Guidelines on Public-Private Collaboration in Delivery of Health Services Including Family Planning for Women of Reproductive Age

May 10, 2006

DOH ADMINISTRATIVE ORDER NO. 2006-0008

 

I. BACKGROUND

The country has achieved considerable progress in improving health outcomes for women, particularly with respect to those outcomes associated with pregnancy and child bearing. This improvement is reflected in significant declines of one of the most important indicator of women's health, maternal mortality rate (MMR). National average MMR, which measures women's risks from dying at childbirth, has declined considerably from its high levels during the early period after Philippine independence to 209 maternal deaths per 100,000 live births in the 1987-1992 period, to 172 in the 1991-1997 period, to an estimated 138 in the most recent 1998-2002 period.

Despite this improvement, however, there are still too many Filipino women who die during pregnancy or childbirth given available knowledge, means and services for their proper care. One out of every 100 Filipino women is likely to die from maternity-related causes over her lifetime, and maternal deaths comprise as much as 14% of all deaths of women of reproductive age (15 to 49 years old). As a reflection of society's desire to make pregnancy and childbearing safer for women, among the Philippines' Millennium Development Goals (MDGs) is for MMR to decline to 112 maternal deaths per 100,000 live births by 2010 and lower still to 80 by 2015.

The Department of Health (DOH) has defined the package of essential health services that every Filipino woman should access and use in order to have a safe and healthy pregnancy and birth and therefore reduce the risk of maternal death. This package includes: (a) family planning counseling and provision of preferred method of child spacing; (b) antenatal care, tetanus toxoid immunization and micro-nutrient supplementation of pregnant women; (c) treatment of diseases and possible complications co-existing with pregnancies; (d) early detection and management of complicated pregnancies; (e) safe delivery and support to breastfeeding. The country's main strategy for attaining its MDG on reducing risks of maternal deaths consists of making this package of essential services with adequate quality available, accessible and utilized according to the needs of every woman of reproductive age.

Available information regarding the actual population-wide coverage of each of these essential services suggests that there is ample room for further expansion in women's use of these health services as soon as possible. Contraceptive prevalence rates (portion of all married women of reproductive age using a family method of their preference) needs to increase to 80% from 48% for all methods in 2003, and to 60% from 33% for modern methods only. Portion of all pregnant women with at least 4 antenatal visits needs to increase to 80% from 72% in 2003, while portion of pregnant women with at least two doses of tetanus toxoid immunization needs to increase even much more to 80% from 37% in 2003. Percentage of all deliveries with skilled attendance at birth also needs to increase to 70% from 54% in 2003. It is the judgment of public health experts that if the Philippines attains these targeted increases in population-wide coverage of these essential services as soon as possible, then the country should be able to achieve its 2010 and 2015 MDGs to reduce risks of maternal death, aside from contributing to securing other valuable benefits in terms of healthier newborns and children (reduced infant and child mortality) and reduced impoverishment due to illness or premature death (reduced poverty), among others. DcICEa

The scale of improvement needed from present levels to targeted levels of increased population-wide coverage of various essential health services for women of reproductive age is indicated by the following priorities: nearly a tripling of current tetanus toxoid immunization of pregnant women; a doubling of present contraceptive prevalence rates; a 20% increase over present coverage of skilled attendance of all births; and a 10% increase in current use of adequate antenatal care of all pregnancies. This scale and scope of improvement is deemed attainable by the Philippines but it will not be attainable by the Philippine public sector alone. Fortunately, the Philippines has a large, vigorous and progressive private sector in health that can contribute to the attainment of improved population-wide coverage of essential health services for women.

Of total 85,000 hospital beds in the country, nearly 40,000 are private hospital beds. Private physicians, nurses, pharmacists, midwives and other professional health providers are ubiquitously practicing their professions and providing care in most Philippine communities and localities. The private pharmaceutical market from where women obtain many beneficial goods, products and drugs amounts to a massive P65-70 billion in sales annually (2004 data). A 2000 survey of households indicated that of the 77% of households that reported recent use of a health facility, half used public facilities and the other half used private health facilities (including a small portion of private traditional healers). These data suggest the tremendous capacity for providing care to the population that is available in a private sector consisting of practitioners, facilities, hospitals and a vital and large drugs and pharmaceuticals industry.

