the 2018. This represents the following items: Family Health and Responsible Parenting (FHRP), Expanded Program on Immunization (EPI), and Health Facilities Enhancement Program (HFEP). POPCOM allocated 60% of its Php516.88 million budget. This covered reproductive health/family planning and adolescent health development/population and development (POPDEV) integration, among others. The National Health Insurance Program (PhilHealth) reimbursed a total of Php121.04 billion. Of this amount, 26% (Php31.12 billion) was paid for the government-sponsored members and at least 17% (Php21.41 billion) was paid for RPRH-related benefits. In 2018, there were 811 accredited facilities with trained and certified FP providers which are mostly from Central Visayas, NCR, and MIMAROPA regions. The Local Government Units (LGUs) allocated around Php406.4 million for FP training, FP- related workshops, and procurement of FP commodities, among others. This FP budget represents only1.04% of the total budget of LGUs. Various development partners (Php2.11 billion) and CSOs (Php74.43 million) also allocated huge budgetary support for the implementation of the RPRH Law. Maternal, Newborn, Infant Health, and Nutrition The DOH Field Health Service Information System (FHSIS) showed that maternal health outcomes improved for the past five years, with a maternal mortality ratio (MMR) of 58/100,000 livebirths in 2018. However, the Maternal Mortality Estimation Inter-Agency Group i in 2015 demonstrated a maternal mortality ratio of 114 per 100,000 live births. It would be difficult to assess status of maternal health outcomes using only the FHSIS since MMR can only be accurately calculated from considerably large sample sizes. Meanwhile, perinatal mortality rate increased over the years. In 2018, a total of 8,574 perinatal deaths were accounted for which translates to 5.06/1,000 live births. In contrast, infant mortality rates declined from 8.15/1000 live births in 2016 to 7.48 in 2017 but showed a marginal increase for the current reporting year of 7.78/1,000 live births. The biggest challenge the DOH faced in 2018 was the weak national immunization coverage. Only 66% of children less than one year old were fully immunized, a decrease of 9 percentage points from 2014. Major interventions to improve Maternal, Neonatal, Child Health and Nutrition (MNCHN) services include: Provision of pre-pregnancy services and commodities which includes iron and folate supplementation, counseling and provision of family planning (FP) methods, and prevention and management of infection and lifestyle-related diseases; xii  Strengthening of antenatal care through development of new policies and continued demand generation activities; Sustained training of health professionals for Basic Emergency Obstetric and Newborn Care (BEmONC) and provision of safe delivery kits nationwide; Development of strategies to eliminate preventable causes of pregnancy-related deaths exemplified by the Maternal Sepsis Elimination Campaign; Passage of the First 1000 Days Law; Capacity building of health staff in the Philippine Integrated Management of Acute Malnutrition; and Communication and social mobilization through intensified and sustained community awareness of the risk of measles and the benefits of vaccination through various channels and local champions. Improvements in maternal health outcomes were evident in this reporting year. However, a number of mothers are still dying due to preventable causes of pregnancy-related deaths. While quantitative measures of skilled birth attendance (SBA) and facility-based delivery (FBD) show progress, antenatal and post-partum care lag behind. Challenges in the delivery of child health interventions particularly in the implementation of the immunization program has been an immense problem in 2018. This resulted to measles outbreaks and increase in measles-related mortalities for the current reporting year. Recommendations on MNCHN include, but are not limited to: Evaluate BEmONC and Comprehensive Emergency Obstetric and Newborn Care (CEmONC) implementation in the entire country and the barriers of Emergency Obstetric and Newborn Care (EmONC) delivery; Align the 2008 MNCHN policy to the Sustainable Development Goals, Philippine Development Plan, and the Universal Health Care Law; Address results of the maternal death surveillance and response; Intensify and sustain community awareness of the risk of measles and other vaccine- preventable diseases and the benefits of vaccination through various channels and local champions; and Identify and address effectively the barriers to breastfeeding, and the whole infant and young child feeding. Family Planning In 2018, 7.4 million women of reproductive age (WRA) were provided with modern family planning (MFP) methods in both public and private facilities and clinics. This is equivalent to about 2.6 million unintended pregnancies prevented, 1.6 million probable abortions avoided, and 1,410 maternal deaths averted. Based from the FHSIS, modern Contraceptive Prevalence Rate (mCPR) increased from 53% to 57% in 2018. However, this only represents service utilization in the public sector and does not reflect performance of the private sector. The target mCPR under the Philippine Development Plan (PDP) is 65% for married women of reproductive age (MWRA). The NDHS 2017 reports mCPR at 40% which covered both public and private sector performance. xiii A comparison of Executive Order 12 Zero Unmet Need for Modern Family Planning (EO 12) performance in 2017 and 2018 showed that in 2018, 1 3.9 million WRA were reached and identified with unmet modern family planning (MFP). This figure already exceeded the estimated number in 2017. 2 Of the 3.9 million WRA reached, 1.2 million (31%) women were served 3 and newly accepted a modern family planning method in 2018 based on FHSIS data. However, while the number of WRA reached already exceeded the estimated number of women with unmet need for MFP, there remains 2.3 million WRA who have not yet been served and remains to have unmet need for modern family planning. This implies that 2.3 million WRA were not provided with MFP, which translates to 835,000 unintended pregnancies that could have been avoided, 492,000 possible abortions prevented, and 440 maternal deaths that could have been averted. The challenge of reducing the gaps in linking demand generation to service delivery remains. Key interventions that supported 2018 Family Planning program performance were: Demand generation activities that were able to reach 252,184 WRA identified with Unmet Need for Modern Family Planning and where a total of 214,971 (85%) were referred and served with MFP methods; Social marketing strategies that includes quad-media campaigns that were able to reach 104,594,768 viewers nationwide; Service delivery to a total of 1.2 million WRA who were served and accepted a new method: 54% from the regular public health facilities and 33% through post-partum FP service, while 13% of WRA accepted MFP through the conduct of outreach FP services. In 2018, Php162,642,000.00 was spent to procure family planning commodities at the national level. Based from the logistics monitoring reports, a total of 2,360 out of 2,450 (96%) facilities reported having no stock outs of FP commodities in 2018. A number of challenges still needs to be addressed. This includes: Setting of the national goal, strategic directions and multi-year costing of the National Program on Family Planning under a co-management arrangement between the DOH and the POPCOM under NEDA; Resolving bottlenecks in the implementation of the collaborative framework of the national program on Family Planning under the co-management arrangement between the DOH and POPCOM at the national and regional levels Addressing the shift in the distribution mechanisms of FP commodities from direct to service delivery point mode to regional distribution scheme. The need to review and revise the M&E RPRH Framework following the directional plan of the national FP program; Unresolved bottlenecks in operations such as service delivery structure, in particular, the implementation of the service delivery network; timely provision of critical inputs to service delivery, namely family planning supplies and trained workforce; and information, behavior change and communication; and Challenges related to DOH budget utilization and PhilHealth benefit utilization. 