Supporting local planning and budgeting for maternal, neonatal and child health in the Philippines

With an estimated population of over 92 million people, the Philippines is one of the most populous countries in the world. Overall, child health has improved in recent years; however, the rate of decline of infant and under-five mortality has slowed, and maternal and neonatal mortality has declined little since the 1990s [1, 2]. Under the decentralised system of the Philippines, the delivery of health services has been devolved to local governments (municipalities, provinces and cities) [3]. These local government units (LGUs) are now responsible for developing their own health plans and budgets, and securing the corresponding financial resources. However, limitations in their capacity to undertake these tasks have been recognised as one of the impediments to implementing national reforms such as universal health coverage [4].

In response to the problem of local level capacity, the National Department of Health (DOH) introduced the concept of Province-wide Investment Plans for Health (PIPH), requiring local plans to be proposed to a central appraisal committee. Insufficient central level capacity to provide direct technical support to the 82 provinces and limited roles for regional health offices in the early years hampered the original aim of this process. In more recent years, delegating technical assistance and financial responsibilities to regional health centres attempted to address these short-comings; however, a mechanism to improve capacity for strategic problem-solving and a formal approach to support evidence-based health planning and budgeting at local level was also required.

Here we describe the experience of implementing an initiative to support local planning, prioritisation and budgeting for maternal, neonatal and child health (MNCH) in a number of sub-national units in the Philippines. In partnership with local health officials, we implemented the Investment Case (IC) approach in two mainly rural provinces (Northern Samar, population 670,000; and Eastern Samar, population 440,000), and one highly-urbanised city (Pasay City, population 410,000). This approach engages local policymakers and planners in structured problem solving to identify key health system constraints to the provision and uptake of MNCH interventions, and develop strategies to overcome identified problems. A decision-support model that estimates the cost and impact of alternative approaches is used to guide the selection and prioritisation of strategies [5]. We outline how the initiative was implemented, the aspects that worked well, and the key limitations identified in the sub-national application of this approach.

The cornerstone of the IC approach is strategic problem-solving for MNCH planning and budgeting [5]. The process starts with a critical assessment of the available evidence on six parameters related to the performance of health systems; three on the supply side, two on the demand side, and one on quality [6]. Indicators for each of these parameters are site-specific and are defined for a range of critical MNCH services by the local health officials, in consultation with the IC research team and guided by local data availability. Using the evidence collated, local health planners, providers and other stakeholders are engaged in a structured, systematic examination of the key constraints hampering the scaling-up of priority MNCH interventions in disadvantaged populations. After key stakeholders have identified the root cause of the problems, feasible strategies required to address those constraints are identified, and the resultant increases in coverage of relevant health services are estimated. An epidemiological and economic decision-support model that builds on the conceptual framework of bottleneck analysis [5] is used to estimate the impact and the associated costs of the different strategies. The model includes sixty six interventions for which there is global evidence on efficacy to reduce the burden of MNCH mortality [7–9]. These interventions cover the continuum of care, from pre-pregnancy interventions such as family planning, to childhood interventions such as use of antibiotics for pneumonia. Finally, the estimated impact and cost of the different identified strategies are then reviewed to guide decision-making for planning and priority setting.

To ensure the IC findings would be able to support the development of local MNCH plans and budgets, it was important to involve government stakeholders at all stages of the process [10]. Meetings were first held with DOH for endorsement and approval of the process and for site selection. The DOH identified two provinces (Northern Samar and Eastern Samar) and one city (Pasay City) in which to implement the IC. The selection was driven by two types of considerations: i) Capacity to benefit: these were considered to be LGUs where assistance with planning would be most beneficial, and where the LGU health official is responsive and motivated; ii) Equity: Northern Samar and Eastern Samar are among the poorest provinces in the Philippines, and experience some of the worst MNCH outcomes. The rapid growth of cities in the Philippines has led to significant urban poverty [11], presenting specific challenges to the delivery and uptake of MNCH services amongst the poor. Overall statistics suggest that Pasay City residents experience better MNCH outcomes relative to national averages; however, as is typically observed in cities, such statistics mask great inequity [2]. Despite the close proximity of health services, for the most disadvantaged residents of Pasay City there remain significant barriers to accessing key MNCH interventions.

Following site identification, meetings were then held with the relevant regional health offices, and with provincial and city health officials of the three proposed LGUs to discuss the approach and gauge local interest in implementing the process. The initiative was considered and accepted as an approach that had potential to provide inputs to each LGU’s five-year Health Investment Plans and/or Annual Operational Plans (AOP).

The detailed review of available local data undertaken for the IC highlighted the deficits in information that can be used effectively for planning at the sub-national level. Rather than creating a sense of futility in the use of evidence for planning, this recognition focused health officials on understanding how to improve their local health information system to enhance future planning and budgeting, and to enable more effective monitoring. Indeed, recognising the gaps in local data prompted health officials in Pasay City to allocate funding in their plans for the recruitment of a data management specialist. This also highlighted a possible area to which technical assistance from the Regional Offices of the DOH could be directed.

A recent independent review of the IC in the Philippines confirmed that health officials engaged in the process found particular value in the structured analysis of constraints, referring to earlier approaches to defining constraints as haphazard [13]. Some officials observed that their standard approach to understanding system constraints had involved a focus on supply side factors only, thus the bottleneck analysis approach to understanding the root cause of problems by analysing not only supply, but also quality and demand factors, was particularly well received. In one site, the approach to analysis of root causes was reportedly then adopted by the tuberculosis program.