Given the country's desire to expand total population-wide coverage of essential health services for women of reproductive age as a key strategy to achieve its MDG on reduced risks of maternal death, and the large available private sector capacity that can contribute to this expansion, the DOH recognizes the need for a national policy on public-private collaboration in delivery of health services to women of reproductive age. As the prime national agency for the protection and promotion of the nation's health, the DOH hereby formulates, advocates and implements such a policy after conducting requisite technical studies, consultations with various stakeholders and preparations for proper implementation.

II. STATEMENT OF POLICY

It is the national policy to establish and sustain a supportive public and professional opinion climate, conducive regulatory regime, fair health financing system, and responsive operating and business environment in the health sector that promote efficient, effective and equitable collaboration between public and private sectors delivering services necessary for population-wide coverage of essential health services to women of reproductive age at levels sufficient to reduce risks of maternal deaths.

III. GOAL and OBJECTIVE

A. Goal

To improve and sustain reduction of Filipino women's risks from dying due to maternal causes as measured by following:

• Decline of the maternal mortality rate consistent with meeting the country's commitment to this specific MDG in 2010 (MMR not higher than 112) and 2015 (MMR not higher than 80).

• Decline of the maternal mortality rate consistent with meeting the country's commitment to this specific MDG in 2010 (MMR not higher than 112) and 2015 (MMR not higher than 80).

• Expansion of population-wide coverage of the following essential health services:

• Family planning services: counseling and provision of preferred legal methods (contraceptive use of at least 60% for all modem methods)

• Maternal care services: antenatal care with tetanus toxoid immunization and micronutrient supplementation, plus early detection and management of complicated pregnancies (not less than 80% of all pregnancies), treatment of diseases and complications in pregnant women, safe delivery and support to breastfeeding (not less than 80% of births attended by professional health provider) IAcDET

B. Objective

To provide policy direction for the public-private collaboration in the health sector within the context of increasing share of private sector provisions in total population-wide coverage of essential health services for women of reproductive age (i.e., private sector share of total contraceptive use, antenatal care and skilled attendance at birth).

IV. SCOPE and COVERAGE

The policy encompasses the operation of all agencies comprising the Department of Health, including its attached agencies like the Philippine Health Insurance Corporation (PHIC) and the Commission on Population (POPCOM) upon concurrence by these agencies' respective governing Boards, which the Secretary of Health chairs. It also covers the operation of government health agencies under the various national agencies and departments (DepED, DOLE, DND, among others) as well as those under the local governments at province, city and municipal levels in so far as these agencies' health services operations are governed by technical guidelines and standards mandated by the DOH. It further covers private entities (persons and enterprises) engaged in the provision of health goods and services in so far as this aspect of their operations are similarly governed by technical guidelines and standards mandated by the DOH.

V. DEFINITION OF TERMS

1. Health sector — refers to health system, including all institutions, organizations, enterprises and entities involved in actions that protect, promote or advance health status of individuals or populations; conceptually includes all aspects of society that influence health status but operationally focuses on those entities specifically organized to provide or govern the provision of health services and goods.

2. Public sector — refers to health providers (individual practitioners, health centers, hospitals, organizational units, agencies) operating within the rules and regulations of the government and all providers under the administration and control of the DOH, other national agencies (DepED, DOLE, DND, etc.) or of local governments (provincial, city or municipal governments).

3. Private sector — refers to health providers and facilities (individual practitioners, clinics, hospitals, facilities, drug outlets) licensed and regulated under existing laws but otherwise operating outside the ownership or management of the government; includes the drugs and pharmaceutical industry, non-government organizations as well as proprietary enterprises providing health services as part of their activities.