1 DOH Administrative Data: EO 12 Monitoring report 2017-2018 2 DOH Administrative Data: EO12 Monitoring Report 2018 3 DOH FHSIS 2018 xiv Adolescent Sexual and Reproductive Health A slight decline was observed in the following: adolescent fertility rate, the proportion of women who have had a birth or are pregnant with the first child, the number of babies born to adolescent parents, and the number of newly diagnosed HIV positive cases among the 15-24-year age group. The number of teens who began childbearing in 2018 remains high at 425,000. The Philippines still has one of the highest adolescent fertility rates, ranking closely with countries with the worst performance. Unmet need is still highest among the youngest age group and the proportion of HIV positive cases among the 15-24 age group more than doubled in the past ten years. Major policies in 2018 include the issuance of the Department of Education (DepEd) Guidelines on the Implementation of Comprehensive Sexuality Education, the development of Adolescent Health and Development Program Directions 2018-2022, and the signing of the ‘Philippine HIV and AIDS Policy Act’ expanding access of adolescents to HIV services and the ‘Nutrisyon ng Mag-Nanay Act’. Training and information dissemination activities related to Adolescent Sexual and Reproductive Health/ Adolescent Health and Development Program (ASRH/AHDP) were also continued in 2018. There are still several measures that need to be done. Training of K-12 teachers in schools need to be fast tracked to scale up the Comprehensive Sexual Education (CSE) program. There is also a need to streamline structures and arrangements on ASRH and Adolescent and Youth Health and Development (AYHD) to avoid duplication of adolescent health-related initiatives and confusion in roles and responsibilities of concerned agencies. The disaggregation of relevant health data by age and build on adolescent database need to be pushed, too since it should guide the design of ASRH service delivery, training, and IEC interventions. Adolescent-friendly health service packages should be developed to address unique needs of adolescents and youth in terms of correct information and access to RH services especially among 18-19 years age group where pregnancy rate is the highest and compliance to parental consent is not required by Law. Sexually Transmitted Infections and HIV AIDS The Philippines remains as a low HIV prevalence country. However, current estimates show that the number of HIV cases in the country will triple in the next ten years—from 80,000 in 2018 to 266,000 by 2028. In 2018 alone, there were 11,427 new HIV confirmed positive individuals. From 13 cases per day in 2013, the number of daily new diagnosed cases increased to 32 in 2018. HIV infection among 15 to 24 years old doubled from 13% in 1999-2008 to 29% in 2009-2018. More males (95%; 10,828) were diagnosed with HIV in 2018 compared to females (5%; 599). The number of diagnosed women in 2018 was a two-fold increase from the same period in 2013 (299). HIV in the Philippines is primarily transmitted through sexual contact and this has not changed since 1984. Currently 83% (49,078) of infections transmitted through sexual contact were among males and transgender women who have sex with males (M/TSM). More than half of all diagnosed HIV cases in 2018 came from three regions alone, the National Capital Region (31%; 3,596), Region 4A (16%; 1,817), and Region 3 (11%: 1,230). xv Deaths among people living with HIV (PLHIV) in 2018 were primarily in males (67%; 567), and mostly among the 25 to 34 years old age group. These reported deaths were due to any cause, not necessarily due to their HIV status. The World Health Organization (WHO) however, reports that among PLHIVs, the number one killer remains to be tuberculosis (TB). In January to December 2018, 98% of the 36,838 PLHIV were screened for TB, up by 14% from 2016 DOH data. Among those screened, 14% (5,094) were positive for TB coinfection, subsequently referred for TB-Directly Observed Treatment Short Course (TB-DOTS) facilities. To reduce new HIV infections and improve health outcomes and wellness of PLHIV, 4 National AIDS/STD Prevention and Control Program (NASPCP) adopted the 90-90-90 global target for HIV: 90% of all PLHIV should know their status, 90% of all PLHIV will receive antiretroviral therapy (ART), 90% of all receiving ART are virally suppressed. Tried and tested advocacy events such as International AIDS Candlelight Memorial and World AIDS Day were conducted. New events were launched to encourage key populations at risk for HIV to get tested early and seek treatment if they have HIV. Through various training sessions, NASPCP ensured that the quality of health care services was in accordance with the existing DOH policies and guidelines. To install Social Hygiene Clinics, Primary HIV Care Facilities, and Sundown Clinics, the Integrated Services for HIV Care (iSHC) was expanded in various locations, increasing access to HIV testing and treatment. A demonstration project on HIV Pre-Exposure Prophylaxis (PrEP) continued in 2018 with results expected in 2019. There are still hurdles that are yet to be overcome to control the HIV/AIDS epidemic in the country. There is still a low level of knowledge on HIV, especially on the mode of transmission and ways of prevention, even among those who already engage in risky sexual behavior. The use of condoms among those who engage in anal sex is only 50%. The implementation of a comprehensive sexuality education through DepEd is recommended. The DOH may also reclassify condoms as an infection prevention commodity, not as a family planning commodity to increase accessibility to minors. Stigma and discrimination are ongoing challenges that need to be addressed because they delay access to screening and testing. The DOH needs to test more at a faster rate, given the increasing trend in diagnosed cases per day from 22 in 2015 to 32 in 2018. Currently, testing for HIV is limited to HIV-proficient medical technologists who are authorized by the DOH to perform the tests. Provisions of RA 11166 5 on lowered age of HIV testing coupled with the use of a Rapid HIV Diagnostic Algorithm may be implemented soonest coupled with mobilization of non-medical technologists for a step zero in HIV screening. Access to ART is limited to 15 to 24-year-old PLHIV, with only 14% initiated on treatment. 6 Near stock-out and near expiration of anti-retroviral drugs were also reported across regions. The limited availability of treatment for other HIV co-infections remain a burden for many PLHIVs. It is recommended that time from diagnosis to initiation of ART be routinely reported by age group. This will allow program adjustments where necessary, more targeted messaging, and better logistics management to avoid stock outs. Finally, out-of-pocket expenses of PLHIVs, especially for management of co-infections, need to be measured as part of program implementation and to inform enhancement of PhilHealth's HIV package. 