In some cases, the IC analysis challenged existing beliefs about the nature and scope of local constraints and the strategies required. For example, in Eastern Samar, maternal deaths had largely been attributed to “the three delays” [14]. Through the workshop discussion and data review, it became apparent that most maternal deaths took place in hospitals, and resulted from a lack of critical supplies, such as blood, and inadequate staffing. Strategies to overcome these constraints were identified, such as removing the out-of-pocket cost of donating blood, which was considered a key factor in limiting the available supply. The IC process also provided an opportunity to consider new ways of thinking about recognised problems. An example of this was encountered in Pasay City, where greater engagement with the private sector to increase equitable access to maternity services was identified during problem-solving workshops as an alternative to the existing plan to build additional public facilities. However, several stakeholders who were involved in the IC approach and subsequently interviewed two years later reported that the analysis simply confirmed their original understanding and knowledge of constraints, albeit this time with quantifiable estimates [13].

Given the limited number of novel and innovative strategies that actually emerged from the problem-solving or were adopted in practice, it could be argued that the process added little value [13]. However, our experience with officials was that the real value in undertaking the analysis was to help them more systematically ask questions, for example, focusing on the underlying constraints and root causes of demand-side weaknesses in health care as well as the traditional focus on supply-side constraints. Many of the scale-up strategies were based on national guidelines for MNCH. The IC helped officials decide between the range of different scaling-up strategies advocated by the national government, and to tailor different approaches according to local problems, needs and resources. In these cases, local health officials reported that the IC process helped to guide, or at least confirm, their decision-making and the development and prioritisation of different strategies, to validate whether existing assumptions were supported by the data and put numbers to these problems. For example, one of the proposed strategies reflecting recent priorities and approaches supported by the national government is the strengthening of community health teams. The use of evidence and systematic discussion helped determine whether such strategies were indeed the best way to address local health system constraints, and at times the national recommendation was adapted to accommodate the local context. For instance in the two provinces the IC process estimated the funds required to implement the national recommendation to install one midwife per barangay (village) to support community health teams. Given the high observed cost of this strategy and recognising the local human resource shortage, local officials ultimately opted instead to increase midwife numbers to reach a ratio of 1:3 considering this to be a more feasible plan in the short to medium term. The analysis also helped to define the specific local health system inputs and activities that would be required to implement these strategies.

In addition, we noted how the process of devolving responsibility for decision-making can result in simple issues being overlooked. For example, following decentralisation some key medical supplies are no longer being funded by the national government. While the supply of these items had become the responsibility of the local government, the IC discussion and review of data exposed the fact that local officials were still following previous practice of not allocating funding in their local budget. The simple strategy to address this issue was to amend the local budget to include a line item for the relevant supplies and to allocate responsibility for ensuring this additional cost was included in the budget.

Pasay City’s novel strategy of engaging with the private sector to expand access to delivery services had been included in the City’s 2011 AOP, and potentially could have led to substantial savings, but subsequent amendments in the 2012 budget saw a reversion to the earlier strategy of constructing a new public facility. A greater focus on sustaining our partnership with the local government beyond the drafting and submission of the plans would likely have helped retain momentum and interest in the strategies. In retrospect, it is clear that government officials need to expend time, energy and “bureaucratic capital” to convince higher-up decision makers to try new approaches. Simply having the evidence-base of a potentially better approach is not sufficient in itself to achieve step-wise changes in policy. Traditional ways of doing things can be easier and less resource-intensive than using what appears to be an untried mechanism. It is also recognised that, in any setting, there is a range of factors that will impact on prioritisation, plans and funding allocation.

We observed a further example of this in defining strategies around increasing access to family planning. While the evidence for efficacy and cost suggests strategies should focus on expansion of modern methods, in some sites the focus remained on expanding access to less efficacious but more locally acceptable methods. The influence of broader factors such as the political environment in guiding planning and priority-setting has been noted previously [15], and observed in other IC sites [5]. Indeed the 2012 review of the Philippines IC noted that political issues were considered critical in determining what is ultimately included in plans and implemented [13].

The IC assisted in the thinking about and prioritisation of strategies to respond to identified local problems, and most of those strategies were reflected in the plans and budgets of the participating LGUs. Many of these were approaches being advocated by the national government, thus it is possible that the LGUs may have pursued such strategies through their routine planning mechanisms. The contribution of the IC was to enable these approaches to be adapted to the local setting, provide a higher level of confidence by providing quantitative estimates about projected outcomes and costs, and a more systematic way of analysing the root causes of problems in both the demand and supply side of essential health care. One novel policy option was accepted initially and reflected in initial budget papers, but the option was not pursued, with officials reverting to a more traditional approach.

The lack of data available at the sub-national level is a major impediment to local planning. We undertook highly time- and resource-intensive one-off data collection and collation activities from a broad range of sources in order to identify the best available information for analysis. Such activities are simply not sustainable or replicable for routine planning by LGUs. Supporting longer-term evidence based planning at local level will require significant improvements in the scope and quality of locally-representative health system data, such as health service coverage data. Decentralisation allows greater local flexibility to implement plans that respond to local priorities and needs, but this accordingly requires stronger data systems that allow identification of problems, and monitoring of strategies to improve health service access and health outcomes. The IC process aided in identifying critical data gaps that need to be addressed to further improve sub-national planning and prioritisation for MNCH.

It should be acknowledged that however good the data are, evidence is only one of the factors influencing investments in health. Such evidence-based investments have to fit in with national priorities and at a local level compete with more politically attractive alternatives. In addition, issues relating to decentralisation, such as delays in disbursement of funds from the national level and confused responsibilities for health service delivery and reporting between different levels of government [16], limit the extent to which local level governments can fund and implement their plans. Whilst improving local capacity to produce evidence-based plans and budgets is an important step, parallel efforts at higher levels of government to relieve funding flows and coordination issues are critical for any evidence-based planning approach to have a significant impact on health service delivery.