5. *  Public health authorities — refers to government entities that have technical responsibility for monitoring, maintaining, protecting and advancing general health status of the population (or public health) within given political jurisdictions such as Municipal or City Health Office for a municipality or city, Provincial Health Office for a province, Center for Health Development (CHD) for a region, and the Department of Health for the whole nation. These entities — MHO, CHO, PHO, CHD and DOH — often have service provision and delivery activities, which are covered by their inclusion as public sector in health, and thus the emphasis in their being identified as public health authorities is in their technical governance function in the health sector.

6. Essential health services for women of reproductive age — refers to family planning services (i.e., counseling and provision of preferred legal methods) and maternal care services (i.e., antenatal care with tetanus toxoid immunization and micro-nutrient supplementation, plus early detection and management of complicated pregnancies, treatment of diseases and complications in pregnant women, safe delivery and support to breastfeeding) defined by the DOH as the package of essential health services for women aged 15-49 years old.

7. Inter-local health zone — refers to any form of institutional arrangement among different health providers and facilities serving a common population within a local geographic area under the jurisdiction of more than just one local government (e.g., multi-municipalities-province, municipalities-city-province, multi-provinces with component municipalities and cities), which meets the DOH's functional criteria on inter-LGU coordination of health service delivery. HEDCAS

VI. GENERAL GUIDELINES

A. Supportive Climate for Public Private Collaboration

1. DOH shall raise the awareness of the general public and promote informed consensus within the community of health professionals in order: (a) to support commonly shared health goals and aspirations of the nation and its component localities, and (b) to emphasize the vital necessity of wide, organized, and sustained cooperation and collaboration of everyone in the successful pursuit of these goals and aspirations. The DOH shall advocate the concept of one health sector serving the collective health of one community and nation. The official promulgation and wide dissemination of the National Objectives for Health, including the country's commitment to achieving the MDGs related to health, shall serve as a Core foundation for this central advocacy.

2. In support of attaining the specific MDG on reduced risks of maternal deaths, the DOH shall in due course issue new national technical program standards for family planning and maternal care that: (a) apply to public and private sectors; (b) adjust service arrangements to the changing and diverse local environments in health care delivery, and; (c) adequately reflect the increased importance of public-private collaboration in attainment of public health objectives.

In order to secure the widest possible support for these national technical program standards for family planning and maternal care and ensure willing compliance of the whole health sector, the DOH shall obtain the participation in, contribution to, and eventual endorsement of, these standards by the key national professional organizations of providers of these essential health services to women of reproductive age.

3. DOH entities that operate in various localities (such as Centers for Health Development and DOH-owned/managed hospitals) as well as PHIC and POPCOM field units in the regions are hereby instructed to jointly establish and maintain in their respective areas active forums and other social mechanisms for regular on-going dialogues among public and private providers in the locality in order to promote the concept of one health sector serving the collective health of one community and nation. These dialogues shall seek to improve sharing of information, promote common understanding, address barriers to collaboration and enhance mutual trust and respect within the health sector of each locality.

4. DOH shall assist public providers to recognize the benefits to them from collaborating with private providers. Public providers shall be encouraged to recognize the potential benefits from: (a) accessing specialized services available only in the private sector; (b) easing congestion from excessive workloads by referring some patients to the private sector; (c) securing opportunities for adapting useful innovations and practices pioneered in the private sector; (d) obtaining political support from the private sector in getting resources to meet their budgetary and operational needs; (e) success in securing availability of a complete range and package of services needed by the community using combined capabilities of both public and private sectors together.