4 6th Aids Medium-Term Plan 5 HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immunodeficiency Syndrome) Policy Act of 2018 6 DOH, 2016 xvi Elimination of Violence Against Women and Children The Philippines continues to narrow the gender gap between men and women in the country. It ranked 8th among 149 countries in the 2018 Global Gender Gap reported by the World Economic Forum. To date, the country has closed 80% of its overall gender gap. Despite this, violence against women continues to be a serious problem in the country. Data from the Philippine National Police (PNP) Women and Children Protection Center (WCPC) and DOH Violence Against Women and Children (VAWC) Registry System show a declining trend in the reported cases of violence against women and children over the past three years. PNP reported a 19.5% decrease in VAW cases from 2016 (32,073) to 2017 (25,805); and another 26% decrease from 2017 to 2018 (18,947). A similar decline in the trend of cases on violence against children (VAC) was reported by the PNP over the last three years. There was a 9% reduction of cases from 2016 (28,686) to 2017 (26,143) and a decrease of 21% (20, 728) in 2018. The DOH VAWC Registry System also reports a substantial decreasing trend in reported cases from the hospitals. A 50% decrease in the VAWC cases was noted from 2016 (3,167 cases) to 2017 (1,574 cases). This further went down by 49% in 2018 (800 cases). The decline may be due to unreported cases especially from far-flung and isolated areas and less reporting compliance from participating hospitals. Interventions to help eliminate violence against women and children in 2018 are as follows: Statement of commitment of funding to operationalize Strategic Plan 2017-2022 by issuing IACVAWC Resolution No.2, s. 2018; Issuance of the National Advocacy and Communication Plan 2017-2022 and conduct of specified activities; Issuance of DILG Memo Circular 2018-144 for the retention/re-appointment of current VAW desk persons in the barangays; Conduct of training on the 4Rs (recognizing, recording, reporting, referring) of 9,311 public providers and 6,273 private providers in 1,270 LGUs; Establishment of women and children protection program in 577 LGUs with a dedicated coordinator and a trained provider; Training of 7,646 PNP officers on Women and Children Protection; Establishment of VAW desk in 37,723 barangays; Assistance provided to VAWC victims by the Department of Social Work and Development (DSWD), DOH-Women and Children Protection Unit (DOH-WCPU), and the National Bureau of Investigation (NBI). Several measures need to be done to effectively reduce VAWC. Since there is no common recording and reporting of cases, there is a need to unify the registry of cases. Accurate data is important in determining the need for appropriate service providers, in the establishment and enhancement of facilities, and drafting/revision of policies for the program. It is imperative that the concerned agencies work together to marry their systems. xvii Other recommendations are as follows: Review of existing protocols and guidelines and standardize services across the country; Conduct of inventory of all available services that should be disseminated as reference for referrals. It will also serve as basis for establishment of additional facilities; Establishment of VAW desk in remaining barangays and ensure their functionality and the re-appointment or retainment of current VAW desk officers; Harmonization of capacity building activities for service providers; Advocacy of policies and legislations that reduces/eliminates discrimination of women; Ensuring the provision of a comprehensive package of services for VAW victims (psychosocial care & evaluation; rescue & protection; legal assistance; reintegration); and Facilitation of quick resolution of VAWC cases. i Maternal Mortality in 1990-2015WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division, xviii Other recommendations are as follows: Review of existing protocols and guidelines and standardize services across the country; Conduct of inventory of all available services that should be disseminated as reference for referrals. It will also serve as basis for establishment of additional facilities; Establishment of VAW desk in remaining barangays and ensure their functionality and the re-appointment or retainment of current VAW desk officers; Harmonization of capacity building activities for service providers; Advocacy of policies and legislations that reduces/eliminates discrimination of women; Ensuring the provision of a comprehensive package of services for VAW victims (psychosocial care & evaluation; rescue & protection; legal assistance; reintegration); and Facilitation of quick resolution of VAWC cases. i Maternal Mortality in 1990-2015WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division, xviii RPRH 5th Annual Report 1 POLICY & GOVERNANCE Executive Level While the lifting of the Supreme Court Temporary Restraining Order (TRO) on contraceptives in 2017 played a crucial role in implementing the key provisions of the RPRH law, the unequivocal support of the Duterte administration to reproductive health has enabled its swifter implementation. This support was shown in several ways. First, the administration included strengthening of the implementation of the Responsible Parenthood and Reproductive Law in its 10-Point Socio-Economic Agenda. As a follow through strategy, the President issued Executive Order No. 71 on December 2018. This changed the name of the Commission on Population (POPCOM) to the Commission of Population and Development (CPD or POPCOM) and reverted its attachment from the DOH to the National Economic and Development Authority (NEDA) for policy and program coordination. The integration of population and development is one of the crucial strategies of the Philippine Development Plan 2017-2022 to improve the country’s economic growth. This structural change will improve coordination with NEDA on the implementation of population-related programs. As a result, the DOH and CPD now co-manages the National Program of Family Planning. This involves setting the national FP goal, strategic directions, and multi-year costing of the National Program on Family Planning. It also includes setting the specific tasks and responsibilities of the DOH and CPD under the collaborative framework of the National Program on Family Planning to ensure the smooth implementation at the field level. The DOH initiated a major and significant policy enhancement by issuing Administrative Order 2018-0014, “Strategic Framework and Implementing Guidelines for FOURmula One Plus for Health (F1+)” on May 2018. It aligns health initiatives into four (4) strategic pillars: Financing, Regulation, Service Delivery, and Governance. In addition to these original pillars is a cross cutting initiative for Performance Accountability. To provide the medium-term roadmap towards the achievement of Universal Health Care, the DOH formulated and issued the National Objectives for Health 2017-2022. It specifies the objectives, strategies and targets of DOH FOURmula One Plus for Health. The DOH also issued several policies that specifically enables the implementation of the RPRH law. One of this is AO 2018-0003, National Policy on the Prevention of Illegal and Unsafe Abortion and Management of Abortion Complications. This policy reiterates the importance of family planning to prevent unintended pregnancies. It details the mechanism for managing abortion complications. DOH issued policies that specifically addresses AIDS/HIV related concerns. One is the “Revised Policies and Guidelines on the Use of Antiretroviral Therapy (ART) among People Living with Human Immunodeficiency Virus (PLHIV) and HIV-exposed infants.” This emphasized the “treat early,” “treat all” of newly diagnosed PLHIV. It also released a new department memorandum for the updated list of DOH-designated HIV treatment hubs and primary HIV care facilities. This memorandum aims to expand the accessibility and maximize