Guidelines on Identifying Geographically-Isolated and Disadvantaged Areas and Strengthening Their Health Systems

May 27, 2020

DOH ADMINISTRATIVE ORDER NO. 2020-0023

 

I. RATIONALE

For the past 30 years, the Department of Health (DOH) had undertaken key structural reforms and continuously built on programs to achieve Universal Health Care (UHC). However, the health situation in geographically-isolated and disadvantaged areas (GIDAs), which is generally characterized by high morbidity and mortality resulting from poor access and delivery of quality health services as well as lack of health facilities and inadequate logistical support, proves to be a persistent concern. Additionally, the decentralized health system resulted to the fragmented delivery of comprehensive primary care services.

As a response to reduce health inequity in GIDAs, the DOH issued AO 185, s. 2004 or the "Establishment of the Geographically-Isolated and Disadvantaged Areas (GIDA) in Support to Local Health Systems Development." It was also issued to improve the availability of and access to health resources and services as well as ensure the provision of culture-sensitive health services for Indigenous Peoples (IPs). The strategy that would ensure that no one is left behind as health reform implementation moves forward pertains to GIDA health systems strengthening (HSS). It recognizes vulnerable and hard-to-reach areas, such as, islands, mountainous areas, internally-displaced persons (IDPs) in conflict-affected areas (CAAs) and IPs within the local health system.

Republic Act (RA) 11223 or the "Universal Health Care Act" and its implementing rules and regulations (IRR) strengthened the commitment of the DOH, together with PhilHealth and LGUs, to prioritize GIDA through the provision of assistance and support such as, but not limited to, health human resources, infrastructure, medical equipment and supplies towards the equitable distribution of health services and benefits. In addition, section 29.2 of the IRR mandates the DOH to develop the guidelines for identifying GIDA barangays.

Thus, this Order is being issued to provide guidelines on the identification of GIDA in the country. It also recommends strategies in the strengthening of GIDA health systems in terms of health service delivery, human resources for health, financing and resource allocation, pharmaceuticals and medical supplies, regulations of health facilities, leadership and governance, and health information systems. CAIHTE

II. OBJECTIVES

This Order shall provide the guidelines and directions for identifying GIDAs and strengthening their health systems. Specifically, this Order aims to guide all stakeholders in improving access to quality health care through province-wide/city-wide health systems, and equitable and sustainable health financing in GIDAs.

III. SCOPE OF APPLICATION

This Order shall apply to DOH Central Office Bureaus, Services and Attached Agencies, Centers for Health Development (CHDs), DOH hospitals, National Government Agencies (NGAs), Local Government Units (LGUs), and other stakeholders that provide assistance related with the development and strengthening the health systems in GIDAs.

In the case of Bangsamoro Autonomous Region in Muslim Mindanao (BARMM), the adoption of this Order shall be in accordance with RA 11054 or the "Bangsamoro Organic Act" and the subsequent laws and issuances by the Bangsamoro government.

IV. DEFINITION OF TERMS

A. Culture-sensitive health services — refer to health services that are provided with acknowledgement and respect for the cultural diversity among the populace.

B. Geographically Isolated and Disadvantaged Areas (GIDAs) — refer to barangays which are specifically disadvantaged due to the presence of both physical and socio-economic factors.

C. Health Systems Strengthening — refers to initiating activities in the internationally accepted core health systems functions, namely: human resources for health; financing and resource allocation; leadership and governance; health information system; medical products, vaccines, and technologies; regulations of health facilities; and, service delivery.

D. Physical factors — refer to characteristics that limit the delivery of and/or access to basic health services to communities that are difficult to reach due to distance, weather conditions, and transportation difficulties.

E. Primary Care — refers to initial-contact, accessible, continuous, comprehensive and coordinated care that is accessible at the time of need including a range of services for all presenting conditions, and the ability to coordinate referrals to other health care providers in the health care delivery system, when necessary.

