National Program Support for Kalusugan Pangkalahatan/ Universal Health Care

Indigenous People’s Plan

Revised Draft

November 25, 2011

BACKGROUND

This Indigenous Peoples Plan aims to ensure compliance of the National Program Support for Kalusugan Pangakalahatan/Universal Health Care with the Philippines Indigenous Peoples Rights Act (1997) and the World Bank’s OP/BP 4.10 on Indigenous People’s (IPs).

Policy Context

The Project will adopt the definition of indigenous peoples under the Philippines’ Indigenous People’s Act (Republic Act No. 8371)[1] which states that IPs are: “… a group of people or homogenous societies identified by self-ascription and ascription by other, who have continuously lived as organized community on communally bounded and defined territory, and who have, under claims of ownership since time immemorial, occupied, possessed customs, tradition and other distinctive cultural traits, or who have, through resistance to political, social and cultural inroads of colonization, non-indigenous religions and culture, became historically differentiated from the majority of Filipinos. ICCs/IPs shall likewise include peoples who are regarded as indigenous on account of their descent from the populations which inhabited the country, at the time of conquest or colonization, or at the time of inroads of non-indigenous religions and cultures, or the establishment of present state boundaries, who retain some or all of their own social, economic, cultural and political institutions, but who may have been displaced from their traditional domains or who may have resettled outside their ancestral domains” (Section 3, Article III).

Further, the Project shall contribute to the promotion of the various rights of indigenous people in the Philippines as provided for in the IPRA. Specifically, Section 25 of Chapter IV of IPRA guarantees the access of IPs to basic services, including health. Moreover, the project shall be implemented in a manner that promotes the important rights of IPs to self governance and empowerment (Chapter IV) and cultural integrity (Chapter VI).

The World Bank’s Indigenous Peoples policy (OP/BP 4.10) contributes to the Bank's mission of poverty reduction and sustainable development by ensuring that the development process fully respects the dignity, human rights, economies, and cultures of Indigenous Peoples. For all projects that are proposed for Bank financing and affect Indigenous Peoples, the Bank requires the borrower to engage in a process of free, prior, and informed consultation. The Bank provides project financing only where free, prior, and informed consultation results in broad community support to the project by the affected Indigenous Peoples.Such Bank-financed projects include measures to (a) avoid potentially adverse effects on the Indigenous Peoples’ communities; or (b) when avoidance is not feasible, minimize, mitigate, or compensate for such effects. Bank-financed projects are also designed to ensure that the Indigenous Peoples receive social and economic benefits that are culturally appropriate and gender and inter-generationally inclusive.

Indigenous Peoples in the Philippines and Their Health Situation

Data from the National Commission on Indigenous People show that there wereabout 12 million indigenous peoples in the Philippines. The majority (61%) of the IP are in Mindanao while 33% reside in Luzon. The remainder 6% are scattered among the Visayan Islands. Historically, the IP communities resisted assimilation thus, they have been driven to remote rural areas with no or inadequate access to basic services such as health. Thus, most IP’s are among the indigent sectors in the country. A large body of research exists in the country on the health of indigents as well as the problems faced by indigent families in accessing health care. Health outcomes among indigent families in the Philippines are significantly worse than among non-indigent families.

Access problems relate to: (i) distance to health facilities/services, (ii) lack of medicines, drugs in facilities, (iii) lack of awareness of PhilHealth benefits and how to access these benefits. Given that IPs are included in the indigent population, these problems are equally relevant for this group. In addition, IPs face various cultural, social barriers, although the extent of these barriers vis-à-vis implementation of universal health care are not well documented. Consultations with non-governmental organizations indicate that many of these barriers may be related to potential discrimination faced by IPs when they visit health facilities. Moreover, IPs practice indigenous medicine, and these practices need to be integrated to the extent possible to make health services more accessible to IPs. Use of traditional midwives (hilots) is also critical.

There are instances when basic health services reach the IP communities. However, detailed information on the specific health situation as well as resources of the IPs, including their indigenous health practices, beliefs and health seeking behavior is limited. Anecdotal stories tell of IPs’ apprehension in having their children immunized. Consultation with the National Commission on Indigenous Peoples (NCIP) reveals that some IPs do not even want to go to hospitals and prefer to deliver their babies at home, as well. Home deliveries have been said to account for high maternal and neonatal deaths among IPs.

Through the Second Women’s Health and Safe Motherhood Project, IPs in Surigao del Sur have organized themselves as an initial strategy to enhancetheir awareness on women’s health and safe motherhood, which is geared towardseventual representation in the local health board (LHB).The health sector, in the context of implementation of KP/UHC needs to recognize the challengesin addressing IP health issues and needs, as well as to understand their health-seeking behaviorsin order to be able to come up with culturally and locally appropriate strategies to engage them in health activities, and strengthen their awareness.Furthermore, balancing professional and clinical protocols with respect to the uniqueness and rights of IPs is highly emphasized.