coverage of in-patient and/or out- patient prevention, treatment, care and support services to PLHIV including but not limited to 1 antiretroviral therapy, HIV testing services, clinical management, patient monitoring, and other care and support services; The DOH, together with other concerned agencies, released a Joint Memorandum Circular (JMC) on Pre-Marriage Orientation and Counseling (PMOC) with the topics on: Marriage and Relationship; Responsible Parenthood; Family Planning; and, Pregnancy and Child Care. It was finalized and signed by the DOH, Department of the Interior and Local Government, (DILG), DSWD, CPD, and the Philippine Statistics Authority (PSA). The updated JMC required among others the re-orientation and accreditation by DSWD of all PMOC counselors. Laws to improve assistance in the prevention of gender-based violence are still needed. During the 17th Congress, the Philippine Commission on Women (PCW), women’s groups, CSOs and other concerned agencies have actively pushed for the passage of the bills in the Women’s Priority Legislative Agenda. There are several bills that seek to amend or repeal discriminatory provisions of existing laws and new legislations that promote gender equality and women’s empowerment. These include: Amending the Anti-Rape Law; - Sen. Risa Hontiveros introduced Senate Bill 1252 that will strengthen the Anti- Rape Act of 1997 during the 17th Congress. The Senate Committees on Women, Children, Family Relations and Gender Equality; and Justice and Human Rights were able to conduct hearings and report it at the Plenary Session in May 2017. Unfortunately, it only reached interpellations and is still pending at 2nd Reading. In the House of Representatives, Rep. Teddy Baguilat, Jr. also filed a bill revising the Anti-Rape Law. It did not progress much beyond the Committee on Revision of Laws. Repealing Article 247 of the Revised Penal Code which exempts from criminal liability a spouse who harms or kills his spouse caught having sex with another. It also exempts a parent who harms or kills his child caught having sex with another; Expanding the Anti-Sexual Harassment Law; Sexual Orientation and Gender Identity and Expression (SOGIE) law; The DILG issued Memorandum Circular No. 2018-144 dated August 24, 2018 to assist the LGUs in maintaining the competence of the Violence Against Women (VAW) Desk personnel/officers in barangays. This encourages the Punong Barangays and Sangguniang Barangay members to retain/re-appoint the current VAW desk officers. The term of the VAW desk officers expire at the end of the term of the barangay officials. This policy aims to maximize the training and skills gained by the current VAW desk officers. Legislative level The 17th Congress passed the Universal Health Care Act (UHC) and the President signed it as RA 11223 in early 2019. The law aims to: a. progressively realize the universal health care in the country through a systemic approach and clear delineation of roles of key agencies and stakeholders towards better performance in the health system; b. ensure that all Filipinos are guaranteed equitable access to quality and affordable health care goods and services, and protected against financial risks. The UHC law’s implementing rules and regulation is currently being drafted. This law reorganizes the way health services and commodities (including reproductive health) are financed, procured, delivered and accessed through the service delivery network. 2 The 17th Congress also passed other laws that enhance the implementation of RPRH. Republic Act 11148, otherwise known as the “Kalusugan at Nutrisyon ng Mag-Nanay Act,” scales up the national and local health nutrition programs through a strengthened integrated strategy for maternal, neonatal, child health and nutrition in the first 1,000 days of life to improve the nutritional status of infants and young children, adolescent females, pregnant and lactating women. It also mandates sustained allocation of resources from the different concerned agencies to achieve the law’s objectives. Republic Act 11210, otherwise known as the “105-Day Expanded Maternity Leave Law” increases the maternity leave period to 105 days for all female workers; with an option to extend for an additional 30 days without pay; and an additional 15 days for solo mothers. It also passed the Philippine HIV and AIDS Policy Act (RA 11166) which strengthens the country’s policy on HIV/AIDS prevention, treatment, care and support. It lowered the minimum age requirement (from 18 to 15 years old) for the availment of HIV testing and counseling without parental or guardian’s consent but with the assistance of a licensed social worker or health worker. Local level The Regional Implementation Teams 1 report that there are 341 LGUs with local policies on maternal and neonatal health. However, budget allocations, expenditures and sources of these LGUs supporting these policies were not disclosed. There are 1,869 local policies supporting maternal and neonatal health but only Cordillera Autonomous Region (CAR) was able to disclose the budget that backed these policies at PhP3.5 million. Specifically, ordinances were issued in CAR for the establishment of lactation and breastfeeding stations in the workplaces; and the construction and installation of an elevator within the City Hall for the benefit of the pregnant women, elderly and the persons with disability (Resolution No. 354, series of 2018). The number of LGUs in CAR with local policies, however, was not disclosed. Challenges and Recommendations The data presented above does not provide a complete picture of the status of LGU support for maternal and neonatal health, as well as for other aspects of the RPRH implementation. All indicators should be reviewed for cleaner data so that implementation at the local level can clearly and easily be seen. This is the only way the issues are determined. National policies and specific supporting interventions could be accurately provided if implementation at the local level can be assessed using cleaner data. As in the previous years, there is still a lack of overall strategic direction for the implementation of RPRH. While there are strategic plans for the different aspects of implementation (MNCHN, FP, ASRH, STI and HIV/AIDS, elimination of VAWC), there is no strategic plan that covers all these KRAs. It is imperative that specific activities are stated with the corresponding agencies and units that should be held accountable for the fulfillment of the RPRH goals and objectives. 1 The National Implementation Team (NIT) and the Regional Implementation Teams (RITs) were created to coordinate and monitor the joint implementation of the RPRH law at the national and local levels (DOH AO 2015- 0002). 3 4 2 BUDGET AND FINANCING National Government Budget Based on DOH and POPCOM allocation, the national government budget for the implementation of the RPRH Law in 2018 amounted to Php41.88 billion (Table 1). This is 10% higher than the Php37.4 billion RPRH budget in 2017. The DOH remains to be the main source of funds with its total budget allocation of Php41.35 billion in 2018 comprising of 39% of its total budget in the 2018 General Appropriations Act (GAA) amounting to Php106.08 billion. There was a moderate increase in the DOH budget allocation for RPRH-related line items compared last year. Table 1. Indicative National Government Budget Allocation and Obligation for RPRH 2017 and 2018 Agency/Program 2017 2017 Total 2018 Adjusted 2018 Total Obligation Adjusted Obligation Allotment for (in billion Php) Allotment for RPRH RPRH (in billion Php) (in billion Php) (in billion Php) DOH 37.18 35.36 (95%) 41.35 37.85 (92%) Family Health 4.20 3.68 (88%) 3.64 2.25 (65%) and Responsible Parenthood (FHRP) Expanded 7.10 7.08 (99%) 7.44 7.30 (98%) Program on Immunization (EPI) Health Facility 25.88 24.60 (95%) 30.27 28.30 (93%) Enhancement Program (HFEP) POPCOM 0.42 0.42 (100%) 0.52 0.51 (98%) Total 37.60 35.78 41.88 38.36 Compared to its 2017 budget, there was a slight decrease in the utilization of the 2018 DOH RPRH-related budget line items such as EPI and HFEP. The decrease in the utilization rate of FHRP in 2018 was due to difficulties in the procurement process. 