F. Socio-Economic factors — refer to social, cultural, and economic characteristics of the community that limit access to and utilization of health services. DETACa

V. GENERAL GUIDELINES

A. The framework for defining a barangay as GIDA shall primarily consider both physical and socio-economic factors that limit the availability of and accessibility to basic health services among the population in that area. As such, a barangay identified as GIDA shall be a priority in the provision of technical and financial assistance to improve health services, as stipulated in Section 29.4 of the UHC Act IRR.

B. A GIDA information system shall be implemented at the national and local levels to serve as the core monitoring and evaluation system for determining current health status and health intervention gaps. As such, its generated data shall be disseminated among concerned DOH offices, NGAs, LGUs, and stakeholders through the DOH website and technical reports as their basis for determining priorities.

C. The LGUs shall prioritize the health agenda of the Indigenous Cultural Communities/Indigenous Peoples (ICC/IPs) and those who are living in GIDA. In accordance with Chapter IV, Section 16 of RA 8371 or "The Indigenous Peoples' Rights Act of 1997" and Section 19.16 of the UHC Act IRR, IPs shall be represented in the Provincial and City Health Boards where their representative shall initiate integration of IP/GIDA specific initiatives in policies and plans of the LGUs through the Local Investment Plan for Health (LIPH) and the Annual Operational Plan (AOP).

D. The health systems strengthening in GIDA shall be ensured by the LGU where all people living in GIDA have access to basic health services by improving the core health system functions.

VI. SPECIFIC GUIDELINES AND IMPLEMENTING MECHANISMS

A. Criteria for Classification as GIDA

The CHDs, in coordination with the LGUs, shall classify a barangay as GIDA if both physical AND socio-economic factors are present:

1. Physical factor of a barangay — at least 25% of sitios/puroks should have no access to a Rural Health Unit (RHU) nor a hospital within 60 minutes of travel in any form of transport, including walking;

2. Socio-economic factor of a barangay — at least ONE of the following conditions:

a. At least 10% of its population are IPs;

b. At least 10% of its population are affected by Armed Conflict or Internally Displaced or the barangay is identified as a Communist Terrorist Group (CTG)/Local Extremist Group (LEG) area by the National Intelligence Coordinating Agency (NICA); aDSIHc

c. At least 50% of its population are enrolled in Pantawid Pamilyang Pilipino Program/Conditional Cash Transfer (4Ps/CCT);

d. The performance of the barangay, in at least four (4) out of the following indicators, is less than their latest provincial data:

i. Infant Mortality Rate;

ii. Under Five Mortality Rate;

iii. Fully Immunized Child;

iv. Adolescent (Age 10-19) Birth Rate;

v. Contraceptive Prevalence Rate;

vi. Proportion of pregnant women with 4 or more pre-natal visits;

vii. Proportion of deliveries attended by skilled birth attendant; and

viii. Household with access to improved water supply.

B. GIDA Profiling

1. The LGUs, in partnership with the CHDs, shall conduct a thorough profiling of their barangays using the GIDA Profiling Tool (i.e., to be issued by the DOH separately), which shall be considered as a scoring system to use in decision-making for prioritization. The profiling tool shall be able to:

a. Identify and validate GIDA barangays;

b. Analyze gaps in terms of the current availability and readiness of essential health service delivery, human resources for health, health facilities, medicines and social health insurance, among others; and

c. Identify priority areas and their needs.

2. The DOH Central Office, through the Bureau of Local Health Systems Development (BLHSD), shall issue an official GIDA list that shall be updated annually. The list, which is considered to contain priority areas, shall be shared to all stakeholders through the DOH website and technical reports.

3. The CHDs shall issue individual certifications to the barangays that are identified as GIDAs, as needed.

4. The ICCs/IPs and those who are living in GIDA shall be considered as priority beneficiaries of technical and financial assistance from both domestic and foreign assisted projects on health.