Health Policies and Programs for IPs

Health is a priority of the State especially for disadvantaged populations, which includes indigenous peoples. The 1987 Constitution of the Philippines mandates the protection and promotion of the right to health of the people and instills health consciousness among them. This state policy is operationalized through Kalusugan Pangkalahatan (KP), a focused approach to health reform implementation ensuring that all Filipinos receive the benefits of health reform, which shall be measured by the progress made inprioritizing the poor and the marginalized, such as indigenous population, older persons, differently-abled persons, internally-displaced population(Administrative Order No. 2010-0036 “Achieving Universal Health Care for All Filipinos”).

As early as 2004, the Department of Health has issued a policy on geographically isolated and disadvantaged areas (GIDAs), a local health systems development strategy for far-flung areas and marginalized populations, such as islands, mountainous areas, conflict-affected areas, and IPs to achieve equity in health and improve access to health resources and services. The GIDA implementation provides for regular consultations with IPs at the local level. Recently, DOH directed significant fund allocation for the development of GIDAs, and systems-wide interventions to increase and extend coverage of health service provision through Department Memorandum No. 2011-0239 “Prioritization of GIDAs in Province-wide Annual Operations Plan (AOP) to Support KP Execution Plan.” Specific interventions for IP as identified in province-wide annual operational plans have previously included:

MCH – birthing facility at community level – CEMOC/BEMOC to improve access to FBD by IPs; upgrading of FBD priority on GIDA areas
IP health workers – scholarship for IP midwives;
Program materials/IEC materials – community-health workers’ manual which is illustrated and localized

An Operations Manual for Community Volunteer Health Workers (CVHWS) has long been in use in the country to guide volunteer health workers in delivering appropriate and responsive health services to communities. The Manual provides guidelines, as well as illustrations on various health care work and services for all members of the community.

The National Program Support for Kalusugan Pangkalahatan/Universal Health Care

Universal Health Care is an approach that seeks to improve, streamline and scale up the reform strategies in the Health Sector Reform Agenda and Fourmula One for Health in order to address inequities in health outcomes by ensuring that Filipinos, especially those belonging to the lowest two income quintiles, have equitable access to quality health care.This approach shall strengthen the National Health Insurance Program (NHIP) as the prime mover in improving financial risk protection, generating resources to modernize and sustain health facilities, and improve the provision of public health services to achieve the Millennium Development Goals (MDG).

The National Program Support for KP/UHC is fully aligned to the GOP’s agenda of achieving universal health care, which primarily refers to increasing access of underserved populations,including the indigenous people, to quality health services. The main project development objective is to: “increase effective coverage (Health insurance coverage, utilization and financial protection) under the National Health Insurance Program for households identified through the National Household Targeting System-Poverty Reduction (NHTS-PR). It is estimated that 16 percent of the 5.2 million households in the NHTS-PR database are identified as IPs (835,000). In addition to expanding health insurance coverage, the project will also support the Department of Health and LGUs undertake selected interventions to upgrade the quality of the health facilities, train health workers, and institute community health team (CHTs) which will have an outreach function vis-à-vis households, especially IP households that, due to a range of culturally specific reasons, are more difficult to bring into the health sector. Moreover, the implementation of KP/UHC is targeting 12 breakthrough regions which are under-performing in the health sector. These include Geographically Isolated and Disadvantaged (GIDA) provinces as well where many IPs are residing. At a broad, macro level, KP/UHC is well targeted to IPs.

The aforementioned project development objective (PDO) will be achieved through the implementation of the following Components:

Component 1: Health Financing: The objective of this Component is to support financial risk protection for poor Filipino families identified through the NHTS-PR by expanding NHIP enrollment and benefit delivery. . Poor families are to be protected from the financial impacts of health care use by improving effective coverage/ the Benefit Delivery Ratio or BDR (enrollment, utilization and financial protection) of the NHIP. This will be achieved through: (i) expanding membership coverage into the NHIP, (ii) improving the availment/utilization of PhilHealth membership services, (iii) improving support value of the NHIP benefits package, (iv) supporting efficient health spending through risk pooling, fund management and strengthened strategic purchasing functions. This component would enroll the 835,000 IPs classified as poor by the NHTS. Moreover, along with the DOH, this component will support the implementation of Community Health Teams (CHTSs) that will serve as a key interface between the household and health services. Among other tasks, the CHTs will help enrolled families understand their PhilHealth benefits, make sure that families are enrolled with a Rural Health Unit and help them access hospital level services.