2 POPCOM allocated 90% of its Php 516.88 million budget in the 2018 General Appropriations Act (GAA) to cover the programs on reproductive health/family planning, adolescent health development/population, and development integration, among others. 2 DOH-Disease Prevention and Control Bureau (DOH-DPCB) 5 Apart from the above budget, the DOH also appropriated Php11.46 million for the operation of the Philippine National AIDS Council. In addition, it allocated Php94.37 million for the Cancer Program to be utilized for program implementation review of Cancer Medicine Access Program, Breast Cancer Awareness, procurement of drugs and medicines, among others. Social Health Insurance The premium collection for the National Health Insurance Program reached Php132.43 billion in 2018, a 23% increase from 2017 which stood at Php107.45 billion. 3 Out of the total amount collected, PhP37.16 billion came from the National Government as appropriated in the GAA for the premium contribution of the National Household Targeting Survey for Poverty Reduction (NHTS-PR) households. Approximately Php420.92 million came from premium contributions of women who were about to give birth (WATGB), 4 Php138.46 million from the premium collection under the Point of Care Program and Php3 billion from the 2018 GAA as budgetary support to PhilHealth for the premium payment enrolled under the Point of Service (POS) Program. 5 PhilHealth reported 104.49 million registered beneficiaries in 2018, which comprises 98% of the country’s projected population for the year. Of the total registered beneficiaries, 33% (34.46 million) were indigent members and dependents from the NHTS-PR households. 6 Western Visayas, Central Visayas and Autonomous Muslim Mindanao are the top three regions with large number of registered indigent members (Table 2). Table 2. Number of Indigent Program Members and Dependents Among NHTS Poor Households 7 Region Members Dependents CAR 267,240 355,421 I 638,000 923,396 II 490,617 716,376 III 894,975 1,358,366 NCR 631,793 657,432 IV-A 1,034,672 1,332,596 IV-B 665,894 800,151 V 1,240,882 1,679,078 VI 1,642,114 1,675,703 3 Corporate Planning Department, PhilHealth 4 Ibid 5 POS refers to the program provided in the GAA for the current year, to cover all Filipinos under the National! Health Insurance Program (NHIP), including the unregistered and inactive registered members especially those who are financially incapable. 6 PhilHealth Stats and Charts 2018, www.philhealth.gov.ph 7 Corporate Planning Department, PhilHealth 6  Table 2. Number of Indigent Program Members and Dependents Among NHTS Poor Households 7 VII 1,341,016 1,226,745 VIII 1,140,289 1,567,272 IX 1,205,333 1,229,594 X 1,115,211 1,143,538 XI 455,086 748,363 XII 894,029 997,483 CARAGA 678,804 861,624 ARMM 1,382,927 1,470,155 Total 15,718,882 18,743,293 Source: PhilHealth Corporate Planning Department, 2018 Figure 1. RRH-related PHIC Reimbursements Benefit Payment In the 2018 Stats and Charts, 8 PhilHealth reimbursed a total of Php121.04 billion. Of this amount 26% (Php31.12 billion) was paid for the government-sponsored members and at least Php20.93 billion was paid for RPRH-related benefits. The benefit payment for RPRH-related services steadily increased in the last four years of RPRH implementation from Php11.3 billion in 2014 to Php23.8 billion in 2017. 9 However, benefit payment for RPRH-related services is 11% lower in 2018 compared to 2017. This may be because some claims are still in process. These figures are presented in Table 3. Source: PhilHealth 2018 8 Accomplishments of PhilHealth 9 4th Annual Report of the RPRH Law Implementation, 2017 7  Table 3. Benefit Payment for RPRH-Related Services for 2014, 2015, 2016, 2017 and 2018 Benefit Package Total Amount Paid (Php Million) 2014 10 2015 11 2016 12 2017 13 2018 14 FP 15 21.00 13.60 1,315.42 44.35 366.22 (277.62) MNCHN 16 8,274.70 11,560.00 16,340.10 21,953.00 16,805.63 Post-abortion care 258.70 394.15 569.60 240.63 652.17 STI and HIV 53.36 120.00 242.00 338.00 471.10 Breast and 2,547.00 582.11 1,329.00 1,165.80 2,472.15 Gynecologic 17 Men’s Health 18 110.44 130.11 472.34 46.13 171.46 Total 11,265.20 12,799.97 20,268.46 23,787.91 20,983.72 Two RPRH packages are included in the top ten procedures/packages reimbursed by PhilHealth in 2018. These are Newborn Care Package and deliveries (Normal and Caesarian Section). These two comprised 35% (Php2.40 million) of the Php11.89 million total claims paid by PhilHealth. 19 Based on 2018 FHSIS data, a total of 601,113 are new and other acceptors of long acting and permanent methods (LAPM). Correlating the total number of new and other acceptors of LAPM with PhilHealth paid claims for FP services, only 19% or 111,903 claims were reimbursed by PhilHealth. Relative to this, the agency paid only 2% of No-scalpel Vasectomy (NSV) counts. Among the FP methods reimbursed by PhilHealth, there was substantial improvement in the number of claims filed and paid for subdermal implant package in 2018 which increased by 41% (17,396 claims) compared to 2017 (10,217 claims). These figures are presented in Table 4. 10 The First Annual Consolidated Report on the Implementation of the RPRH Act, 2014 11 The 2nd Consolidated Report on the Implementation of the RPRH Act, 2015 12 3rd Annual Report on the Implementation of the RPRH Act, 2016 13 4th Annual RPRH Report, 2017 14 Source: Case Rates from Powerbi 03-20-2019 based on Admission Year, Paid Claims, Computed Amount Z Benefits from Special Benefits Team 15 Includes BTL, IUD Insertion, SDI and NSV 16 Includes deliveries (normal deliveries, caesarian sections, breech and complicated vaginal deliveries); antenatal care, pregnancy-related conditions; and infant and child health care (newborn care package and perinatal conditions) 17 Includes payment for medical case rates and procedures as well as cancer treatment (Z Benefit Packages) 18 Includes reimbursement for procedures and treatment for diseases of male genital tract including Z benefit for prostate cancer 19 Stats and Charts 2018, www.philhealth.gov.ph 8 The primary driver for subdermal implant claims in 2018 remains to be the private MCP-accredited birthing facilities reflecting 81.3% of total claims, followed by Level 3 private hospitals at 10.6%. 20 Also, from the same study, top three facilities for subdermal implant reimbursement are from the private sector namely: Likhaan Center for Women’s Health (Bulacan), FPOP-Community Health Care Clinic-GenSan (South Cotabato), and Gaspang Aguillon Birthing Clinic (Leyte). 21 Table 4. Number of New and Other Acceptors 22 and Claims Paid for LAPM 2017 and 2018 23 FP Method 2017 2018 2017 2018 New and Other New and Other Claims Paid Claims Paid Acceptors Acceptors BTL 83,057 251,574 69,064 63,144 NSV 2,800 2,844 54 56 IUD 132,513 113,069 32,397 31,307 SDI 90,630 233,626 10,217 17,396 Source: DOH- FHSIS, 2017 & 2018 Facility Accreditation As of December 31, 2018, 1,928 facilities (hospitals and infirmaries) and 2,911 accredited MCP providers are accredited by PhilHealth, which is 11% lower compared to 2017. This may be due to the mandatory requirement of LTO for PhilHealth accreditation of birthing facilities. Also, in 2018, PhilHealth started accrediting FP Stand-Alone Clinics. By end of 2018, there were 811 accredited facilities with trained/certified FP providers which are concentrated in Central Visayas, NCR and MIMAROPA. Facilities with trained/certified FP providers Table 5 shows that the ratio of PhilHealth-accredited PCB providers to total cities and municipalities declined from 94% in 2017 to 81% in 2018, which is partly due to LGU difficulty in complying with the accreditation requirement for physician. Meanwhile, there was marked decline in MCP ratio to total cities and at 66%, which is due to mandatory requirement of License to Operate (LTO) for accreditation of birthing facilities. This means that facilities were not able to comply and secure LTO from DOH which is a requirement for accreditation. 