Guidelines on the Development of Local Investment Plans for Health

May 21, 2020

DOH ADMINISTRATIVE ORDER NO. 2020-0022

 

I. BACKGROUND

In 2005, initial 16 convergence provinces were guided to develop Province-wide Investment Plans for Health (PIPH) to achieve health sector goals of better health outcomes, financial risk protection and responsive health system. The strategy of health investment planning was later expanded to all other provinces, highly urbanized cities (HUCs) and independent component cities (ICCs). The Province-/City-wide Investment Plans (P/CIPH) for Health were key instruments in forging DOH and Local Government Unit (LGU) partnership to achieve health sector goals.

The P/CIPH has since been institutionalized and renamed as Local Investment Plan for Health (LIPH), a generic term to cover any level of LGU developing its investment plan for health. The time frame of the plan has also been changed to three years to coincide with the term of the Local Chief Executives (LCEs).

In 2018, Administrative Order 2018-0014 or the "Strategic Framework and Implementing Guidelines for FOURmula One Plus for Health" was issued. It mandates that technical assistance from the DOH be consolidated and matched with the needs outlined in the LIPH.

With the passage of RA 11223 or the Universal Health Care (UHC) Act and its Implementing Rules and Regulations (IRR) in 2019, the significance of LIPH is highlighted. Section 22 of the UHC Act states that "the national government, through the DOH, shall provide financial and non-financial matching grants . . . in accordance with the approved province-wide and city-wide health investment plans."

There is an urgent need to update the LIPH guidelines to support the progressive realization of the UHC goals and objectives.

II. OBJECTIVE

This Order aims to provide guidelines and procedures in the development of LIPHs and Annual Operational Plans (AOPs) for partners and stakeholders in support of the implementation and achievement of UHC. TIADCc

III. SCOPE OF APPLICATION

This Order shall apply to offices and attached agencies under the DOH, other National Government Agencies (NGAs), LGUs, Non-Government Organizations (NGOs)/Civil Society Organizations (CSOs), health partners and donors, and all others concerned.

In the case of Bangsamoro Autonomous Region for Muslim Mindanao (BARMM), the adoption of the local investment planning for health for LGUs under the BARMM shall be in accordance with RA No. 11054 or the Organic Law for BARMM and subsequent laws and issuances.

IV. DEFINITION OF TERMS

A. Annual Operational Plan (AOP) — refers to the yearly translation of the Local Investment Plan for Health, which details the programs, plans and activities (PPAs) and systems interventions that are to be implemented in Province/City-Wide Health Systems (P/CWHS) in a particular year.

B. City-wide Health System (CWHS) — refers to the Highly Urbanized City (HUC) — and Independent Component City (ICC)-wide health system. This includes the health offices, health centers or stations, hospitals and other city-managed health care providers under the administrative and technical supervision of the City Health Board (CHB).

C. Contracting — refers to a process where providers and networks are engaged to commit and deliver quality health services at agreed costs, cost sharing and quantity in compliance with prescribed standards.

D. Individual-based health services — refer to health services which can be accessed within a health facility or remotely, through the use of digital technologies, that can be definitively traced back to one recipient, has limited effect at the population level, and do not alter the underlying cause of illness. These services include ambulatory and inpatient care, medicines, laboratory tests and procedures, among others. AIDSTE

E. LGU Investment Needs — refers to the matrix of needs/requirements to address health gaps and meet targets and objectives, with corresponding fund requirements and proposed fund sources, such as DOH, LGU and other stakeholders.

F. Local Health System — refers to all health offices, facilities and services, human resources, and other operations relating to health under the management of the LGUs to promote, restore or maintain health.

G. Local Investment Plan for Health (LIPH) — refers to a medium-term public investment plan for health that specifies the strategic direction of the concerned LGU for the next three years in terms of improving health service delivery, strengthening the health systems operations and addressing social determinants of health, and specifies actions and commitments of different local stakeholders.

H. Menu of Assistance — Program priorities, directions and thrusts, and list of available specific DOH support for LGUs, such as health facilities development and information and communications technology (ICT), Human Resource for Health deployment and scholarships, drugs/medicines and commodities, and other forms of technical assistance, with corresponding unit cost and formula used for LGU allocation, used as input to local planning.