5. DOH shall similarly assist private providers to also recognize the benefits for them from collaborating with the public sector. Private providers shall be encouraged to recognize the potential benefits from: (a) facilitating the referral to the public sector of some patients requiring subsidized care beyond their means to sustainably support; (b) accessing from the public sector the numbers and types of patients necessary for an adequate clinical training and research program; (c) obtaining through active collaboration with the public sector more favorable public perceptions as a responsible public service enterprise; (d) participating through close cooperation with public sector in policy advocacy and information sharing for health sector priorities and goals. cECaHA

B. Conducive Regulatory System

1. Within the limits and constraints of applicable laws, the DOH shall seek, in general and in an evolutionary manner, to eventually include explicit mandates for regulated providers to serve public health (or "public health mandates") in future formulation and implementation of all regulations within the health sector. Such "public health mandates" may eventually require regulated entities to perform, as part of their social obligation, certain functions such as the following: (a) to report to public health authorities critical information essential to proper disease surveillance and prevention in the community; (b) to provide to their patients, clients or customers the correct information from public health authorities; (c) to observe technical and clinical practices deemed by public health authorities as essential to effective disease control in the population; (d) to cooperate and participate in public service activities that protect or promote the general health of the community. As a matter of principle, the DOH shall seek to make the performance of certain tasks critical to the general advancement of the nation's collective health by collaborating with public health authorities an integral part of requirements that regulated professionals, organizations or enterprises must meet in order to operate within the health sector.

2. The regulation of professional practice in the field of health (i.e., practice of medicine, nursing, pharmacy, midwifery, laboratory technology, physical therapy, among others) shall continue to be governed by existing laws, institutions, rules, regulations and procedures. The DOH shall coordinate with authorities involved in the regulation of health professions in order to include in future standards and requirements in licensing such professionals their recognition and acceptance, regardless of sphere or area of practice, of their inherent obligation to contribute to meeting the shared health goals of the country through their collaboration with public health authorities.

3. The regulation of drugs and pharmaceuticals, hospitals and other health facilities shall also continue to be governed by existing laws, institutions, rules regulations and procedures. The regulatory agencies that are part of the DOH are hereby instructed to pursue in their future regulatory standards and practices any and all opportunities to integrate, whenever legally or administratively feasible, the performance of appropriate and relevant "public health mandates" by regulated entities.

4. PHIC is hereby requested to adopt a policy that, in future improvements of provider accreditation standards under the National Health Insurance Program (NHIP) and within the limits of applicable laws, it give due consideration to including explicit requirements for providers to demonstrate evidence of their organized collaboration with public health authorities in their catchment area in order to protect or promote the general health of the area's population.

C. Fair Health Financing System

1. As a general policy, the DOH shall seek to clearly distinguish, on one hand, the financing of public health authorities' functions (referring to the essential technical functions necessary for effective governance of the health sector at national, regional, provincial, city and municipal levels) from, on the other hand, the financing of health provision functions (referring to the public and private provider functions in delivering services and goods necessary for health).

Adequate financing of public health authorities' functions shall be mainly supported by a sufficient share in the annual tax-financed government budgets (portions of the DOH budget for functions at national and regional levels, of the provincial government budget for functions at the provincial level, and of the city or municipal government budgets for functions at the city or municipal levels) with supplementary financing from revenues through cost recovery fees and charges for some of these functions (such as regulatory and technical support services). IEAacT

2. In the financing of health care provision, delivery and use, which accounts for the overwhelming bulk of health sector expenditures, DOH shall in general promote greater efficiency, effectiveness and equity through enhanced public-private collaboration.

3. With regards to the portion of the DOH budget, authorized by Congress to be used for health service delivery (such as operation of DOH hospitals, provision of goods and services as part of national health programs), the DOH shall progressively increase the share used to procure goods and services from the private sector, rather than itself produce such goods and services. The DOH via this policy can thus modestly contribute to increasing the assistance of the private sector in the overall population-wide coverage of essential health services using national and regional level public funding to finance private sector services.

4. With regards to portions of LGU budgets, authorized by their respective local legislative councils to be used for health services delivery (such as operation of local hospitals, health centers, barangay health stations and other local health service activities and provision of goods), the DOH shall encourage these LGUs, through modeling, education, technical advise and advocacy, to explore and consider alternative and cost-effective means for using local public funds to increase population-wide coverage of essential health services via contracting or procurement of goods and services from the private sector. Should LGUs respond positively and strongly to this direction, LGU spending for health can be a major factor in increasing private sector contribution to population-wide coverage of essential health services.