5. The LGU, DOH, and other stakeholders shall use the GIDA profile in formulating a list of priority interventions for sharing with different bureaus within DOH, other government agencies, and stakeholders for the prioritization of their resources. ETHIDa

6. The CHDs, in coordination with the LGUs, shall conduct the mandatory GIDA profiling once every three years as part of the monitoring, evaluation and further improvement of GIDA health systems through the GIDA information system core component.

7. The CHDs may engage other stakeholders including the National Commission on Indigenous Peoples (NCIP), National Mapping Resource Information Authority (NAMRIA), and partners from the academe in the conduct of GIDA mapping.

C. GIDA Health Systems Strengthening

1. The LGUs shall include all strategies and activities needed to strengthen the health systems of GIDA barangays in their respective LIPH and AOP.

2. The LGUs, in coordination with the DOH, shall ensure that people living in GIDA have access to basic health services through the proposed strategies provided in Annex A, such as, but not limited to, the following core health system functions:

a. Health Service Delivery — The LGUs, in coordination with the DOH, shall be enjoined to develop a strategy in establishing an appropriate and efficient referral system within the Primary Care Provider Network to ensure smooth delivery of services even in emergency situation. This shall include services that are effective in promoting health and wellness, prevention and treatment of diseases and rehabilitation of complications secondary to these diseases.

b. Human Resources for Health — The DOH, through the National Health Workforce Support System, shall promote and prioritize deployment of health workers to GIDAs. This includes the Rural Health Midwives, Nurses, Doctors to the Barrios (DTTB) and other human resources for health care that may be applicable.

c. Financing and Resource Allocation — The LGUs shall be enjoined to equitably allocate funds across GIDA barangays specific to the health needs of each community. The DOH shall leverage its support by prioritizing GIDA for assistance.

d. Medical Products, Vaccines, and Technologies — the DOH shall augment LGU supplies and prioritize GIDA in the distribution of medicines, vaccines, and other commodities to ensure that the population living in GIDA has access to affordable essential drugs on a sustainable basis.

e. Regulation of Health Facilities — Every GIDA shall have a Barangay Health Station (BHS)/birthing facility designed in compliance with DOH licensing standards, PhilHealth accreditation, which provides culture-sensitive health services. Birthing facilities in GIDAs shall be prioritized in the processing of applications and issuance of a License to Operate and Certificate of Accreditation for health facilities. cSEDTC

f. Leadership and Governance — The LGU shall ensure that the health agenda of IPs and GIDAs are being prioritized. As applicable, ICCs/IPs, in accordance with RA 8371, shall also be represented in Provincial, City and Municipal Health Boards. The representative shall initiate integration of IP/GIDA specific initiatives in the policies and plans of the LGUs.

 The LGU shall ensure that local officials in the GIDA (i.e., barangay council) are adept in making appropriate and strategic plans for their respective area, which shall coincide with the municipal/city development plans.

g. Health Information System — The LGUs shall utilize the GIDA information system as the basis for identifying priority areas for financial and technical assistance.

D. Monitoring and Evaluation

The BLHSD shall lead the national level monitoring and evaluation of access, equity, and responsiveness of GIDA health systems using the data generated from the GIDA Information System. The parameters to be analyzed shall include health system elements indicators, health outcomes and health service utilization indicators and fund utilization indicators.

VII. ROLES AND RESPONSIBILITIES

All concerned DOH bureaus/units and entities shall appropriate funds for the development of GIDA health systems. The following are the roles and responsibilities of concerned DOH Bureaus/units and other stakeholders in GIDA health systems strengthening:

A. Bureau of Local Health Systems Development (BLHSD)

1. Develop and update the GIDA Profiling Tool to be used by CHDs and LGUs;

2. Develop, update, and maintain the GIDA information system in collaboration with Knowledge Management and Information Technology Service (KMITS);

3. Interpret and analyze data, produce technical reports, and disseminate information in the GIDA registry;

4. Issue an official GIDA List to stakeholders that shall be updated annually;

5. Develop strategies, interventions and recommend equitable allocation of resources based on GIDA Profiling data, in coordination with other DOH Bureaus; SDAaTC

6. Develop guidelines to identify priority areas based on the specific needs of identified GIDA barangays; and

7. Monitor and evaluate access, equity and responsiveness of GIDA health systems.

B. Other DOH Bureaus and Offices

1. Health Facilities Development Bureau (HFDB) shall develop standards for health facilities, taking into consideration the different GIDA/IP settings.