I. Population-based health services — refer to interventions such as health promotion, disease surveillance, and vector control, which have population groups as recipients.

J. Province-wide Health System (PWHS) — composed of municipal and component city health systems; which includes: the Provincial, Component City and Municipal Health Offices; Provincial, Component City, District and Municipal Hospitals; Rural Health Units/Health Centers, Barangay Health Stations; and, other LGU-managed health care providers under the administrative and technical supervision of the Provincial Health Board (PHB).

K. Special Health Fund (SHF) — refers to a pool of financial resources at the P/CWHS intended to finance health services and health systems operations.

L. Technical Management Committee (TMC) — composed of technical staff from the member health facilities, DMO assigned in municipalities/component cities, patient representative and others, health officers of member municipalities/component cities, and representative from the private sector. AaCTcI

M. Terms of Partnership (TOP) — refers to a legal instrument used to formalize the agreement on the implementation of the AOP between the DOH and LGU.

V. GENERAL GUIDELINES

A. LIPH Development

1. The LIPH shall be anchored on the following UHC principles: (a) integrated and comprehensive approach to ensure health literacy, healthy living conditions, and protection from hazards and risks; (b) health care model that provides comprehensive health services without causing financial hardship; (c) whole-of-system, whole-of-government, whole-of-society approach in the development, implementation and monitoring and evaluation of health plans; and, (d) people-oriented approach centered on people's needs and well-being.

2. The LIPH process is a bottom-up planning procedure that allows lower level units such as barangays, municipalities and component cities to have their plans incorporated in the province-wide health plan; or in the case of highly urbanized cities and independent component cities, to have their plans consolidated in the city-wide health plan. It shall have clear health goals and objectives as part of the overall 3-year strategic plan of the LGU, which focuses on the strengthening of the local health system covering all dimensions of the building blocks of the health system.

3. The LIPH shall be developed by every LGU based on the local health epidemiology and situation, local objectives for health, and guided by the AmBisyon Natin 2040, Sustainable Development Goals (SDG), Philippine Development Plan (PDP), and the National Objectives for Health (NOH).

4. The LIPH shall serve as the costed strategic plan of the P/CWHS for the implementation of the UHC, covering the needs of all its municipalities (for provinces) and barangays (for cities).

5. As the primary local health plan reference, it shall also serve as the basis for health inputs to the Regional Development Plan, and the Local Development Investment Program (LDIP)/Comprehensive Development Plan (CDP).

6. The LIPH shall address the health needs of the majority of the local population and equally provide consideration to the health needs of the vulnerable population such as, but not limited to, population in Geographically Isolated and Disadvantaged Areas (GIDA), Indigenous Cultural Communities/Indigenous Peoples (ICC/IP), indigents, senior citizens, PWDs, women, and children. It shall also include activities on intra-governmental, civil society engagement and private sector collaboration to address the social determinants of health. EcTCAD

B. LIPH Implementation

1. The LIPH shall maximize local and national resources towards the development of a responsive local health system.

2. The LIPH shall be translated into three Annual Operational Plans (AOPs).

3. The Terms of Partnership (TOP) shall serve as the contractual arrangement between DOH and the LGUs in the provision of grants.

C. Aligning DOH Plans and Budget to the AOPs

1. The AOPs shall be considered by the DOH in its yearly budget proposals, with appropriate feedback provided to LGUs.

2. The AOPs shall be the basis of financial and non-financial grants from the National Government, particularly DOH, and other health partners.

VI. SPECIFIC GUIDELINES

A. Organization of LGU Planning Teams

1. To ensure the development, implementation, monitoring and evaluation of the LIPH, an LGU planning team shall be organized which may be composed of, but not limited to, the following:

a. Municipality/Component City

i. Health Officer, Development Management Officer (DMO) assigned in Municipal/City DOH Representative, Municipal/City Planning and Development Coordinator, Councilor for Health, Chief of LGU Hospital (if any), Budget Officer/Accountant, and representative/s from ICC/IP, NGOs/CSOs, private sector, and other key partners;

b. Sub-provincial Health System, as applicable

i. Technical Management Committee (TMC), composed of technical staff from the member health facilities, DMO assigned in municipalities/component cities, patient representative and others, health officers of member municipalities/component cities, and representative from the private sector; HSAcaE

c. Province/HUC/ICC

i. Health Officer, DMO assigned to the Province/City, Planning and Development Coordinator, Councilor for Health, Chief of Provincial/HUC/ICC Hospital, Budget Officer/Accountant/Treasurer, and representative/s from ICC/IP, NGOs/CSOs, private sector, and other key partners.