5. With regards to health benefit payments of Philhealth under NHIP, the DOH supports the continued and prudent expansion of overall benefit spending currently ongoing which equally cover costs of whichever public and private providers are used by Philhealth beneficiaries. In the future, when Philhealth shall have developed additional standards for accreditation that considers public-private collaboration, it might then be possible to reward through the benefit payment mechanism those providers that adopt the most efficient, effective and equitable public-private collaboration practices.

D. Responsive Operating And Business Environment

1. In order to assure that women without the means to pay for care (such as those with insufficient incomes to pay out of pocket, and without Philhealth insurance coverage or without an employer-supported health benefit) are nonetheless able to access and use family planning and maternal care services essential for them to avoid increased risks of maternal mortality, the DOH shall seek to install nationwide a safety net level of free family planning and maternal care services available at each locality supported by an adequate level of public funding and provided either through services of the public sector or through publicly financed services of the private sector.

2. CHD shall arrange and assemble this safety net level of free (publicly funded) family planning and maternal care services at each locality by: (a) having the DOH budget and DOH hospitals cover part of the needed services; (b) securing provincial government support to cover another part through the provincial health budget; and (c) securing city and municipal governments support to cover the final part through their respective city or municipal health budgets. This arrangement for safety net services in each locality should have specific quantitative target coverage, an agreed criteria for priority beneficiaries and preferred users, and explicit functional assignments among DOH, province, and city/municipality funding and providers for each essential health service included in the package for women of reproductive age. EaICAD

3. CHD chiefs of DOH hospitals and PHIC area managers shall cooperate to determine the level of services needed beyond the scope of the safety net arrangements. The service needs for family planning and maternal care of other women of reproductive age that are beyond the scope of coverage of the safety net arrangement shall be principally met by the private sector, which shall be funded by Philhealth benefit payments for enrolled beneficiaries, supplemented by employer-supported benefits for those with employers, and by out of pocket payment for costs not covered by other sources. Private sector collaboration with the public sector shall be arranged to ensure that all women of reproductive age have continued access to essential health services within the safety net as well as beyond its coverage. A key policy at the local level will be the routine and smooth referral by the public sector to the private sector of any client or potential user that is beyond the scope of coverage of the safety net arrangements in place at the locality.

4. DOH shall work with LGUs to promote further expansion of private sources of services for family planning and maternal care in their respective localities. This shall include both workplace-based, employer-supported providers as well as freestanding fee-for-service providers in the community. DOH shall encourage LGUs to adopt local policies to officially encourage local private providers to meet service needs that LGUs cannot cover, to facilitate cross-referrals between public and private sectors, and to create a business-friendly environment for private health providers.

5. DOH shall implement these policies first in localities most likely to respond to opportunities and challenges. The most urgent geographic priorities where the safety net coverage for family planning services needs to be arranged and also where rapid growth and business response by the private sector is most needed to meet existing demands are in those provinces and cities where donated condoms, pills and injectables being used by current users are scheduled to be phased out starting the last quarter of 2006. In these affected localities, increase in unmet needs for family planning should be prevented by insuring that: (a) the safety net arrangements are in place as soon as possible; (b) alternative private sources of service are made available for those beyond the coverage of the safety net arrangement; and (c) public-private collaboration functions well in meeting the needs of current and future new users of various family planning methods. The Centers of Health Development responsible for these provinces and cities are therefore correspondingly advised to give these affected localities utmost priority.

6. DOH shall encourage localities to make their inter-local health zones functional first in delivering family planning and maternal care services to women of reproductive age. Such inter-local health zones should integrate both public and private providers in their organizational and service delivery arrangements. Publicly-funded and/or publicly provided services in the inter-local health zone should form core of the safety net arrangement and private providers as well as cost-recovery public provisions should meet whatever needs are beyond the safety net arrangement.