Component 2: Health Services Delivery: The objective of this component is to support the Department of Health (DOH) implement Strategic Thrust 2 of KP/UHC which focuses on “improved access to quality hospitals and health care facilities[2].” The health service delivery reforms identified under KP/UHC complement the health financing interventions.

Component 3: Building DOH and PhilHealth Capacity in Results-based M&E: The objective of this component is to support DOH and PhilHealth in the strengthened implementation of the various scorecards for results-based management of KP/UHC as well as strengthen systems for monitoring and evaluation of KP/UHC. The DLIs for this component include:

Establishment of institutional mechanisms within DOH and PhilHealth for KP/UHC M&E;
Implementation of revised scorecards (DOH, CHD, LGU, Hospital and PhilHealth) consistent with the KP/UHC roadmap;
Implementation of a baseline, mid-term and final survey among NHTS-PR families to measure the impact of KP/UHC in increasing effective coverage/BDR among this target group;
Strengthening of specific administrative data systems to enable more systematic and timely reporting on data for tracking KP/UHC (Philippines National Health Accounts, FHSIS, PhilHealth claims data).

FOCUSED PLAN FOR UNIVERSAL HEALTH CARE FOR IPs

The pursuit of Universal Health Care would inherently improve access of indigenous people to basic health care services and financing. The following sections defines the specific strategies, policies and major activities by which the UHC will promote health for IPs. This plan was informed by the regular consultations with IP groups at the local level, particularly as experienced suring the implementation of the 2WHSMP and the NHRSP. Moreover, the NCIP was in agreement with the general design of this project as articulated during a consultation in November 2011.

Strengthening Information base on health of IPs

Prior to the strategy to achieve universal health care, the identification and enrollment of the indigent in the NHIP was primarily the responsibility of the LGU’s. Under the Aquino Health Agenda, the identification and enrollment of IP populations has been streamlined through the adoption of the NHTS-PR of the DSWD to which the DOH has access. With the application of this instrument, the risk that IP enrollment into PhilHealth’s Sponsored Program will be left to LGUs is completely mitigated. For IPs that may have been left out during the survey, the DSWD has a mechanism that allows inclusion and exclusion into the NHTS-PR list whereby such omissions may be corrected. Constant dialogue with IP groups is being undertaken by DSWD will facilitate that process.

Establishment of health data on IPs is necessary to build evidence on their real health condition. This will also be a basis for comparing disparity in health outcomes between IPs and non-IPs in the country that will support evidence-based prioritization and allocation of resources. The IP data on health is envisioned to be developed and integrated to the Field Health Service Information System (FHSIS) or the Unified Management Information System (UMIS) for pilot-implementation.

Increasing Access of IPs to Health Services

Since the Universal Health Care Project aims to increase coverage of health services among underserved population, it is expected to improve the access of indigenous people to health care. The project will benefit IPs by increasing access of the IP population to quality health services – both through the expansion of the National Health Insurance Program (NHIP) to reach the poorest households in the country, as well as through the upgrading of health facilities. Currently, PhilHealth has instituted case rate payments and no balance billing in all government hospitals. This means that any eligible members under the Sponsored Program will have complete access to hospital services and will not be compelled to pay out of pocket.

Under the project, PhilHealth will also improve health insurance benefits like the Out-Patient Benefit package. In the improvement of this and other packages, PhilHealth and/or the DOH will conduct consultations with the IP groups. They will also develop appropriate communication messages and media that will take into consideration the particular needs of IPs as they access healthcare. The benefits package and the communication messages shall be evaluated as to cultural appropriateness for the IP groups.When LGUs update their annual plans for the implementation of KP/UHC (with technical assistance from DOH), the specific needs of IP communities will be evaluated (with NGOs working in the area) and adequately reflected.

Through the service delivery component,IPs are expected to have improved access to health services. The establishment and roll-out of Community Health Team (CHTs), and specific training provided for CHTs and providers in adopting culturally-appropriate behaviors and messages towards IPs is expected to enhance IP availment of health services. The CHTs, whose main task is to serve as an interface between poor households and the health system, will play a special role in bringing IPs into the NHIP and making sure that they access health services. The implementation of similar CHT’s (Women’s Health Teams or WHTs) under the ongoing Second Women’s Health and Safe Motherhood Project has shown that such teams can be highly effective in improving access of IPs to health services. In the case of the Women’s Health Teams, the traditional midwives (hilots) who serve IP communities are included. For the CHTs, a similar practice will be followed by including hilots in the CHTs.

There is, thus, a need to strengthen the capacity of CHTs as facilitators of health service access, and more importantly as community organizers. Engagement with IPs entails much consultation and community building. Therefore, the design of CHT trainings incorporates and emphasizes IP dimensions.