2. The LGU Planning Team shall be supported by an appropriate policy such as an Executive Order (EO) or a Sanggunian Resolution, which defines the roles and responsibilities, the funding allotment, and other logistical resources to ensure the functionality of the team.

B. LIPH Development

The LIPH process (Figure 1) shall be participatory and inclusive, bottom-up, and province/city-wide in scope.

 

Figure 1: LIPH Process

1. Call to Plan

a. The Center for Health Development (CHD) shall initiate the call for LGUs to formulate their LIPH;

b. The Provincial/City Health Office shall initiate the formulation of the LIPH of the P/CWHS. These plans shall be aligned with the LDIP/CDP of the concerned LGUs;

c. Municipal and Component City Health Offices shall likewise initiate the formulation of their municipal/city investment plans for health. HESIcT

2. Local Health Planning

The LIPH shall follow the planning process of situational analysis, identification of needs based on accurate and verifiable data, identification of appropriate and evidence-based strategies and determining investment costs and sources of fund.

a. Situational Analysis

Situational analysis shall include a review of current local program and health outcomes and system performance, namely: SDGs; PDP; NOH; program strategic plans; Field Health Service Information System (FHSIS); LGU Health Scorecard benchmarks; previous LIPH/AOPs; and other LGU health or health-related plans such as the Disaster Risk Reduction and Management Plan for Health (DRRM-H), Executive Legislative Agenda (ELA), LDIP, CDP, and Annual Investment Program (AIP); and, social determinants of health and other health-related data. This shall also include analysis of the internal and external environment

B. Identification of gaps, LGU investment needs, strategies and cost requirements

i. The vision, mission, goals and strategic objectives shall be developed based on the local health situation;

ii. Strategies and interventions shall be identified based on gaps and priorities;

iii. Strategies and interventions shall include both population-based and individual-based health services;

iv. Where available, health needs/activities in Ancestral Domain Sustainable Development and Protection Plan (ADSDPP)/Ancestral Domain Investment Plan for Health (ADIPH) shall be considered. Copies of these plans may be secured from the National Commission on Indigenous Peoples (NCIP) Provincial Service Centers; caITAC

v. DOH National program managers (NPMs) shall provide a menu of assistance to CHD program managers; this shall include program directions, priorities and thrusts, costing and guide for computation for allocation of goods and services, list/information on DOH commitment on technical assistance (e.g., health facility development and ICT, Human Resource for Health deployment, commodities, training, others) or historical data on such, to serve as guide for the LGUs during planning workshops;

vi. LGUs shall utilize the menu of assistance as one of the bases for planning and costing of interventions;

vii. LGUs shall map available resources for health, such as LGU general fund, PhilHealth income, special health fund, DOH grants, and development partners' assistance;

viii. Complementation of existing resources from the private sector shall be taken into account; and

ix. LGUs may include unfunded interventions in the LIPH for fund sourcing.

c. Province/HUC/ICC consolidation, writing, and submission of LIPH

i. The Province/HUC/ICC Planning Team shall consolidate and incorporate health plans and health needs from the different health units, hospitals and facilities, and consider inputs from different stakeholders and population groups:

(a) Review of municipal/component city investment plans for health shall be conducted by the DMO assigned in Municipal/City, together with the LGU planning team prior to submission to the Province/HUC/ICC Planning Team for consolidation;

(b) Municipalities and Component Cities that opted to form sub-provincial health systems shall submit a consolidated LIPH to the TMC; and ICHDca

(c) Review of the sub-provincial health system LIPH shall be conducted by the TMC prior to submission to the Province Planning Team for consolidation.

ii. The Province/HUC/ICC Planning Team shall submit the consolidated LIPH to the Provincial/City DOH Office (P/CDOHO) for joint review; and

iii. Planning forms, content outlines, templates and timelines for LIPH, and updates thereof, shall be issued separately by the DOH.