20 Powerpoint presentation on Initial Analysis of PSI Consumption (July-December 2018) and PhilHealth Reimbursements (2017 And 2018), RTI (Usaid Project), 2018 21 Ibid. 22 FHSIS, DOH, 2017 And 2018. 23 PhilHealth, 2017 and 2018 9  Table 5. Number of Accredited PCB and MCP in Cities and Municipalities, 2017 and 2018 2017 24 2018 25 PCB MCP PCB MCP Number of accredited outpatient clinics 2,455 3,243 2,349 2,911 Number of cities and municipalities with 1,541 1,493 1,330 1,078 accredited clinics Percentage to total number of cities and 94% 91% 81% 66% municipalities Source: PhilHealth, 2017 and 2018 Enabling Policies In 2018, PhilHealth developed and implemented RPRH-related policies. These policies have accompanying “Tamang Sagot” information sheet, a list of frequently asked questions, for PhilHealth members and health care providers. To further facilitate understanding of RPRH- related policies, PhilHealth Regional Offices regularly organized orientation activities such as “Alamin at Gamitin (ALAGA Ka)” Program and “Project REACHOUT.” These activities aim to ensure the same understanding of the policies and details of operational mechanisms. These policies are: 1. PhilHealth Circular 002 s. 2018 on the Department of Health License to Operate (DOH- LTO) as Mandatory Requirement for Accreditation of Birthing Homes and Maternity/Lying- in Clinics Starting CY 2018 (Date Published: May 15, 2018). This policy guidelines and mandatory requirements to facilitate accreditation of birthing homes/lying-in clinics and ensure reimbursement for MCP, NSD and NCP services. 2. PhilHealth Circular 004 s. 2018 on the Accreditation of Stand-Alone HIV Treatment Hubs and Satellite Treatment Hubs as Providers of PhilHealth Outpatient HIV /AIDS Treatment (OHAT) Package (Date Published: June 7, 2018). This policy aims to increase access of affected population to the PhilHealth OHAT Package. The package provides a mechanism for people living with HIV (PLHIV) to have access to effective HIV /AIDS treatment and care in PhilHealth accredited health care institutions. 3. PhilHealth Circular 005 s.2018 on the Guidelines for Accreditation of Free-Standing Family Planning (FP) Clinics (Date Published: May 18, 2018). This policy provides standards and guidelines on the accreditation of family planning clinics and health care professionals for family planning packages of PhilHealth done in non-hospital-based facilities. 4. PhilHealth Circular 008 s. 2018 on the Guidelines on the Implementation of Point of Service (POS) Enrolment Program under the GAA 2018 Onwards (Date Published: June 15, 2018). The policy aims to address the gaps in coverage of both financially capable 24 4th Annual Report of the RPRH Law Implementation, 2017 25 Stats and Charts 2018, www.philhealth.gov.ph 10  and incapable Filipinos, and registered inactive members and to ensure 100% availment rate in covering the poor under the National Health Insurance Program. 5. PhilHealth Circular 0016 s. 2018 on Display of NBB Streamer within Health Care Institution (HCI) Premises (Date Published: Oct 11, 2018). The objective of this policy is to create awareness among PhilHealth members and dependents that no co-payment policy is being implemented on the said facility. This approach supplements existing information dissemination initiatives on NBB policy and empower entitled members to avail of the NBB coverage. 6. PhilHealth Circular 0021 s. 2018 on Enhancement of Newborn Care Package (Date Published: Dec 21, 2018). This Circular provides policies and procedures on the implementation of the Newborn Care Package which includes expanded newborn screening test. Financing Support from Other Sources The LGUs allocated around Php406.4 million for FP training, FP- related workshops, and procurement of FP commodities, among others. This FP budget represents only1.04% of the total budget of LGUs. 26 Various development partners actively supported the implementation of the RPRH Law through allocation of budgetary support. - USAID allocated around Php900 million for FP and Php150 million for MNCHN programs 27 to improve access to quality FP/MCH services, fortify behavioral change, and strengthen health system and remove barriers to FP/MNCHN use. - UNFPA allocated Php250.31 million to cover programs for sexual and reproductive health of women, adolescents and youth, empowering youth and women, gender equality, among others. - Global Fund allocated Php420 million (US$ 8.4 million) for HIV - The Government of Canada released Php391 million to support the implementation of RPRH 28 - Civil Society Organizations (CSOs) reported that in 2018, Php74.43 million was allocated for the implementation of RPRH programs, of which 91% was utilized. This amount was used to fund the following activities: support to policy development, conduct of demand generation, capacity building, and service delivery. Funding for CSOs was made possible through the support of ARROW, Australian Embassy, Bill and Melinda Gates Foundation, DAP, DepEd, DOH, EMpower Foundation, FP2020, InterPares, IPPF, KOICA, Medecins Sans Frontieres, PCPD, POPCOM, Save the Children, and UN Women, among others. 26 Source: 2018 LGU Annual Operational Plan (provided by the DOH) 27 Php50 currency exchange rate 28 Php38 currency exchange rate 11 Challenges and Recommendations Challenges Recommendations 1. Consistently low utilization of FP PhilHealth may need to review its membership Packages of PhilHealth. services to determine barriers encountered by WRA and health care providers in benefit availment. Low utilization may also arise from confusion between patients and Develop strategies and operational mechanisms to providers brought about by differing improve women’s use of FP services. interpretations in the implementation of the guidelines. Introduce and institutionalize effective approaches and practices that will support the DOH and PhilHealth address operational bottlenecks. Review operational and policy bottlenecks and out- of-pocket spending that affect equity and financial risk protection in health. 2. Decrease in the number of PhilHealth- Review the reasons why there is a decrease in the accredited MCP facilities number of PhilHealth-accredited MCP facilities such as but not limited to existing DOH and PhilHealth guidelines and requirements for accreditation. DOH may assist LGUs in upgrading of existing and constructing new health facilities in areas with limited accessibility to birthing services. DOH and PhilHealth to develop mechanism/system where public and private providers will be organized to form a network that will be responsible for the health needs of the community in the light of Universal Health Care. 12 3 PROGRESS ON THE KEY RESULT AREAS Key Result Area 1: Maternal, Newborn, Child Health and Nutrition Maternal, Infant and Child Health, and Nutrition including Breastfeeding is the second element of the RPRH Care Law. This section discusses health outcomes under this element including the interventions implemented and policies developed. The challenges and recommendations on program implementation are also included in the report. Maternal Health The DOH FHSIS showed that maternal mortality rates Figure 2. Philippine Maternal Mortality Ratio decreased in the past years. 