VII. ROLES and RESPONSIBILITIES

The roles and responsibilities of DOH, local government units and private partners relative to the establishment of public private collaboration in health are as follows:

A. Department Of Health

1. Central Office

a. Policy and Standards Development Team for Service Delivery

• Responsible for the overall development and management of implementing the public-private collaboration for women's health services;

• Formulate strategic plans, programs, projects including mechanisms to operationalize the public-private collaboration;

• Conduct policy forums to advocate concepts and thrust, address concerns and share good practices on public-private collaboration; CAaSED

• Develop technical standards and guidelines on collaborative health service delivery that are appropriate for both public and private entities; and

• Develop monitoring and evaluation tools and systems to track progress of collaboration efforts.

b. Policy and Standards Development Team for Financing

• Responsible for overseeing the development of fair health financing system for public-private collaboration thrust and efforts;

• Develop financing schemes and models that will increase the contribution of public-private collaboration in the overall population wide coverage of essential health services;

• Advocate to government authorities and private entities increase in budget shares or financing for purchase of goods and services in the population wide coverage provision of essential health services; and

• Review and develop policies to expand PHIC benefit package for Family Planning and Maternal care.

c. Policy and Standards Development Team for Regulation

• Oversee the integration of "public health mandates" in the development of new regulatory standards for drugs and pharmaceuticals, hospitals and other health facilities;

• Coordinate with and advocate to public health authorities and other regulating agencies to include "public health mandates" in the regulations of professionals, organizations or enterprises operating within the health sector; and

• Include explicit requirements of demonstrated evidence of collaboration with public health authorities in the development of new PHIC accreditation system for providers.

d. Sectoral Management and Coordination Team

• Provide management support and coordinating function to the implementation of public-private collaboration in the health system;

• Ensure linkage and adoption of public-private collaboration approach in the overall Fourmula One thrusts and efforts; and

• Formulate policies and guidelines that will create responsive operating and business environment for public-private collaboration.

2. Center for Health Development

• Formulate strategic plans to implement the public-private collaboration for women's health services in the region;

• Conduct advocacy campaigns and forums on public-private collaboration among LGUs and private partners;

• Provide technical assistance in setting up public-private collaboration in particular localities;

• Arrange and assemble safety net level of free family planning and maternal care services at each locality in the region;

• Provide resources for coordination and critical health service provision functions; and DacTEH

• Monitor and evaluate the development and implementation of the collaboration efforts.

B. Local Government Units (Province and City) and Autonomous Region for Muslim Mindanao (ARMM)

• Ensure that the package of essential health services for women are available to its constituents;

• Establish coordination mechanism with private partners;

• Develop and implement strategic plans and projects with partners on public-private collaboration;

• Provide resources for coordination and other critical health service functions particularly for safety net level;

• Formulate and issue local policies, ordinances and resolutions supportive of collaboration efforts; and

• Coordinate with CHD in ensuring safety net level of free family planning and maternal care services in their area.

• Formulate and issue local policies, ordinances and resolutions supportive of collaboration efforts; and

• Coordinate with CHD in ensuring safety net level of free family planning and maternal care services in their area.

C. Private Sector

• Develop and strengthen policies and programs on maternal care services and family planning services in their respective associations or organizations in line with national health policies, standards and mandates;

• Recommend policies, programs, standards and mechanisms to increase share of private sector provision in the total population-wide coverage of essential health services for women of reproductive age;

• Participate in the development of technical standards, regulations and mechanisms related to the inclusion of public health mandates in regulated professionals, organizations or enterprises;

• Coordinate with CHD, LGUs and other local public and private entities in the development and implementation of tasks related to the advancement of essential health services for women, public health mandates, in each locality;

• Supplement identified available resources and technical assistance deeded; and

• Ensure continued access to essential health services for women of reproductive age.

VIII. REPEALING CLAUSE

The provisions of previous orders inconsistent or contrary with the provisions of this administrative order are hereby revoked, revised, modified accordingly, rescinded and/or repealed. AcICHD

IX EFFECTIVITY

This order shall take effect immediately.

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