2. Health Facility Enhancement Program-Management Office (HFEP-MO) shall allocate funds for construction, and improvement of health facilities in GIDA or those serving GIDA barangays.

3. Health Human Resource Development Bureau (HHRDB) shall develop policies and programs for scholarships, human resource development, and HRH deployment prioritizing GIDA barangays.

4. Health Policy Development and Planning Bureau (HPDPB) shall ensure the inclusion and/or prioritization of GIDAs in sectoral policies and investments.

5. Disease Prevention and Control Bureau (DPCB) shall develop policy and guidelines on primary care service packages and standards and delineation of population-based and individual-based health services.

6. Knowledge Management and Information Technology Service (KMITS) shall assist in the development and maintenance of the GIDA information system and capacity building of BLHSD and the CHDs on the system.

7. Financial Management Service (FMS) shall support in the facilitation of the allocation of appropriate funds in the development of GIDA health system.

8. Health Facilities and Services Regulatory Bureau (HFSRB) shall develop the framework and guidelines on appropriate service capability in GIDA for purposes of preferential licensing of health facilities and contracting of health services.

C. Centers for Health Development (CHDs)

1. Identify barangays as GIDA and issue certifications for such as needed; acEHCD

2. Conduct GIDA profiling once every three years, together with LGUs;

3. Interpret and analyze data, produce technical reports with disaggregated data according to the needs of stakeholders, and disseminate information in the GIDA registry;

4. Provide technical support to Local Health Boards (LHB) of all levels through the DOH Representatives to ensure GIDA health systems strengthening strategies are integrated to higher-level plans such as LIPH/AOP; and

5. Monitor and evaluate access, equity and responsiveness of GIDA health systems.

D. Philippine Health Insurance Corporation (PhilHealth)

1. Provide information to all members on the automatic inclusion of every Filipino into the National Health Insurance Program and the available benefit packages; and

2. Provide expedited accreditation process, if possible, that ensures culture-sensitive and innovative interventions for health facilities in GIDA.

E. Local Government Units (LGUs)

1. Conduct GIDA profiling once every three years, together with the CHD;

2. Develop strategies to ensure availability of essential health services in GIDA and referral to higher level of care;

3. Develop GIDA HSS Plan in consultation with the community;

4. Ensure that the GIDA HSS Plan shall be integrated in the LIPH;

5. Ensure every GIDA has access at minimum to midwifery service at BHS;

6. Provide additional incentives for health workers serving in GIDA;

7. Inform the population in GIDAs of their PhilHealth membership, as well as the other pertinent information such as available benefit packages; and

8. Participate in DOH local governance training programs.

VIII. REPEALING CLAUSE

Administrative Order 185, s. 2004 dated 27 August 2004 or the "Establishment of the Geographically-Isolated and Disadvantaged Areas (GIDA) in Support to Local Health Systems Development" and other related orders, rules, regulations, and issuances pertaining to GIDA that are inconsistent with or contrary to this Order are hereby repealed, amended, or modified accordingly. All other provisions of existing issuances which are not affected by this Order shall remain valid and in effect. SDHTEC

IX. SEPARABILITY CLAUSE

If any part or provision of this Order is rendered invalid by any court of law or competent authority, the remaining parts or provisions not affected shall remain valid and effective.

X. EFFECTIVITY

This Order shall take effect immediately.