3. Review and Appraisal of the LIPH

The LIPH of the P/CWHS shall undergo the following review and appraisal process:

a. Review by the Province/HUC/ICC Planning Team and Provincial/City DOH Representatives

i. Review of the plan shall be jointly undertaken by the Province/HUC/ICC Planning Team and Program Managers together with the DMO assigned to the Province/City, and other stakeholders; and

ii. If the plan passes the review or has minor corrections only, the PHO/CHO shall forward the plan to the CHD for appraisal. Otherwise, the plan shall be revised to incorporate corrections and recommendations. Technical assistance from the DMO assigned to the Province/City is critical in this case. cDHAES

b. CHD Appraisal

i. Appraisal shall be undertaken by the CHD using an appraisal tool, which shall be issued in a separate memorandum;

ii. The CHD shall convene an Appraisal Team composed of, but not limited to the following:

(a) Assistant CHD Director;

(b) Division Chiefs;

(c) LIPH Coordinator;

(d) Planning Officer;

(e) Cluster Heads/CHD PMs;

(f) DMO assigned to the Province/City;

(g) Hospital Representative/s; and

(h) CHD Budget Officer/Accountant.

iii. Development Partners working with LGUs in the Region, and other key stakeholders may be invited to participate in the appraisal;

iv. If the plan passes the appraisal or has minor corrections only, the LIPH Coordinator shall return the plan to the PHO/CHO to facilitate approval. Otherwise, the plan shall be revised to incorporate corrections and recommendations. Technical assistance from the Province/City DOH representatives and CHD Program Managers is critical in this case.

4. Concurrence of the Plan

a. The Province/HUC/ICC Planning Team shall incorporate the comments of the CHD Appraisal Team, if any, and submit the revised/enhanced LIPH to the Provincial/City Health Board (P/CHB) for approval; ASEcHI

b. The P/CHB shall endorse the approved LIPH to the CHD for concurrence;

c. The P/CHB shall ensure the inclusion and harmonization of the LIPH in their LDIP/CDP.

C. LIPH Implementation

The LIPH shall be translated into three detailed AOPs, for Year 1, Year 2 and Year 3 of the LIPH period.

Figure 2: AOP Process

1. Translation of the LIPH into the AOP

The AOP shall adopt the same LIPH process but with provisions for contractual arrangement, plan implementation and monitoring (Figure 2):

a. The AOPs shall be anchored on the LIPH;

b. The Year 1 AOP shall be developed in the same year as the LIPH is developed;

c. The Years 2 and 3 AOPs shall update the LIPH, highlighting additional investments, which were not previously indicated in the LIPH. Adjustments may include emerging needs, new priorities and directions, availability of new sources of investment funding, or unimplemented programs and projects from the previous year's AOP;

d. The AOP shall be aligned with the LGU's Annual Investment Plan (AIP) to ensure LGU budget allocation; and

e. A separate guideline shall be issued by the DOH for priorities and thrusts, timelines, and revision/updating of planning forms for each AOP year. ITAaHc

2. Contractual Arrangement

a. The P/CHB and the CHD represented by the Regional Director shall enter into a contractual arrangement for the implementation of the AOP;

b. The Terms of Partnership (TOP) shall be the legal instrument for the contractual arrangement;

c. A separate policy for contracting P/CWHS and template for the TOP shall be issued by the DOH.

3. Plan Implementation

The Province/City/Municipal Health Offices shall lead the AOP implementation, in coordination with the CHD, and all other stakeholders.

D. LIPH Monitoring and Evaluation

1. The LIPH/AOP Monitoring Team shall be composed of LGU Health Officers, Provincial/City DOH Representatives and CHD staff. Other stakeholders shall be invited to participate in monitoring activities.

2. The following shall be covered in the monitoring:

a. Status of physical accomplishment of PPAs (e.g., PPAs of major health programs implemented or not implemented on a target period);

b. DOH assistance particularly for the major cost drivers/investments, namely: health facilities development and ICT, human resource for health, commodities, other technical assistance and major programs, project, activities (PPAs) (e.g., comparison of LGU Investment Needs for major health programs against actual assistance provided by the DOH thereto);

c. Local counterpart through the AIP (e.g., comparison of LGU counterpart on major health programs against actual health programs funded through the AIP);

d. Other areas that may be identified as necessary to be monitored.