2013-2018 It dipped to 54/100,000 livebirths in 2017 from Maternal Mortality Ratio, 2013-2018 74/100,000 livebirths in 2015. For the current reporting 100 year, MMR slightly increased to 58/100,000 livebirths. 80 73.89 73.71 64.76 66.51 While DOH FHSIS data 60 57.93 53.82 Rate showed a lower maternal mortality ratio, the Maternal 40 Mortality Estimation Inter- Agency Group i in 2015 20 demonstrated a maternal mortality ratio of 114 per 0 100,000 live births. It would 2013 2014 2015 2016 2017 2018 be difficult to assess status of Source: DOH FHSIS, 2013-2018 maternal health outcomes using only the FHSIS since MMR can only be accurately calculated from considerably large sample sizes. The DOH is still challenged by the need to accurately measure maternal mortality owing to gaps in the timeliness and completeness in reporting and the quality and private sector inclusiveness of its data. The fact remains that women are still dying from pregnancy-related complications every year. To halt preventable cause of maternal deaths and to effectively achieve the Sustainable Development Goals, innovative interventions and stronger efforts are needed. Similar to previous years, the leading causes of mortality remain to be hemorrhage and hypertension which account for about 70% of direct causes. Maternal sepsis in the Philippines has also been increasing and accounts for 9% of the total maternal deaths. These pregnancy- related diseases can be abated by the provision of quality obstetric care and access to CEmONC- capable facility. In addition, the Maternal Death Surveillance and Response (MDSR) report showed that beyond the clinical causes of death, health system delays and social determinants of health greatly affect the outcome of pregnancy. 13 In terms of regional performance, DOH has reported a lower number of livebirths in 2018 (1,693,508) with more than 114,000 difference compared to 2017. Absolute count of maternal deaths on the other hand, increased for the present year. While maternal mortality rate in majority of the regions decreased (CAR, 1, 2, 4A, 4B, 5, 8, 9, and 10), some regions are still over the desired Sustainable Development Goal target of 70/100,000 livebirths, namely Regions 5, 6, and 11 (Table 6). Table 6. Maternal Mortality Ratio and Live Births across Regions 2017-2018 Number of Maternal Region Livebirth (Number) MMR (per 100,000 LB) Deaths 2017 2018 2017 2018 2017 2018 PHL 1,807,728 1,693,508 973 981 54 58 NCR 246,580 247,653 125 149 51 60 CAR 32,587 32,640 14 13 43 40 1 82,683 79,438 48 41 58 51 2 57,352 57,009 29 20 51 35 3 180,600 152,703 73 67 40 44 4A 213,194 174,634 90 68 42 39 4B 55,156 51,112 44 33 80 65 5 117,373 116,242 92 89 78 77 6 110,058 101,480 72 88 65 87 7 169,568 143,266 51 83 30 58 8 79,244 75,837 62 43 78 57 9 58,899 63,191 37 39 63 62 10 97,183 96,094 58 50 60 52 11 98,823 102,588 58 77 59 75 12 84,683 83,945 48 51 57 61 ARMM 74,964 74,742 40 35 53 47 CARAGA 48,781 40,934 32 35 66 86 Source: DOH FHSIS, 2017 and 2018 14  Figure 3. Perinatal and Infant Mortality Rates 2017-2018 Perinatal and Infant Health Perinatal mortality is defined as fetal deaths of 22 weeks or more and 20 newborns dying under seven days of 15 life. FHSIS reports showed that Rate 10 perinatal mortality rates increased 8.68 8.3 7.92 8.15 7.48 7.78 5 5.11 5.01 5.06 from 2014 to 2015. This showed no 3.43 3.09 4.38 significant change until 2018 when a 0 total of 8,574 perinatal deaths were 2013 2014 2015 2016 2017 2018 accounted for which translates to PM IM 5.06/1,000 live births. Source: DOH FHSIS, 2017 and 2018. Unlike previous years, perinatal mortality is included in this report as this indicator plays an important role in providing the information needed to Figure 4. Prevalence of Malnourished Children 0-59 improve the health status of pregnant months 2013 and 2015 women, new mothers, and newborns. This information allows decision- 50 makers to identify problems, track 40 30.333.4 Prevalence temporal and geographical trends and 30 20 21.5 disparities, and assess changes in 20 8 7.1 public health policy and practice. 29 In 10 5.1 3.9 contrast, infant mortality rates declined 0 from 2013 to 2017. But 2018, it Underweight Stunting Wasting Overweight marginally increased to 7.78/1,000 2013 2015 livebirths. Source: National Nutrition Survey, 2013 and 2015. 29 WHO Neonatal and Perinatal Mortality Country, Regional, and Global Estimates, 2016. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/43444/9241563206_eng.pdf?sequence=1 15 Nutrition Data on nutrition are highly dependent on survey data. Based on the National Nutrition Survey in 2013 and 2015. Prevalence of underweight and stunted children slightly increased from 20% to 22% and 30% to 33%, respectively from 2013 to 2015 as shown in Figure 4. On the other hand, a marginal decline was also reported in the prevalence of wasting and overweight among under- five children. Key Interventions Figure 5. Maternal Care Service Utilization Indicators Maternal Health Services 2017 and 2018. The MNCHN core package of services Maternal Service Utilization consist of interventions that will be Indicators delivered for each life stage: pre- 2017-2018 pregnancy, pregnancy, delivery, post- 90 94 93 95 100 partum, newborn, and child care. These 80 Percentage 52 53 58 57 services are anchored on the 60 Implementing Health Reforms for Rapid 40 Reduction of Maternal and Neonatal 20 Mortality issued as DOH Administrative 0 Antenatal Post Partum Facility based Skilled Birth Order 2008-0029. This policy issuance Care Visit delivery Attendance provides the strategy to rapidly reduce maternal and neonatal deaths through 2017 2018 the provision of packages for maternal, newborn, child health, and nutrition Source: DOH FHSIS 207 and 2018. (MNCHN) services. For this reporting year, data from DOH FHSIS will be utilized to compare performance in 2017 and 2018. This will differ from the 4th RPRH Annual Report for maternal care service utilization since it used the National Demographic Health Survey 2017. Service utilization for maternal care gradually increased in 2018. DOH FHSIS data showed that the number of pregnant women with at least four prenatal check-ups (antenatal consultations or ANC) increased by one percentage point from 52 to 53 in 2017 and 2018, respectively. This is approximately 1,506,395 women. Antenatal care is relatively low compared to facility-based delivery as reporting for ANC should commence in the 1st trimester of pregnancy. Pregnant women who failed to visit during the first trimester are automatically not counted in the ANC indicator. Field reports also showed that women usually seek prenatal care when quickening 30 is felt usually at 20 weeks age of gestation or at the second trimester of pregnancy. Facility-based delivery (FBD) and skilled birth attendance (SBA) were reported at 94% and 95% respectively in 2018. The increase from 2017 is an indication of women’s preference to give birth 30 Quickening Is the perception of fetal movement beginning at 16 to 20 weeks (Cunningham, G. Et Al., Williams Obstetrics, 22nd Edition, 2005.) 