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary of Health

ANNEX A

Proposed Strategies for GIDA Health Systems Strengthening

1. Health Service Delivery

a. Behaviour Change Communications (BCC): To promote healthy lifestyle which includes proper hygiene and health education, nutrition counselling and desired health seeking behaviour among others. BCC materials will be adapted to local language and culture to create social mobilization effects.

b. Partnerships with private and traditional health service providers, religious leaders, IP leaders and other community leaders whom the community trust should be considered as part of strategic priority.

c. Enhanced functions of health services: To provide supplementary services, in addition to essential health services, including:

• Nutrition specific programs for under-nourished children in coordination with LGUs and other relevant agencies;

• Provide trained HRH and resources for emerging, re-emerging and infectious diseases for internally-displaced populations (IDPs);

• Set-up relocation sites and access to calamity fund to provide emergency health provision in conflict-affected and disaster-prone areas; and

• Work with DSWD on regular and modified conditional cash transfer interventions to promote health behaviour change among those who are economically or culturally marginalized.

d. Adopt-a-Community Strategy: To provide direct health services, and/or assistance to health facilities and community projects focusing on the marginalized and vulnerable populations through a medium or long-term engagement among DOH, foreign-based and local organizations and Local Government Unit. This strategy is done to ensure continuity and sustainability of services provided by foreign and local missioners.

• Medical, surgical, dental missions, and vaccination campaigns in hard-to-reach areas; AScHCD

• Make-shift satellite health facilities to provide the basic package of health services; and

• Mobile health clinics or teams.

e. Community Organization and Mobilization: Mobilization of the community to effectively participate in joint decision-making and guarantees its local health development initiatives, including:

• Participatory needs analysis and planning together with BHW and other relevant stakeholders to identify health related-needs, community-driven solutions and initiatives;

• Community-led resource mobilization and allocation from government and private sector to support community health development initiatives; and

• Public Private Partnership with health service providers including NGOs, military, other government agencies, businesses among others to enhance health service delivery specifically in hard-to-reach areas.

f. Health Care Provider Network (HCPN): The RHU/HC, with its barangay health stations, and birthing facilities must be part of the Primary Care Provider Network that is linked to secondary and tertiary care providers. This shall include the availability of appropriate transport services and communication tools such as, but not limited to, telemedicine. For landlocked or mountainside community, manual carriage, animal driven carts or motorcycles must be made available. For shoreline and island communities, river crafts or motorboats must be made available. Use of satellite connection and wireless mesh network could be considered for areas without network coverage.

g. Hospitals shall have a Public Health Unit and a GIDA coordinator to ensure expedited consultation or provision of referral services. This will facilitate access and utilization of hospital services that is not readily available in the GIDA community.

2. Human Resource for Health (HRH)

a. Each GIDA barangay shall have at least a midwife who is trained and competent, either as a resident or on scheduled basis, to provide consistent and regular service at least 3 of the 5 working days of the week. If feasible, the health worker may reside in the GIDA community. Adequate amenities, safety, and privacy should be made available for their accommodation.

b. Recognition and incentives for health workers serving in GIDA shall be supported by the government. LGUs will be encouraged to provide additional incentives to those assigned to GIDA. This can be in the following forms:

• Travel and/or hazard allowances;

• Recognition and award system specific for GIDA health personnel. Awards can be in the form of grant for special projects; and

• Competency training such as BEmMONC, scholarship for higher education, and career development pathway.

c. Prioritize provision of scholarship programs for health-related courses to residents in GIDA, volunteer health workers including BHW, nutrition scholar, community health workers and their immediate family members. It may also include former traditional birth attendants and their immediate family members. Return service agreement must be signed and implemented.

• Selection of scholars shall focus on their willingness to serve and social responsibility of the student, low socio-economic status of the family and recommendations from the community. AcICHD

• Scholarship should include full tuition and other school fees, accommodation, and adequate living allowance.