3. The monitoring may include the conduct of systems or program-based Program Implementation Review (PIR), LGU Health Scorecard review, regular staff meetings, submission of monitoring reports, review of implementation evidences, among others.

E. Aligning DOH Plans and Budget to the AOPs

The AOP shall be considered in the DOH and CHD budget proposals through the following processes (Figure 3): CHTAIc

Figure 3: Aligning of DOH Plans and Budget to the AOP

1. LGU Submission of Investment Needs to CHDs

a. LGU investment needs with corresponding fund requirements shall be identified based on situational and gaps analyses and desired health targets and objects; the forms for the AOP and LGU investment needs are the same.

b. LGU investment needs shall be categorized into the following:

i. health facility development and ICT;

ii. human resource for health deployment and scholarships;

iii. health commodities; and

iv. other technical assistance.

c. Categorization of investment needs may be revised/updated, if deemed necessary for ease of planning and submission.

d. Possible fund sources for these investment needs shall be identified.

e. The Province/City Health Officer shall submit a copy of the LGU investment needs to the DMO assigned to the Province/City.

f. The DMO assigned to the Province/City shall review and validate the LGU investment needs.

2. CHD Review of LGU Investment Needs

a. The DMO assigned to the Province/City shall forward the LGU Investment Needs to the CHD, through the LIPH Coordinator, who shall distribute these to the CHD program managers.

b. The CHD program managers shall review and validate the LGU investment needs, and prioritize incorporation in the CHD Budget Proposal and summarize Program Investment Needs per LGU. EATCcI

c. The CHD program managers shall inform the LGUs of the specific items included in the CHD Budget Proposal through the CHD LIPH Coordinator which becomes the basis for AOP revision/enhancement.

d. The CHD LIPH Coordinator and Planning Officer shall consolidate the LGU investment needs, properly noting which of these have been incorporated into the CHD Budget Proposal, for submission to the Regional Development Council (RDC).

e. The CHD Director shall endorse the LGU Investment Needs to the DOH Central Office.

3. Central Office Review

The CHD LIPH Coordinator shall forward the duly vetted LGU Investment Needs to BLHSD.

a. The BLHSD shall distribute the LGU Investment Needs to appropriate DOH Offices/national program managers (NPMs).

b. The national program managers shall review the LGU Investment Needs and prioritize incorporation of these needs in the DOH Central Office (DOH-CO) budget proposal.

c. The national program managers shall inform the CHD program managers of the specific items included in the DOH-CO budget proposal, copy furnished to the BLHSD.

d. The CHD program managers shall relay the same to the LIPH Coordinator.

e. The national program managers shall submit their respective budget proposals to the Health Policy Development and Planning Bureau (HPDPB).

f. The HPDPB shall follow the usual national planning process and submission of national budget proposal to DBM.

4. Feedback to LGUs

a. The CHD LIPH Coordinators and program managers shall consolidate feedback from national program managers and CHD program managers by LGU (Province/HUC/ICC), and forward these to the Province/City DOH Office and LGUs concerned, copy furnished the BLHSD. DHITCc

b. LGUs shall take note which of their proposals have been incorporated in DOH-CO and CHD budget proposals and update/revise their proposed AOPs.

c. The regular AOP process and timelines shall then follow.

VII. ROLES AND RESPONSIBILITIES

The following shall be the roles and responsibilities of key offices and personnel pertaining to LIPH and AOP processes:

A. DOH Central Office

1. Bureau of Local Health Systems Development (BLHSD)

a. Steer and spearhead the LIPH/AOP process nationally;

b. Develop guidelines on the LIPH/AOP process, including forms, tools, and templates, in consultation with relevant stakeholders;

c. Provide technical assistance to DOH Central Office and Bureaus, CHD LIPH Coordinators and key partners, as may be requested, on the LIPH/AOP processes;

d. Lead in the conduct of monitoring of DOH CHDs, LGUs and MOH-BARMM on LIPH/AOP implementation and set-up feedback/reporting mechanisms.

2. Field Implementation and Coordination Team (FICT)

Oversee the development, implementation, monitoring and evaluation of LIPH through the Centers for Health Development.