16 in licensed health facilities attended by skilled health professionals. However, it must be noted that 5% of pregnant women still give birth at home assisted by traditional birth attendants or “hilots.” Improvements in FBD rate can be attributed to the support PhilHealth provided to women giving birth in health facilities through its maternity and newborn care packages. It can also be ascribed to the issuance of local health resolutions prohibiting deliveries at home and the provision of incentives for traditional birth attendants and community health volunteers in bringing pregnant women who are about to deliver in birthing clinics and hospitals. Table 7. Maternal Care Service Utilization Indicators per Region, 2018 ANC (%) PPV (%) SBA (%) FBD (%) PHL 53 57 95 94 NCR 66 67 98 97 CAR 50 51 98 96 1 60 56 100 98 2 51 57 98 96 3 53 55 98 91 4A 39 45 95 93 4B 48 57 86 95 5 47 59 95 94 6 43 49 95 94 7 51 59 97 96 8 44 44 * * 9 59 59 91 91 10 66 66 * * 11 52 52 93 93 12 65 65 92 92 ARMM 58 58 76 68 CARAGA 53 53 94 92 *No report in FHSIS Source: DOH FHSIS, 2018. Post-partum visit (PPV or post-natal check-up) decreased by one percentage point from 58% in 2017 to 57% in 2018. PPV is done at least twice - within 24 hours and within seven days after delivery. Field reports collected attribute the low post-partum visits to the inability of mothers to seek care as they are most likely occupied with child care. Post-partum visits are important as most maternal and newborn deaths occur during or immediately after delivery. Early post-partum care is critical to promote household practices like exclusive breastfeeding, which is key to child health and survival. Table 7 provides a summary of the four service utilization indicators across 17 regions. Not one region reached the 90% target in all service utilization indicators. However, Regions NCR, CAR, 1, 2, 3, 4A, 5, 6, 7, 9, 11, 12, and CARAGA reached the target of 90% for both SBA and FBD. 17 Pre-pregnancy Services Pre-pregnancy services include provision of iron and folate supplementation, counseling and provision of FP methods, and prevention and management of infection and lifestyle-related diseases. Commodities for these services are provided by both the DOH and LGU. Pre-pregnancy services highlight the provision of modern FP methods to reduce unplanned pregnancies and unmet need of women and adolescents that can expose them to unnecessary risks from pregnancy and childbirth. Unplanned pregnancies are also associated with poorer health outcomes for both mother and newborn. 31 Effective provision of FP services can potentially reduce maternal mortality by around 44%. 32 Family planning services will be discussed in detail in the next section of this report KRA 2: Family Planning. Antenatal Care Services Antenatal care or ANC is defined as the care provided by skilled health professionals to pregnant women and adolescent girls to ensure the best health conditions for both mother and baby during pregnancy. 33 This visit is important because it helps reduce maternal and perinatal morbidity and mortality both directly, through detection and treatment of pregnancy-related complications, and indirectly, through the identification of women and girls at increased risk of developing complications during labor and delivery. ANC ensures referral to an appropriate level of care. 34 Its components include: risk identification; prevention and management of pregnancy-related or concurrent diseases; and health education and health promotion. In 2016, the WHO recommended eight ANC visits to achieve a positive pregnancy experience instead of the four ANC visits proposed in the WHO Focused Antenatal Care Model in 2002. It details health system interventions to improve the utilization and quality of antenatal care. These interventions include women-held case notes; midwife-led continuity of care; Group antenatal care; community-based interventions to improve communications and support; task shifting components of antenatal care delivery; recruitment and retention of staff in rural and remote areas; and antenatal care contact schedules. The Philippines has yet to adopt this guideline, but in 2018, the Safe Motherhood Program began drafting implementation guidelines for ANC to strengthen Administrative Order (AO) 2016-0035, The National Policy on the Provision of Quality Antenatal Care in Birthing Centers and Health Facilities Providing Maternal Care Services. The tracking of pregnancies in the community by the barangay health workers (BHWs) is one of the factors that influence women to seek ANC consultation. BHWs provide both navigation and basic service delivery functions, assist pregnant women in developing birth plans, and help families facilitate access to critical health services. In 2018, Civil Society Organizations (CSOs), reported that 27,668 pregnancies were tracked and 219 pregnant women developed birth plans. “Bantay Buntis,” a practice at the regional level by organized communities with indigenous people, ensure pregnant women avail of professional assistance throughout pregnancy, delivery and 31 DOH, 2011. 32 Ahmed S., Et Al., Maternal Deaths Averted by Contraceptive Use: An Analysis Of 172 Countries. Lancet. 2012 Jul 14;380(9837):111-25. DOI: 10.1016/S0140-6736(12)60478-4. Epub 2012 Jul 10. Retrieved From https:/wWww.ncbi.nlm.nih.gov/pubmed/22784531 33 WHO, 2016. 34 Carroli G, Rooney C, Villar J. How Effective is Antenatal Care in Preventing Maternal Mortality and Serious Morbidity? An Overview of the Evidence. Paediatr Perinat Epidemiol. 2001;15(Suppl 1):1–42. 18 post-partum. This service extends to ensuring the provision of basic health services to newborns up to their childhood. To raise awareness on quality ANC, tarpaulins on Quality ANC Services were produced and provided by the Safe Motherhood Program to all public birthing centers in the country. The tarpaulins were recommended to be displayed in the waiting areas of birthing centers so that women are aware of the ANC service package that they should receive from the health provider. Demand generation activities were also conducted to encourage women and couples to exercise good practices in maternal and infant health. Buntis Congress is a common demand generation activity conducted in LGUs nationwide with the support of various CSOs. In this activity, pregnant women and/or couples are educated in various topics, such as responsible parenting, reproductive health, proper nutrition, what to expect during labor and delivery, breastfeeding, and newborn screening. Provision of free routine laboratory procedures and ultrasound during advocacy campaigns are also done. In 2018, the DOH Health Promotion and Communication Services (HPCS) featured two episodes of Making Pregnancy and Childbirth Safer in the Healthy Ever After Show in GMA News TV. Pregnancy requires a healthy diet that includes an adequate intake of energy, protein, vitamins and minerals to meet maternal and fetal needs. However, for many pregnant women, dietary intake of vegetables, meat, dairy products and fruit is often insufficient to meet these needs, particularly in low and middle-income countries (LMICs) where multiple nutritional deficiencies often co-exist. In resource poor countries in sub-Saharan Africa, south-central and south-east Asia, maternal undernutrition is highly prevalent and is recognized as a key determinant of poor perinatal outcomes. 35 Hence, the provision of macro and micronutrient supplementation for pregnant women and adolescent girls is included as intervention in antenatal care. DOH procures these nutrient supplements to augment LGU supplies. Table 8 shows the units procured and distributed for target beneficiaries. Labor, Delivery, and Post-partum Services Advocacies for facility-based delivery are highly important. They ensure safe labor and intrapartum interventions and consequently safeguard the welfare of women and newborns. The establishment of a network of public and private health care providers of emergency obstetric and newborn care is integral to safe intrapartum interventions. The network is configured to include birthing centers capable of providing BEmONC and a referral hospital that can provide CEmONC. Ideally, a BEmONC-capable facility should be reached within 30 minutes from homes using the most common mode of transportation while a CEmONC should be reached within an hour from each BEmONC-capable facility. 35 Tang Am, Chung M, Dong K, Terrin N, Edmonds A, Assefa N Et Al. Determining A Global Midupper Arm Circumference Cutoff to Assess Malnutrition in Pregnant Women. Washington (Dc): FHI 360/Food