3. Financing and Resource Allocation

a. The GIDA profiling tool shall be developed as a strategic tool that shall outline financial and human resource commitments to support GIDA activities.

b. LGUs will be encouraged to allocate funds equitably across barangays with specific attention to the health needs of GIDA communities. The mechanism of resource allocation shall be documented in the Local Investment Plan for Health. Adequate augmentation support by the DOH to LGUs should also be leveraged.

c. GIDA communities must be prioritized for PhilHealth enrolment.

d. The Philippine Health Insurance Corporation (PhilHealth) shall have an expedited accreditation process that ensures culturally sensitive and innovative interventions for health facilities in GIDA, including:

• A process to accredit network of health services, for example GIDA birthing facility as extension of an accredited RHU birthing facility;

• Contracting health facilities (within HCPN) to provide regular mobile health services to the communities, if possible; and

• Sub-contracting private health service providers and/or non-governmental organizations (NGOs) to provide part of essential health services.

4. Medical Products, Vaccines, Technologies

a. Essential medicines shall be equitably allocated and distributed for GIDA communities with health needs. Storage shall be located at an identified health facility nearest to the GIDA community. Dispensing of medicines must be done under the supervision of the Municipal Health Officer.

b. Specific to GIDA with high proportion of IPs, the complementary role of traditional/alternative medicines and healing practices to health services may be recognized. Appropriate documentation/data gathering, with the corresponding intellectual property protection, shall be a primordial concern.

5. Regulations of Health Facilities

a. Community-based Health Facility: Every GIDA must have a BHS/birthing facility designed to provide the essential health services. Due considerations shall be given to the increased cost of labor and hauling of construction materials due to the geographical isolation. The BHS/birthing facility must be designed in compliance to licensing of DOH and the accreditation standards of PhilHealth. In IP communities, the facility must also be designed to allow culture-sensitive health services.

If a barangay considered as GIDA is unable to sustain a BHS/birthing facility operation, adjoining GIDAs can form a small network, that is an inter-GIDA or inter-barangay health zone, to share the operation and maintenance of a BHS/birthing facility. TAIaHE

6. Leadership and Governance

a. The expanded LHB shall include IP/GIDA representatives. He/she shall be provided with orientation and/or training in basic development planning that pays close attention to the specific needs of the GIDA community. He/she shall be responsible for integrating GIDA specific initiatives, in consultation with the community, into the local health plan. The representatives in the consultation should have a balanced representation in terms of gender, age group and other social parameters. IP health plan should also be included.

b. The plan should contain evaluation of the health services needs of the GIDA community, the current health services in the community, identification of the gaps and strategic interventions to address the gaps. It should also contain clear estimates of the costs of all the strategic intervention and its funding source.

c. These initial steps are directed towards establishing a community-managed health system. To fully realize this, the province and city/municipal LHB must establish clear lines of accountability and support to HSS in GIDA. Point person for each strategic intervention must be identified. Regular review of the implementation during LHB meetings must be undertaken.

d. Aside from the LGU formal structures already mentioned, the LHB may also ask assistance from other government and non-government agencies, as well as private and public health service providers to develop, implement, and manage projects for GIDA health systems.

7. Health Information System

Inaccessibility of health services, policies and programs that are not culturally-sensitive, and inadequate health data specifically on IP are some of the main concerns in GIDA.

It is necessary to bring health services closer to GIDA/IP communities through capacitating potential health workers living in the area that they may deliver health services that are adaptive to their needs, behavior, and cultural beliefs. The following concerns on health information shall be given consideration:

a. Provision of information technology hardware like laptop computers or tablets for the GIDA health workers that they may use for reporting and evidence-based decision-making;

b. Provision of Basic Computer Training for midwives;

c. Development of software application for mobile phones or tablets (e.g., Electronic Medical Record (EMR); cDHAES

d. Health statistics and data, including medicine-reporting/recording, shall be disaggregated for IPs and non-IPs to guide prioritization for future program development and implementation;

e. Data Utilization Training for planning and decision-making;

f. Strengthening of surveillance system.