3. National Program Managers cEaSHC

a. Provide program directions and strategies, and information needed for technical assistance in local planning workshops;

b. Furnish CHD program managers with menu of assistance and commodities, with formulae and standard costs for the LGU's reference in identifying their needs;

c. Use the AOP/LGU investment needs to identify and allocate assistance/support to LGUs through the CHDs;

d. Ensure that national budget proposals are based on AOP/LGU investment needs.

4. Health Policy Development and Planning Bureau (HPDPB)

a. Steers and spearheads the overall health planning process;

b. Ensures the alignment of national health plans to the LIPH through guidelines, reviews and monitoring and evaluation;

c. Conducts assessments of the translation of investments into desired health outcomes.

B. DOH Center for Health Development (CHD)

1. CHD Director

a. Steer and spearhead the LIPH/AOP process in the Region;

b. Provide directions to CHD PMs to utilize the LIPHs/AOPs in program planning and budgeting;

c. Advocate the LIPH process to the Local Chief Executives and Local Health Officers;

d. Ensure the monitoring of LIPH implementation by facilitating the necessary technical assistance, resources, and personnel mobilization. CTIEac

2. CHD LIPH Coordinator

a. Provide technical assistance to CHD staff, LGUs and key partners in the region, as may be requested, on the LIPH/AOP processes;

b. Provide copies of LIPHs/AOPs/LGU investment needs to CHD program managers, and key partners for use as basis for technical assistance, and priority inclusion in the CHD budget proposal;

c. Submit LIPHs/AOPs/LGU investment needs to DOH-CO (BLHSD);

d. Coordinate with PDOHOs/DOH Representatives, CHD Accountant/Budget Officers the submission of Fund Utilization Report (FUR) for transferred funds;

e. Convene and coordinate activities of the CHD pertaining to LIPH/AOP processes.

3. CHD Program Managers

a. Provide Provincial/City DOH Representatives and LGUs with program directions, strategies, menu of assistance and commodities, with formulae and standard costs for the LGU's reference in identifying their needs;

b. Provide technical guidance in the LGU Planning Workshops and planning appraisal;

c. Review LIPHs/AOPs/LGU investment needs, prioritize and incorporate these in the CHD budget proposal;

d. Incorporate the monitoring of LIPH/AOP implementation and fund utilization as part of regular monitoring of program implementation.

4. CHD Planning Officer

a. Work in partnership with the LIPH Coordinator in providing technical assistance on plan development to Provincial/City DOH Representatives and LGUs, conduct of appraisal of LIPHs/AOPs, and monitoring and evaluation;

b. Work together with the LIPH Coordinator in consolidating LGU investment needs for submission to BLHSD. SaCIDT

5. DMO assigned in Municipalities/Cities

a. Assist LGUs in the development of their LIPHs/AOPs;

b. Review and validate LGU investment needs as appropriate to LGU context and health situation, in coordination with local health officers;

c. Organize Province/City level review of the LIPH/AOP;

d. Facilitate the timely submission of LIPH/AOP/LGU investment needs to the CHD LIPH Coordinator;

e. Monitor plan implementation and fund utilization in partnership and coordination with the PHO/CHO/Budget Officer/Accountant and the CHD LIPH Coordinator and Program Managers;

f. Submit reports on plan development, implementation, fund utilization, and other reports, as may be required, to the CHD, on a timely manner.

C. Local Government Units

1. Province/HUC/ICC Health Boards

a. Set the policy directions for the development and implementation of the LIPH/AOP;

b. Ensure the inclusion of the LIPH/AOP in local development plans (LDIP/AIP);

c. Ensure that development, approval and implementation of LIPH/AOP and other matters relating thereto, are regularly taken up in P/CHB meetings.

2. Province /HUC/ICC Health Offices

a. Organize/mobilize teams for planning, implementation and monitoring and evaluation;

b. Provide technical assistance to municipal/component city/district/barangay, in coordination with the Provincial/City DOH Office;

c. Include municipal/component city/district/barangay and hospital plans in the Province/HUCs/ICC LIPH;

d. Review and validate LGU investment needs prior to submission to CHD; cHECAS

e. Develop respective LIPH/AOP based on rational, realistic and participatory planning;

f. Implement, provide counterpart funding, monitor implementation and fund utilization of the LIPH/AOP.

VIII. 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.

IX. REPEALING CLAUSE

All Orders, rules, regulations, and other related issuances 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.

X. EFFECTIVITY

This Order shall take effect immediately.

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